Scale-up of malnutrition screening by the World Health Organization in Syria

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By Mahmoud Bozo, Hala Khudari and Mutasem Mohammad

Mahmoud Bozo is a World Health Organization (WHO) Nutrition Technical Officer for Syria. He has extensive experience in malnutrition detection and management.

Hala Khudari is a WHO Technical Officer for the Eastern Mediterranean Regional Office, Cairo. Hala is a nutritionist with extensive experience in managing and coordinating health and nutrition emergency programmes in Syria and supporting other emergency contexts in the region.

Mutasem Mohammad is a Health Information Management Officer for WHO Syria. Mutasem is in charge of strengthening health information systems, assessments, data management and analysis for evidence-based planning and response.

The authors would like to acknowledge Elizabeth Hoff, WHO representative; Dr Ayoub Al-Jawaldeh, Nutrition Regional Adviser; and Ayman Al-Mobayed, Global Information Systems Officer for their support to this programme and in the writing of this article.

Eight years of protracted crisis in Syria has had an immense negative impact on the living conditions of the population. Violence, interruption of services and forced displacement have compromised access to basic commodities and services, including food, livelihoods, safe drinking water, sanitation, education, shelter and healthcare. This has increased the population’s vulnerability to poverty, food insecurity, poor dietary diversity and disease. This, coupled with inadequate infant, young child and maternal feeing practices and geographical and gender inequalities, has greatly heightened the risk of malnutrition in children under five years of age.

Impact of the crisis on the health system

Health service delivery in Syria has been heavily disrupted as a result of the crisis and attacks have left health centres damaged and, in some cases, non-functional, significantly reducing the availability of essential health services to affected populations. By the end of 2018, out of 1,811 public health centres assessed, only 68% were reported to be functioning (46% fully and 22% partially) and, out of 11 public hospitals, 76% were reported to be functioning (52% fully and 24% partially). Thirty-one per cent of health centres were reported damaged (7% fully and 24% partially), as well as 45% of hospitals (11% fully and 34% partially) (HeRAMS 2018a; HeRAMS 2018b). Figure 1 shows the location of functioning and non-functioning health centers and hospitals across the country, which shows highly vulnerable and hard to reach or besieged areas with limited health services. This situation has been exacerbated by the fact that 50% of health workers have either fled from Syria or to safer locations within the country. Health workers are concentrated in areas considered safer (largely in the central governorates) with reduced availability of skilled health workers in vulnerable areas in the northeast, northwest and southern parts of the country (Figures 2 and 3).

Figure 1: Distribution of public health facilities per governorate in Syria, 2018

Figure 2: Proportion of medical doctors in public health centres per governorate in 2017 and 2018

 Figure 3: Proportion of medical doctors in public hospitals per governorate in 2017 and 2018

Responding to the emerging need of malnutrition

According to the Syrian Family Health Survey (2009), the nutrition situation of children under five years of age was already poor pre-crisis (23% stunted, 9.3% wasted and 10.3% underweight). Only 42.6% of infants under six months old were exclusively breastfed and only 42.2% of newborns were introduced to breastfeeding within the first hour of birth (WHO/MoH, 2009). Micronutrient deficiencies were also common pre-crisis, including prevalent anaemia (29.2%, MoH, 2011), vitamin A deficiency (8.7%, MoH 1998) and iodine deficiency (12.9%, MoH, 1998) amongst under-fives. Neonatal mortality rates, infant mortality rates and under-five mortality rates stood at 12.9/1000, 17.9/1000 and 1.4/1000 respectively. Pre-crisis, severe acute malnutrition (SAM) was managed in paediatric departments in some main referral hospitals. Community-based management of acute malnutrition (CMAM) services have since been established to cater for increased crisis-related burden. Supplementary feeding programmes (SFPs) and outpatient therapeutic feeding programmes (OTPs) are now co-located in 86 centres across the country, managed by the World Food Programme (WFP) and the United Nations Children’s Fund (UNICEF), respectively. Twenty-three stabilisation centres (SCs) for complicated SAM cases are based in public hospitals, supported by the World Health Organization (WHO).

Development of a nutrition surveillance system (NSS)

Prior to the conflict, a national NSS reported cases of acute and chronic malnutrition among children under five years old visiting health facilities for routine immunisations (targeting all children under five years – an estimated 2.7 million children). This service was intended to provide parents with information on their child’s growth through routine monitoring. After the onset of the crisis, concerns regarding increased risk of malnutrition and poor case detection led to a pilot surveillance system in 2014, building on existing growth-monitoring services at 115 health facilities. This was later transformed into an emergency nutrition NSS which, by 2018, covered 802 health centres (WHO Syria Annual report, 2018). The purpose of the NSS is to detect children with acute malnutrition for referral to management services at treatment centres. Global acute malnutrition (GAM) and other nutrition data are collected from public health centres and collated into national consolidated reports to inform evidence-based planning, forecast needs and evaluate programme impact. As children who attend centralised and decentralised health centres in multiple governorates for routine immunisations are monitored (except for inaccessible areas such as Idleb and parts of rural areas of Deir-ez-Zor and Raqqa), GAM rates through surveillance data are considered fairly representative of the country as a whole. Service coverage rates are not currently measured.

Pilot NSS system

The pilot initiative began in early 2014, in collaboration with the Ministry of Health (MoH), United Nations (UN) agencies and national non-governmental organisations (NGOs). The agreed logical approach was to adapt the existing NSS based on growth monitoring in selected health centres in 12 governorates. Adaptations included revised reporting and monitoring tools and training for health workers. The pilot governorates were selected using two criteria: (i) conflict-impacted areas (Daraa, Homs, Aleppo, rural Damascus, Idlib, Quneitera and Deir-ez-Zor); and (ii) densely populated areas with high numbers of internally displaced persons (IDPs) (Damascus, Tartous, Latakia, Hama and Sweida). In the selected health centres, coverage rates of nutrition surveillance, capacity of human resources, availability of physical space and equipment needs were assessed and gaps filled. Nutrition surveillance was also restarted in the highly conflict-affected governorate of Ar-Raqqa through the coordinated efforts of WHO field staff. Many constraints were reported by selected health centres during the pilot period, including lack of human resources, space, equipment and telecommunication-reporting utilities. These obstacles were especially evident in the case of Deir-ez-Zor, a significantly under-staffed and under-resourced area of the country. Despite these challenges, by the end of 2014, 115 health centres were integrated into the pilot NSS, covering 50,000 beneficiaries.

Countrywide NSS system – data and methods

Following the success of the pilot, the system was expanded to additional health facilities from 2015 onwards until, by the end of 2018, 802 health centres were included, screening a total of 928,000 children during 2018 (Figure 4). Of these children, 40% were aged under six months; 16.5% 6-12 months; 19% 12-24 months; and 25% 24-59 months. All children who attended the clinic were included in screening, including those who attended for immunisations and those seeing treatment for sickness. The NSS collects data on weight and height (to assess wasting and stunting), oedema, mid-upper arm circumference and on exclusive breastfeeding (maternal report). Cases of moderate acute malnutrition (MAM) are referred to SFPs, uncomplicated SAM to OTPs and complicated cases of SAM to SCs. WHO has worked closely with the MoH, UNICEF and WFP (co-members of the Nutrition Cluster) to strengthen communication channels between different levels of care to ensure quality referral services. In 2018, 848 complicated cases were referred to SCs and 905 cases admitted; this suggests that the referral system is working.

Data was initially entered manually on paper-based registries, submitted monthly by health centres to district level for collation and submission to Damascus. However, data quality was limited by human errors and a cumbersome (delayed) process. To address this, from 2017, monitoring, reinforced trainings, user-friendly Excel spreadsheets and computerised reporting were implemented at district and central levels. Reporting formats were improved further in 2018 to differentiate between new and returning cases in order to strengthen the quality of data, treatment and follow-up. Since mid-2017, infographics such as those presented in Figure 5 are published on a regular basis to aid communication.

Figure 4: Map of nutrition surveillance centres, 2018

Figure 5: Infographic presenting data from the NSS, 2018

Engaging NGOs and the private sector

In areas where health services were severely disrupted, additional partners were needed to undertake nutrition screening. As a result, surveillance training was expanded to local NGOs able to perform screening in Homs, Aleppo, Hama, Hassakeh, and Raqqa in areas receiving large influxes of IDPs. Training was also provided to 30 private doctors in 2016 and 175 doctors in 2018 in eight governorates (Damascus, rural Damascus, Homs, Aleppo, Latakia, Tartous, Sweida, and Hama) in collaboration with the Paediatric Society. In Aleppo alone, 878 children were screened by private doctors in 2018. Of these, one was found to have complicated SAM, 12 uncomplicated SAM and 54 MAM.¹ All cases were referred to the public health system for treatment.

Reaching the most vulnerable with nutrition screening

In situations such as the East Ghouta evacuation, the Raqqa offensive, or the latest displacement from Hajin and Baghouz in Deir-ez-Zor, hundreds of thousands of people who had been suffering from long-term food insecurity with limited access to health services, water and hygiene, arrived in informal settlements or camps needing urgent support. Among them, children under five years old were at particularly high risk of malnutrition. In response, mobile teams were established, made up of NGO or MoH staff or trained members of the local community, to rapidly screen all children on arrival and refer identified cases of malnutrition for management. A total of 46 mobile teams have been supported by WHO to rapidly screen over 128,000 children in 2018, including in East Ghouta, (70,000 children) Aleppo (4,500 children), Hassakeh (7,000 children), Daraa (26000 children), Quneitera (10,000) and Homs (10,000 children). WHO worked closely with UNICEF to share identified cases and UNICEF deployed mobile teams to provide CMAM services, with complicated SAM cases referred to the nearest SC. Among those screened, GAM prevalence was 12% (1% SAM and 11% MAM) and 30% of children were identified as stunted (higher than the national average of 2.4% in 2018).

Analysis of NSS expansion and GAM trends

Between 2014 and 2018, the number of nutrition surveillance centres expanded from 115 to 802, growing by approximately 200 health centres per year across the country (Figure 6) and increasing the number of children screened (Figure 7). In 2018, among 928,000 children screened, the prevalence of GAM was 2.4% (MAM 1.8%, SAM 0.6% and complicated SAM 0.1%); these cases were referred to SFP, OTP and SCs for treatment.

Since 2015, several approaches have been used to expand the NSS and associated treatment services, including:

1. Geographical expansion through an increased number of facilities integrating nutrition surveillance to increase geographical coverage of screening.
2. Capacity-building of health workers in selected health facilities on nutrition screening to increase the number of qualified health workers to undertake this activity.
3. Increased availability of nutrition supplies in health centres and hospitals providing nutrition services.
4. Increased monitoring and supervision of work established at facility level to help improve quality of care and nutrition services.

An improved security situation in some locations since 2015 (which increased access to facilities by beneficiaries, health workers and supporting agencies) has also facilitated surveillance and treatment. Figure 8 shows the increase in the number of health centres with integrated nutrition surveillance over time. By the end of 2018, the NSS was implemented in all governorates with the exception of Idlib, which was inaccessible from 2015, and Deir-ez-Zor, which was under ISIS control and inaccessible between 2015 and 2017.

Figure 6: Number of nutrition surveillance centres in Syria, 2014-2018