• Lillian Karanja-Odhiambo (L-KO) : Regional Knowledge Management Specialist, East Africa
• Mueni Mutunga (MM): Chief of Nutrition from UNICEF, Sudan

LK-O: Dear listeners, welcome to today´s podcast. I am Lillian Karanja-Odhiambo, ENN´s knowledge management specialist for East Africa. I am happy to be speaking with Mueni Mutunga, who is UNICEF´s Chief of Nutrition in Sudan. I´ll be speaking with Muani about an article titled ‘Skilling up CMAM in protracted emergencies and low-resource settings: experiences from Sudan’. The article appears in the 55^th edition of Field Exchange. Welcome, Mueni.

MM: Thank you Lillian.

LK-O: Please introduce yourself and the work you do in Sudan.

MM: My name is Mueni, and I am the Chief of Nutrition in Sudan for UNICEF. My role is overseeing the UNICEF overall emergency and development nutrition programming in Sudan.

LK-O: Tell us about Sudan and its humanitarian situation.

MM: Okay. Sudan, as you know, is the third largest country in Africa, and we have over 35 million people, and in this we have six million children under five, and in Sudan one of those out of every three children is malnourished. Malnutrition in Sudan is evenly spread across the whole country; the prevalence or the burden is the same in conflict and non-conflict states.

The eastern and northern parts of the country, that are close to the Sahara desert, are characterised by sparse population and harsh environmental conditions. This makes the effective delivery of services a challenge, because of the sparse population and poor infrastructure that is often distant from the communities. In addition, the protracted conflict for over a decade in the western and the southern parts of the country, particularly in Darfur and North Darfur, have resulted in displacements and security challenges for effective healthcare delivery, and these have generated major humanitarian needs that form the larger part of the nutrition response in Sudan.

LK-O: So, having said that, Sudan was one of the first few countries that adopted the outpatient treatment for severe acute malnutrition, which we abbreviate as SAM.

How has the treatment of SAM evolved in Sudan?

MM: so, in the early 2000s the outpatient management option was piloted in Sudan and Ethiopia, but with the conflict in South Sudan and later in Darfur, attention largely focused initially in the IDP camps and the refugee camps, which was largely led by humanitarian actors. But in 2009 the number of NGOs operating in Sudan dropped significantly, and this resulted in gaps, as the MoH facilities were not sufficiently equipped to deal with or treat acute malnutrition. So because of these reasons, Sudan did not scale up CMAM between 2000 and 2010.

In 2010, Sudan adopted a different approach towards institutionalising CMAM within the government health system that started with the endorsement of the approach of CMAM by the Paediatric Association. And then in 2013 a national survey led by UNICEF and the Ministry of Health that desegregated data at the lowest level was done across the whole country, that revealed very high levels of malnutrition. And this I would say was a game-changer, because these shockingly high numbers of malnourished children across the whole country resulted in a government decision to do something about nutrition to change this situation, and fortunately it coincided with the development of the accelerated plan for reduction of maternal and child mortality. As a result, CMAM was one of the strategies adopted in this strategy of accelerated plan for reduction of child and maternal mortality in 2012. That´s how the scale-up journey started, up to where we are at the present.

LK-O: Right. That´s interesting, and we will go into a little bit more detail of what it has meant, the nuance of the things that you have described. But following all the transitions you have described, what key successes would you highlight in the scale-up of CMAM in Sudan currently?

MM: I would say that the first and most important is the government leadership and ownership of the programme, that they have led the planning process and also the implementation process. The second one is the involvement of all the health workers, not just nutrition but the medical staff in different departments of immunisation, maternal and child health and also integrated management of childhood illnesses. And I would say because of the involvement of every staff, health staff within the health facility level, this has led to great ownership and implementation of the plan, and as a result we have seen a five-fold increase in the number of children treated between 2010 and 2016. And also greater reach in the expansion of the number of treatment facilities to areas that previously did not have treatment services available. And lastly, I would say one of the other successes that I would say is quite significant is the government contribution to actually the CMAM scale-up, in terms of food, putting government-owned financial resources in procurement or variety of training of health workers and transportation of supplies.

LK-O: Yes, those are incredible successes that you’ve mentioned. And maybe now, so that we can get into the details of it, what does the scope of integration look like in practical terms?

MM: So, in Sudan the scope of integration is in three parts. First, integrating treatment of acute malnutrition and nutrition as part of the basic package of essential health services within Sudan. And in that we also moved from a nutrition service being provided by a specialised cadre of nutritionists, to making it the responsibility of all health workers within the primary health care units. Also, in terms of policies, Sudan has made progress in having nutrition in health policies. For example, it’s one of the 10 components of the reproductive, maternal, newborn and child health strategy. The second aspect of the scope of integration is also within the supply chain for RUTF. It’s been a process, but I think we are in the journey and in this journey we have made progress in integrating RUTF into the government supply chain. We started with having one supply plan between UNICEF and the government and delivery by UNICEF to the state level and the government taking over transportation from the state downwards. So this is in progress, it’s not where we would like it to be, but we see that we are taking some concrete milestone towards integrating the RUTF supply products into the national medical supply chain.

LK-O: So, you’ve hinted at some problems and some challenges in integrating nutrition into health systems. Maybe you can tell us what the key challenges in planning for integration were in Sudan.

MM: The first one is just the scope of the needs, the number of malnourished children versus the number of treatment facilities available, and also the resources available to treat the children that needed treatment. So this called for an urgent scale-up in the shortest time possible. However, the pace depended on many factors, including finance and the number of health workers, how well trained they were and equipped to provide treatment services, and also the supply chain, the storage facilities and the capacity for the warehouses to accommodate the amount of supplies. So we dealt with this by having a phased scale-up plan, where we had three phases. The second challenge was the role of health workers in the treatment of severe acute malnutrition, and also the link between the nutrition staff and the medical staff, where they were not actually communicating or sharing notes, where a child would be seen by the nutritionist and not necessarily referred to the medical worker. We dealt with this by the Ministry of Health issuing a policy guidance that nutrition was part of the basic essential services and hence it was the role of every health worker. The third challenge has been community mobilisation. Sudan is a large country with different contexts - environmental contexts – and we do not necessarily have adequate community structures or community volunteers, so early case finding has been a problem and we dealt with this initially by doing mass MUAC screening and now we are moving towards using mothers of children that are malnourished or mothers of children that are participating in the infant and young child feeding healthily programme. And then, lastly, I would say the other challenge has been the short-term earmarked emergency funding that does not allow for long-term planning in advance. In Sudan we have dealt with this by having a master plan and allocating or plugging in the donor funds as they came, based on the conditionalities of the earmarked funding.

LK-O: Right. So if we pick up on the last point that you talked about, the short-term emergency funding. CMAM is already perceived as a short-term emergency response, as opposed to a long-term development programme. How has Sudan approached CMAM through the lenses of long-term programming?

MM: I think we have a project from both sides. From one side is that we have used emergency funding to provide the immediate life-saving response while building systems, and also used development funding to respond to emergencies when they occur. And for this we thank our donors for having the flexibility to respond to the emergencies as they come and also to build systems.

So it has been a dynamic interplay, not really a shift, between switching to development funding when the emergency is over, or switching to emergency programming from a development programme when an emergency occurred.

LK-O: Okay, that’s interesting, and can you tell us a little bit more about the role of government financing in this kind of interplay that you have mentioned. What enabled this change in bringing some government financing into the CMAM project and what was UNICEF’s role in this?

MM: As we describe in the article, at the planning stage we faced a prioritisation dilemma, where most of the funding that was available was available for the high-prevalence states, that were largely facing emergency situations, but on the other side the survey - the national survey that was done – showed that in non-emergency states where the population numbers, where we have high population numbers, also there was a high burden – in other words the number of children that were malnourished was quite high. So the government made a decision that the state will mobilise the missing resources to provide treatment services for the children also in these states that are not necessarily high-prevalence but they are high burden.

LK-O: Information systems are considered critical in ensuring quality CMAM services. Tell us about Sudan’s experience in using information to ensure quality treatment.

MM: In the monitoring of the quality of treatment services when we started CMAM scale-up, we put in place a cloud-based monitoring and reporting software, Kobo, that was able to give us real-time data and we were able to see the states that were struggling and provide adequate support to improve the quality of the services that were being provided. In addition, we utilise a lot of on-the-job support and training and from this we are able to collect data and also get feedback from health workers on how they were finding the treatment services and also the areas where they needed more support in developing their skills. In terms of the overall monitoring of the programme, we used what the CMAM standard indicated us to measure the performance and take corrective action, like cured rates, mortality rates and default rate. We also monitored the geographic average by measuring the number of health facilities that were offering CMAM services in comparison with the number of facilities indicated in the target in the CMAM scale-up plan. Also, the number of children, we also monitored the number of children who were treated against the target, and we reviewed this on a quarterly basis, together with the ministry of health and other implementing partners, and were able to identify the challenges and corrective measures and adapt our implementation plan to address any challenges and gaps that were reported.

LK-O: Right, so you talk about using the evidence – real-time data – to adapt your response. And the article also speaks quite a bit about evidenced expansion of services. What sort of evidence was needed to influence policy-makers, programmers and funders?

MM: Firstly, it was the scope of the problem of malnutrition in Sudan, that was generated by a joint survey by the federal Ministry of Health and UNICEF, that showed that malnutrition was a big problem across all the localities in Sudan. And secondly, it was also a roadmap document produced by UNICEF and the Ministry of Health that showed that the treatment facilities available for treatment of severe acute malnutrition in comparison with the PHC services was only a third, sometimes less than 5%, across all the country. And then, thirdly, was the CMAM evaluation that generated some of the lessons learned and provided recommendations on the potential opportunities that were available for scaling up CMAM in Sudan.

LK-O: And what data do you have on estimated coverage of severe acute malnutrition treatment?

MM: In Sudan we are currently using the direct measure of coverage. One is by measuring the facilities that are offering services for treatment of severe acute malnutrition out of the total number of primary healthcare facilities available, and the second is the number of children that we have admitted into the programme for treatment, out of the estimated total case load from the survey that was done in 2012.

LK-O: And how have surges in the case load been managed?

MM: So during the lean season, when we expect malnutrition to peak in Sudan, what we do is advance the positioning of supplies, and also we have a trained team of roving emergency staff that are able to respond to needs as they arise and be deployed within short notice to areas where there is an increase in malnutrition. We also provide - generally with the Ministry of Health - on-the-job training, supervision and mentoring through dedicated UNICEF and federal Ministry of Health monitoring staff. Fourthly, is also by the analysis of the poor-performing centres, at locality and state and federal level, and refocusing efforts, on-the-job training and support to improve the quality of care in these facilities.

LK-O: Tell us also about the local production of ready-to-use therapeutic food in Sudan and how increase in the same was achieved.

MM: In Sudan, when we started the CMAM scale-up, the local manufacturer was part of the planning process, so we were able to plan at the outset how much supplies would be needed and inform them in advance. And this also had been possible through partnership with them, where they are able to continue production even without a purchase order at times when we do not have funds available, and this has sharply reduced the turnaround time because when we receive the funds then we are able to procure immediately. We also have a partnership with them where they have prepositioning of supplies in five hubs within the states. So they are able to produce and transport in advance in the state-level warehouses and this has made it easier to respond in a timely manner and also avoid stock-outs.

LK-O: Interesting. And how important have working groups been to the process of scale-up and integration?

MM: I would say the CMAM technical working group has been instrumental throughout the process, in the sense that it has brought together the technical expertise from the Ministry of Health, the universities, the UN and NGOs into one room. And under the leadership of the technical working group we were able to facilitate a smooth working relationship, while ensuring that the products we produce were both technically sound and also as well as relevant to the Sudanese context.

LK-O: What aspects of programming have been critically informed by the working groups?

MM: In addition to the ongoing technical support and trouble-shooting as we roll out the CMAM expansion in the states, the technical working group has been instrumental in the development of the technical materials, training tools and overseeing the cascade training from national to state level. They are also instrumental in simplifying the national protocol and producing their handbook for health workers.

LK-O: What training messages would you give to a country with a similar context to Sudan embarking on the same journey of CMAM scale-up?

MM: My first message would be to conduct evidence-based planning that involves not just nutritionists but all the health workers: in immunisation, maternal child health and integrated management of childhood illnesses, because this would be key to the implementation and the plan, and also treatment of the medical conditions for the children that are malnourished. My second message would be to put government in the lead and provide technical support as required. And lastly, closely related to that, would be the emphasis on capacity and skills transfer to the government. So this will require coordination and concerted efforts of all agencies working in nutrition and in CMAM scale-up towards transferring capacities to the Ministry of Health rather than running vertical programmes.

LK-O: And so, Mueni, with all the successes that you´ve highlighted, what’s next for Sudan in moving the CMAM agenda forward?

MM: In the last two years we have been able to scale up CMAM five-fold. So our forecast and the next steps is sustaining the quality of what we have and also building systems to make it sustainable. We are working on our monitoring and evaluation systems and also still refining the integration within the primary healthcare context, and that’s part of the basic, essential health package.

LK-O: And of all the key achievements in this journey, what are you most proud of?

MM: I would say as a country we are most proud of integration, that we have been able to move CMAM from being a vertical programme to a programme that is recognised and accepted within the primary healthcare context and one of the essential services for primary healthcare. And secondly, I would say that the scale that we´ve managed to achieve, with a limited resource setting and in protracted emergency – it’s been remarkable.

LK-O: And I think with that, we come to the end of this podcast. Thank you, Mueni, for sharing the incredible journey of scaling up CMAM in Sudan.

MM: Thank you, Lillian, it’s been a pleasure talking to you.

LK-O: We wish you the very best in future initiatives. And, dear listeners, that brings us to the end of this podcast. If you have any comments or queries about this project, or another of a similar theme, you can leave a comment on en-net. A link to the same can be found on the right-hand side of this page. You can also check out the ENN website for a variety of content on CMAM from other country settings. Thank you.

This podcast is recorded in English - an Arabic transcript of this will be published on this page soon.