Community management of acute malnutrition in Mozambique

By Edna Germack Possolo, Yara Lívia Novele Ngovene and Maaike Arts

Edna Germack Possolo is Chief of the Nutrition Department of the Ministry of Health, Republic of Mozambique since 2009, where she has worked since 2007 as a public health nutritionist. Her responsibilities include government policy and strategy development, and coordination and management of public health programmes within the MOH. She is also involved in curriculum development and training of health workers, nutrition technicians, undergraduate and postgraduate health professionals.

Yara Lívia Novele Ngovene is a Mozambican Nutritionist who studied in Porto Alegre, Brazil. She has been working in the Mozambican Ministry of Health since 2011 and is responsible for the management of the Nutrition Department’s Nutrition Rehabilitation Programme.

Maaike Arts has a M.Sc in Nutrition from Wageningen University and works with UNICEF. Since 2009 she has been working as Nutrition Specialist with UNICEF Mozambique, coordinating UNICEF’s support to the country’s Nutrition Programme.

This document was drafted with support from FANTA-2/FHI360 (Alison Tumilowicz, Melanie Remane, Dulce Nhassico, Arlindo Machava), Save the Children (Tina Lloren, Vasconcelos Muatecalene, Isaltina Roque), UNICEF (Sónia Khan, Manuela Cau) and WFP (Nádia Osman, Gilberto Muai).

Brief history and background

National nutrition and health situation

Mozambique has just over 20 million inhabitants, of whom approximately 17% are less than five years of age. More than half of the population (55%) lives in poverty¹. In 2003, under-five mortality was 153 per 100,000 live births². By 2008, this had reduced to 141³. During the same period, infant mortality also slightly reduced from 101 to 95 per 100,000. The main causes of child deaths are malaria (33%), lower respiratory tract infections and HIV/AIDS (10% each), followed by prematurity (8%) and gastrointestinal infections (7%). Acute undernutrition accounts for 4% of deaths in under-fives⁴. It has been estimated that undernutrition is a contributing factor to 36% of child deaths⁵.

Overview of production in the RUTF factory in Beira City

In 2008, 16% of newborns had a low birth weight (less than 2.5 kg). The prevalence of chronic undernutrition has remained stubbornly high for many years: 48% in 2003⁶ and 44% in 2008. However, the prevalence of acute undernutrition is relatively low: 5% in 2003 and 4% in 2008 (2.9% in urban areas and 4.7% in rural areas), with a 1.3% prevalence of severe acute malnutrition (SAM). There has been more improvement in child health and nutrition indicators in rural than in urban areas. There are also marked differences between provinces, with the prevalence of chronic undernutrition (height for age < -2 z scores) ranging from 56% in the northern province Cabo Delgado to 25% in the capital city Maputo. Key indicators are summarised in Table 1. A map of Mozambique with the acute malnutrition regional data from the Multi Indicator Cluster Survey (MICS) 2008 is shown in.

The first ever population-based HIV prevalence survey conducted in 2009 found a prevalence of 11.5% in people between 15 and 49 years of age, 13.1% for women and 9.2% for men. In children up to 11 years, the prevalence was 1.4%, and in children under 12 months it was 2.3%. The northern region showed a much lower prevalence (5.6%) than the central and southern regions (12.5 and 17.8%, respectively). Prevalence in urban areas was significantly higher (15.7%) than in rural areas (9.2%) across all regions⁷.

Vulnerability to emergencies

Mozambique is prone to emergencies, including floods, cyclones and droughts. There are frequent floods in the Zambezi river basin affecting the provinces of Tete, Sofala and Zambézia. Other rivers in the centre and south of the country, such as the Limpopo and Buzi rivers, are also prone to flooding. The highest chance of flooding is from October to March, the southern Africa rainy season, and the cyclone season is usually around February/March. In addition, large parts of the country, particularly in the south, are prone to periods of drought, the impact of which is mostly felt between November and January.

The number of people affected by emergencies varies considerably. The 2007 floods affected about 300,000 people, cyclone Flávio affected approximately 135,000 people in 2007 and a drought in the south in 2009 affected just over 250,000 people. Future climate scenarios suggest that Mozambique’s exposure to natural hazards will increase as extreme weather patterns become more prevalent as a result of climate change.

Where nutrition sits in government systems and structures

The Ministry of Health (MoH) has a Nutrition Department under the National Directorate of Public Health, which is responsible for policy and protocol development, as well as the planning and oversight of nutrition activities at all levels. The treatment of acute malnutrition is mainstreamed into regular health services (both during and outside of emergency situations).

The responsibilities of the Nutrition Department are divided into five main areas:

1. Nutritional Surveillance,
2. Nutrition Education,
3. Prevention and Control of Undernutrition and Micronutrient Deficiencies,
4. Nutrition and HIV and Tuberculosis and
5. Nutrition and Non-Communicable Diseases.

At present, the following programmes are being managed by the Nutrition Department:

1. Nutrition Rehabilitation Programme (Programa de Reabilitação Nutricional (PRN))
2. Micronutrient Supplementation Programmes, including de-worming in preschool children
3. Nutrition and HIV and Tuberculosis
4. Infant and Young Child Feeding (IYCF)
5. Food Fortification
6. Health and Nutrition Promotion and School Nutrition

The government has markedly strengthened its emergency preparedness and response since the beginning of 2000. Multi-sectoral coordination at the national level is the responsibility of the National Institute for Disaster Management (INGC), and each community has focal persons assigned to emergency preparedness and response.

The Technical Secretariat for Food and Nutrition Security (SETSAN) is mandated with the multi-sectoral coordination of food and nutrition security. Originally, the main focus was on food security. Since 2011, coordination of the implementation of the Multi-sectoral Action Plan for the Reduction of chronic undernutrition (see below) has been added to its mandate. SETSAN carries out vulnerability assessments three time per year (around February, May and October) to document the extent of acute and chronic food insecurity.

Linkages with the Scaling Up Nutrition (SUN) Global Initiative

The Council of Ministers approved the Multisectoral Action Plan for the Reduction of Chronic Undernutrition in September 2010. The Technical Secretariat for Food and Nutrition Security (SETSAN) coordinates the implementation. The plan includes all components of the package of interventions included in the Scaling Up Nutrition (SUN) roadmap. However, it does not include the components related to the treatment of acute malnutrition (the PRN programme is not included) in order to avoid overloading the plan. The government participates in inter-governmental meetings relating to SUN and Mozambique received early riser status in September 2011.

CMAM/PRN scale-up

The introduction of CMAM in Mozambique

Until 2004, the standard treatment for SAM among children in Mozambique was inpatient care with specially formulated therapeutic milks (F100 and F75), which were introduced into the routine health system in 2002, following a flood emergency. However, coverage of the programme was low, children were often discharged early or their families took them out of hospital before treatment was complete, risks for cross infections were high, and mortality rates in most centres were above the threshold outlined in international standards^8,9. Recognising these limitations, the MoH in Mozambique revised the PRN and introduced the Community-based Management of Acute Malnutrition (CMAM) as a key component. Initially the programme focused on HIV positive children, but it was soon broadened to cover all children less than 5 years of age with acute malnutrition, regardless of HIV status.

Source: *See footnote 1. ** See footnote 7.

The term CMAM was not well accepted in Mozambique because it suggested that the management of malnourished children is only carried out in communities. The term ‘outpatient treatment’ has therefore been used for this element of the PRN. The PRN contains five components:

1. inpatient treatment for cases of SAM with poor appetite and/or medical complications
2. outpatient treatment for cases of SAM without medical complications
3. outpatient treatment for cases of moderate acute malnutrition (MAM)
4. active case finding and referral at the community level, and
5. nutrition education at the community and health centre levels.

The main aim of the PRN is to reduce the number of deaths due to SAM. In addition, it aims to reduce the incidence of SAM by improving early detection, referral and treatment of children with MAM.

Linkages with other health and nutrition interventions

The MoH actively promotes the integration of services. In principle, nutrition is an integrated component of reproductive and maternal and child health, as well as HIV and AIDS and tuberculosis services. Nutrition is also a component of health promotion, community involvement and school health activities. The extent to which integration actually takes place depends on the level of training and workload of the staff involved. In 2010, the MoH approved the broadening of the definition of child health services to include children up to the age of 15 years. Prior to this, children between 5 and 15 years of age were treated within adult health services (with the exception of those living with HIV). The Ministry is currently revising the protocols and guidelines for all related programmes (in addition to Volume 2 of the PRN), so that they are in line with this new policy. This shift should help strengthen nutrition interventions for children in this age group.

Nationwide scale up of the PRN

Outpatient treatment for SAM without complications was introduced in Maputo City in 2004 as part of treatment services for children with HIV. It was incorporated into general health services and expanded to other provinces in 2007. The health directorate of one district in Nampula Province (Ribaue) initiated a full package of treatment for acute malnutrition as a pilot in 2007, with support from Save the Children, Valid International and UNICEF. This pilot was very successful and was subsequently expanded to other districts in Nampula. By 2010, five districts in Nampula Province had successfully established a pilot learning centre where all five components of the PRN were implemented. The lessons learned from the pilot were incorporated into the revision of the PRN manual, the Manual de Tratamento e Reabilitação Nutricional (Volume 1, covering children aged 0 to 15 years of age). The development of the manual started in 2005 and was completed in August 2010 with the approval of the Minister of Health. The new WHO growth standards (2006) have been incorporated in the revised manual.

Community-based screening, referral and follow up of SAM cases were introduced in 2006/2007 in the Nampula pilot. These have since been gradually rolled out as part of the PRN. The speed of this roll-out is increasing since the approval of the PRN manual in August 2010 and subsequent training in the implementation of these components.

The treatment of MAM was included as an integral part of the programme in the PRN manual. MAM treatment programmes have primarily used Corn Soy Blend (CSB) provided by the World Food Programme (WFP). In 2011, CSB was replaced with ‘CSB Plus’ which contains additional micronutrients. Initially, the protocol for treating MAM covered children less than 5 years of age only. This was expanded to children aged 0 to 15 years of age in Volume 1 of the revised PRN manual. Volume 2 addresses adults, including a specific focus on pregnant and lactating women, and this will be finalised in the near future.

Volume 1 of the PRN manual includes the following procedures for community screening and referral of malnourished individuals. Community-based Health Workers (CHWs), known as Agente Comunitário de Saúde (ACSs), Agentes Polivalentes Elementares (APEs) and activists, screen children aged 0 to 15 years of age for acute malnutrition. This screening involves taking measurements of mid upper arm circumference (MUAC), checking for oedema, and looking for signs of wasting. Screening is also carried out annually during the National Health Weeks (NHWs). There are two rounds of NHWs, one of which includes screening for malnutrition. The CHWs refer those who meet the criteria to the nearest Health Centre (HC) where they are then assessed for acute malnutrition and other health issues and provided with the relevant treatment according to the protocols described below. In addition, children in the ‘well child check-ups’ who are underweight or have growth faltering are referred for screening and can enter the programme through this route.

Patients with SAM who have good appetite and no medical complications are treated on an outpatient basis with Ready to Use Therapeutic Food (RUTF). Patients with SAM and additional complicating factors are treated with therapeutic milks and RUTF, before transitioning to outpatient treatment to complete their recovery. Patients with MAM are treated either with RUTF or CSB Plus, depending on what is available at the HC. The follow up is carried out during the ‘at-risk child’ consultations (Consulta de Criança de Risco or CCR).

Risks of scale up

MUAC measurement in a child in Gaza province during the Child Health Week

A number of possible risks are associated with scale-up, including:

• The rapid roll-out of the new PRN protocols might compromise the quality of training and subsequent implementation. Adequate supervision will therefore be crucial.
• Sufficient funding for the training of staff in all health facilities and related reproduction of materials could also become a constraint. The scale up of community screening, both as a routine service and during NHWs, will most likely lead to increased demands for RUTF, CSB Plus and therapeutic milks. However, the funding for these products is not yet fully secured for the coming years. Many of the donors have a limited mandate in terms of target group, age group, geographical coverage or type of intervention (procurement, technical support, etc.), which can complicate fundraising.
• The MoH’s recommendation to use RUTF for MAM in places where no CSB Plus is available could lead to shortages, since the number of MAM cases is considerably higher than the number of SAM cases. Furthermore, the introduction of Volume 2 of the PRN Manual includes protocols for the use of therapeutic milks and RUTF for the treatment of SAM in older age groups. These new protocols could also lead to shortages of therapeutic products because at present, the national supply only covers children less than five years of age. The vision is that rollout of Volume 2 will only start after the availability of supplies is ensured.

Nutritional products and local production of RUTF and CSB

When outpatient treatment was introduced, UNICEF imported RUTF from Europe. To ensure in-country availability and to increase national ownership of the product, Nutriset in France and UNICEF supported the establishment of a RUTF factory as part of the Nutriset ‘plumpyfield’ network. The factory was set up in Beira City in the centre of the country, managed by the non-governmental organisation (NGO) Joint Aid Management (JAM). Planning and construction of the factory started in 2006, with equipment arriving in mid-2008. The factory was certified for local procurement by UNICEF at the end of 2009 and officially inaugurated in February 2010.

Sugar and oil are procured locally, as are increasing amounts of the peanuts. The remaining ingredients are imported. The factory produced small quantities of RUTF packaged in jars until it obtained a sachet line in mid-2011. Sachets are preferred over jars because of their longer shelf life, they are easier to prescribe (the content of the jars is 220g) and easier to handle by the patients (no spoon is needed).

The Clinton Health Access Initiative (CHAI) procured a proportion of the country’s RUTF needs for 2011 from the local JAM factory via the UNITAID Programme. It is expected that the sales of locally procured RUTF will increase in the future.

CSB has mostly been imported, with the exception of small quantities procured from JAM in 2010. In 2011, WFP expanded its work with JAM to increase the volume of locally produced CSB.

Partnerships and funding

The Ministry of Health and its partners

The MoH is responsible for the management of health facilities in the country. Non-government actors are not leading any health facility. The drafting and revision of protocols and guidelines is the responsibility of the MoH.

Clinical and technical partners provide technical support to health services. At present, these include various PEPFAR¹⁰ supported partners such as CARE, the Elizabeth Glaser Paediatric AIDS Foundation (EGPAF), Vanderbilt University’s Friends for Global Health (FGH), Family Health International (FHI), and the International Centre for AIDS Care and Treatment Programmes of the Columbia University (ICAP), as well as the CHAI, Médecins Sans Frontières (MSF) and Save the Children. Several of these organisations also cover the costs of in-service training and supervision for staff of selected districts or provinces.

Several organisations, including EGPAF, FANTA-2/FHI360, Save the Children, UNICEF, USAID, WFP and WHO, provide technical support at central level. The cost of training and reproduction of training materials and job aids has been shared by several of the PEPFAR clinical partners, FANTA-2/FHI360, UNICEF, USAID and WFP.

Funding

A child in PRN with her mother in one of the pilot health facilities in Nampula Province

In 2011, the MoH’s annual budget was USD 360 million, of which approximately half was provided through external funding sources. There is a Common Fund for the Health Sector, to which 16 donors contribute. The Nutrition Department’s budget for 2011 was approximately USD 260,000, although this amount does not include the vertical funds provided by UNICEF, WHO, USAID, WFP and other partners who support the implementation of specific activities. Funds for the Provincial Health Directorates come from both central level and donors.

Since 2008, CHAI has procured the vast majority of RUTF for the country, with UNICEF filling gaps where needed. Therapeutic milks and other products for the treatment of SAM are in principle procured by MoH, with UNICEF filling gaps where necessary (which included large amounts of therapeutic milks in 2009, 2010 and 2011).WFP provides CSB Plus but the coverage is not nationwide (in 2010, the programme covered selected districts in five provinces). The contribution to training and reproduction of materials is described above.

Implementation

Geographical coverage

In principle, the coverage of the PRN is national, although it will take some time to achieve full roll out across the country. As of mid-2011, 191 out of about 1,280 health facilities in the country (from primary to the fourth level of health care), provide inpatient treatment for SAM and 229 provide outpatient treatment. However, as yet, not all facilities or districts have been trained in the updated 2010 protocols.

Training

In the time between the introduction of outpatient treatment for SAM using RUTF and the official approval of the new PRN protocols, numerous health workers were trained in draft versions of the protocol that were under development. Outpatient treatment was initiated for the rehabilitation phase of SAM treatment and for the relatively small number of SAM cases that presented without complications.

Since the end of 2010, three regional (north, central and south) Training-of-Trainer (ToT) workshops for the new protocols have been conducted, reaching a total of 112 people. The training was rolled-out in a cascade manner starting with the three regions, followed by replication trainings at provincial level and finally, at facility and community levels. To date, each province has undertaken at least one training session for district staff (reaching 376 people). Attempts are always made to include either a trained MoH staff member or a member of a clinical partner organisation to facilitate and/or supervise some of the sessions. Training materials for Mozambique were developed by adapting WHO-recognised scientific guidelines and practices to the national context. The materials were updated and improved using post-training feedback.

The complete PRN training library includes three ‘packages’, each consisting of an orientation training package, facilitators´ guides and hand-outs for participants. Complementary training materials on HIV and nutrition are provided at community level.

A strong focus is placed on training of the full PRN package. The number of days training for each level of participants is as follows:

• Facility-based health workers: 5 days.
• CHWs: 2 days, plus an additional 2 days for training on community-based nutrition and HIV for CHWs and home-based care volunteers.
• Community leaders and traditional healers: 1 day covering the basics of the programme.
• Provincial-level health staff: hands-on 3-day training covering monitoring, evaluation, planning and logistics, orientation to tools and databases for the PRN programme.

There are plans to initiate supervision activities within health facilities to observe the quality of implementation and to provide refresher sessions where needed. A supervision checklist is currently under development.

Recording and reporting

Several tools were developed for programme monitoring, including individual and programme level monitoring forms, a database to track admissions and outcomes and a database to manage the stocks of RUTF, CSB Plus and therapeutic milks. The PRN individual and programme level monitoring forms are summarised in Table 2 with the flow of the monitoring system illustrated in Figure 2 and outlined in Box 1.

Particular emphasis is being placed on the quality of data recording and reporting, as this has been identified as a weak aspect of the PRN for a number of years. A specific data-handling training course was developed alongside the new protocol training. To date, 34 staff have participated in a dedicated five day monitoring and evaluation (M&E) training that focused on the PRN database and the related reporting mechanisms. The general PRN training package also includes a section on M&E.

The implementation of the revised M&E system for the PRN has been halted due to delays in the printing and distribution of instruments required to collect health centre-level data. It is expected that final approved versions of the instruments will be printed and distributed by the end of 2011, with collection of data starting in earnest from January 2012.

Supplies and supply chain management

The primary supplies for the PRN are therapeutic milks (F75 and F100), RUTF, CSB Plus, ReSoMal, routine drugs (e.g. antibiotics, vitamin A, deworming drugs, malaria prophylaxis, etc) and anthropometric equipment (including MUAC tapes, weighing scales and height/ length boards).

The MoH receives support from several partners to procure the products required to treat acute malnutrition, including F75, F100, RUTF and ReSoMal. As mentioned, UNICEF and CHAI have been purchasing imported RUTF for the programme, although this support was phased out in 2010.

The WFP supplies CSB Plus to selected health centres in the southern and central parts of the country. Initially, this was done via NGOs but it is now supplied directly to the provincial health directorates (with financial support from WFP).

Supply chain management capacity at different levels is limited. Stock-outs of RUTF, ReSoMal and therapeutic milks are often reported. In most cases, it is due to inadequate forecasting and communication between the different levels (health facility-districtprovince- central level). The weak and often late reporting of numbers of children treated is a major contributor to the forecasting challenges.

Community involvement

The community components of PRN in Mozambique were initiated as part of the pilot in Nampula Province in 2008 (see earlier). The pilot showed that the strategy of encouraging active community involvement quickly produced results. Health centres in the districts where community activities were being implemented (Memba, Eráti and Ribáué districts) experienced an increase in the number of referrals. However, requirements for RUTF resulting from the subsequent increase in caseloads had not been properly forecasted. When screening of acute malnutrition was integrated into activities of the monthly health day at provincial level, there were further increases in caseloads.

Following the success of the pilot, the programme was expanded to other provinces including Sofala, Zambézia and Gaza. Save the Children (the main provider of technical assistance to MoH in this area) partnered with other community-based programmes to strengthen staff capacity. These staff have, in turn, supported the provincial and district health services in the implementation of the community strategies included in PRN. Partner support has included training of trainers on community mobilisation in the context of PRN and home-based nutrition care for people living with HIV/AIDS in several provinces during 2011.

The experience of Nampula Province showed that it is possible to develop a close link between health professionals and community groups. Monthly meetings were conducted involving health professionals and community groups, to discuss relevant health issues. Health professionals now recognise the importance of active community involvement for wide dissemination of health messages and of community sensitisation to ensure early referrals, when the disease process is at a less advanced state and still relatively easy to treat. Many traditional healers now also recognise that the treatment of malnutrition is complex and requires referral of the child to the health centre for appropriate rehabilitation.

However, it has still proven to be challenging to roll-out the community activities, in part because the focus so far has been at health facility level. There are a limited number of experienced staff who can provide technical assistance to the MoH’s efforts at community level. This will continue to be a problem unless additional efforts and funding are geared toward this gap. The delay in printing and distribution of materials used at the community level, including reference forms, job aids, and MUAC tapes, delayed implementation, even in areas where training and mobilisation were underway.

The MoH recognises the need to prioritise community components of CMAM within the PRN, and is committed to including community-related activities into plans of action. Support will be sought from various organisations and donors. Linkages will be established with the new cadre of CHWs (APEs). In light of the current momentum to establish large-scale nutrition programmes in Mozambique, it is expected that more communities will benefit from efforts to improve community knowledge and skills for the diagnosis, referral and follow up of cases of acute malnutrition.

Coordination

The Nutrition Department of the MoH coordinates the group of partners supporting the PRN. This group meets weekly when needed and less frequently where possible. There is a division of labour between all participants, which can be flexible when required, but is based on each organisation’s mandate and comparative advantage. A formal description of this coordination mechanism is currently being developed.

Results: caseload and outcomes

According to the data available to the MoH (for many provinces only partial data are available), by mid-2011 6,319 children under-five were admitted for inpatient treatment for SAM, of which 701 (11%) died. Just over 900 children were referred to outpatient care to continue their treatment and 5,854 received only outpatient treatment for SAM. The low percentage of children going directly to outpatient treatment is probably related to the fact that training in the new treatment protocols was only scaled up recently.

As reported by the Health Information System, the percentage of facility-based deaths due to SAM has been slowly reducing. However, in 2010 percentage mortality was still just under 10%, with wide regional differences (ranging from 5 to 20%). This could be due to high levels of complications and/or inaccurate application of the protocols and/or inaccurate reporting. This issue has yet to be studied in detail. Mortality for the past years is shown in Table 3.

In 2010, 31,503 children received a supplement for MAM (of which 27,620 received CSB Plus and 3,883 received RUTF).

Successes

The introduction and approval of outpatient treatment of SAM with community involvement has been a success in itself. In the beginning, many paediatricians and other medical practitioners were sceptical about the possibility of treating children with SAM as outpatients, particularly children with oedema. The key decision makers have now been convinced by the evidence from the pilot programmes and are endorsing the new protocols. However it has been stated that all cases of oedema should still to be treated as inpatients.

The PRN is owned by the MoH and all partners have aligned with its protocols and implementation mechanisms, actively taking part in the working group meetings.

Other successes include the development of a set of PRN training and implementation tools (job aids and registration forms and books),the implementation of a pilot learning centre in five districts in Nampula Province, continuation of training and integration in the ‘at-risk child’ consultations (CCR), prevention of mother to child transmission of HIV (PMTCT) services, and triage in many health centres. Additionally, in places where community leaders, practitioners of traditional medicine and APE/ACSs have been trained, there is increasing interest and support from the communities.

A further success of the Mozambique experience is the integration of treatment of malnutrition for people with and without HIV. The existence of one protocol and one national programme aimed at treating malnutrition, regardless of HIV status, has resulted in costsharing and collaboration among partners and donors who support the target group of children less than five years and people living with HIV. For example, PEPFAR-supported partners are very active in supporting the PRN programme.

Finally, there has been an improvement of awareness on nutritional support by many health staff and those in district and provincial health offices. This has led to increasing numbers of patients receiving nutritional assessments, counselling and rehabilitation.

Challenges

A number of challenges remain in the case of Mozambique that will affect national scale-up:

Training

Questions remain as to how to maintain the quality of training at all levels using the ToT cascade model. Potential solutions put forward include the development of a training video, increasing the number of other training tools and ensuring adequate supervision where possible.

Implementation/service delivery

Close follow up is also required for effective service delivery. This has not always been possible due to capacity constraints. It is expected that (where active), NGO clinical partners can assist the government to follow the programme closely, including via clinical mentoring.

Recording and reporting

Sign for the RUTF factory in Beira City

Insufficient capacity (including knowledge of software such as Microsoft Excel), commitment, and understanding of the importance of reporting at all levels create challenges for achieving a timely and accurate reporting system. The data are rarely analysed or further scrutinised (for example, for possible causes of high mortality rates or increasing or decreasing caseloads). This could be due to heavy work-loads of MoH staff, but the barriers need to be identified in order to improve the system.

Supply chain management

Lack of effective supply chain management, forecasting and procurement create major challen- ges to ensuring uninterrupted supply chains. Capacity in this area is weak at all levels, not only for nutrition supplies but for all supplies managed by the MoH.

Therapeutic foods are difficult to transport and store because they are heavy and bulky. Weak logistic skills of health staff have led to poor forecasting of the quantity of products needed, resulting in frequent stock-outs.

Funding issues

The short funding cycles of donors and a lack of financial resource commitment to support the PRN at all levels hinders strategic long-term planning. RUTF supplies are not yet secured after mid-2013.

Other challenges include:

• The health infrastructure is undermined by a lack of qualified staff and high turnover of medical staff and managers. One approach to address this problem would be to train all health facility and hospital staff in districts where PRN/CMAM operates.
• Issues of community access, e.g. distance from health facilities, preference of the traditional care system and shortage of community mobilisation efforts.
• Poor understanding of malnutrition at the community level (malnutrition is not necessarily perceived as a medical or dietary problem, but rather as a spiritual problem), which prevents communities from seeking professional health care. This should also be addressed through the strengthening of community mobilisation and involvement in the PRN activities.

The way forward

While the PRN can already claim success in expanding the availability of CMAM, the following steps are required to ensure a continued and successful scale-up of the implementation of the new protocol:

1. Finalise Volume 2 of the manual for the treatment of acute malnutrition for adults.
2. Strengthen the quality of training, including the development of additional training tools and video-based training modules.
3. Produce and distribute job aids and materials at all levels.
4. Develop a plan to support the implementation of the protocols, once training of health workers is finalised.
5. Establish supportive supervision systems and ensure that they are routinely applied (finalise the tools, implement the supervision).
6. Prioritise community involvement and initiate this in places where it does not exist. This should include building a cadre of specialists who can provide technical assistance on the community components.
7. Strengthen recording, reporting and analysis of the data (promoting the triple A cycle of assessment, analysis and action).
8. Strengthen supply management and logistic systems.
9. Secure adequate and on-going funds for supplies.
10. Consider the establishment of a technical group focusing on community based work.
11. Investigate the causes of mortality in children with SAM.
12. Design a plan for the introduction of the new protocols in pre-service training of health and nutrition workers of all levels.

For more information, contact: Edna Possolo, Head of the Nutrition Department, Ministry of Health. Email: epossolo@misau.gov.mz or ednapossolo@gmail.com, Yara Lívia Ngovene, email: yngovene@misau.gov.mz, Maaike Arts, email: marts@unicef.org

¹Ministry of Planning and Development, 2010. Third National Poverty Assessment, 2008- 2009.

²All 2003 data (unless stated otherwise) are from the Demographic and Health Survey (DHS) 2003 (Ministry of Health/National Statistics Institute, 2004).

³All 2008 data (unless stated otherwise) are from the Multiple Indicator Cluster Survey (MICS) 2008 (National Statistics Institute, 2009).

⁴Ministry of Health, 2009. Mozambique National Child Mortality Study, 2009. The methodology used was verbal autopsies of family members, about child deaths reported during the 2007 General Census. A definition of undernutrition in this report was not given.

⁵USAID, 2006. Nutrition of young children and mothers in Mozambique.

⁶The nutrition data from 2003 (originally based on the NCHS reference population) were re-calculated based on the 2006 WHO growth standards.

⁷National Institute of Health, National Statistics Institute and ICF Macro 2010. Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique, 2009 (INSIDA).

⁸MoH 2006. Proposta para o programa de reabilitação nutricional (CMAM).

⁹UNICEF, 2006 .Draft terms of reference for technical support to introducing community treatment of severe malnutrition in Mozambique.

¹⁰U.S. President's Emergency Plan for AIDS Relief

¹¹Ministry of Health/Health Partners Group Performance Assessment Framework, March 2011.