Managing acute malnutrition with scarce resources in Pakistan

Dr. Mubina Agboatwalla, HOPE Pakistan

Dr. Mubina Agboatwalla is a pediatrician and chairperson of HOPE. She has worked extensively on maternal and child health programmes including community and hospital-based programmes to treat children with SAM.

Introduction

Nutrition in Pakistan is a critical challenge with 44% of children under 5 years of age suffering from stunting and 18% with moderate or acute wasting¹. Following the 2010 and 2011 floods, levels of global acute malnutrition (GAM) increased above the WHO designated emergency threshold of 15%. To address this rise in acute malnutrition, United Nations agencies supported Government, International Non-governmental Organizations (INGOs) and national NGOs to develop community-based management of acute malnutrition (CMAM) projects. After a year, the short-term emergency funding for CMAM was finished and activities to improve the nutritional situation ceased. This article outlines the experience of HOPE, a national NGO that received support to implement emergency CMAM activities in three districts (Thatta, Dadu and Shahdadkot) and how they addressed the continued problem of high levels of acute malnutrition after the emergency funding ended.

By April 2012, external funding for HOPE’s CMAM activities had finished. However, there were large areas, including the towns of Jhimpir, Sakro and Sujawal that continued to have a worryingly high GAM (21.1% based on an ACF/ UNICEF nutrition survey). HOPE decided to try to continue a reduced level of CMAM services with their existing resources in Thatta District, from April 2012 to March 2013.

Project implementation

HOPE’s reduced CMAM service included 1) building capacity of the health centre staff in screening for acute malnutrition and providing nutritional counseling, 2) community mobilisation and 3) providing locally made foods to those with acute malnutrition as described below.

Capacity building. HOPE’s core staff² trained ministry staff working in Maternal and Child Health Centres (MCH) and Basic Health Units (BHUs), in IYCF counseling and screening for acute malnutrition. HOPE staffs at peripheral health centres, that were not initially part of the HOPE nutrition activities, were also trained. Training included breast-feeding promotion and appropriate complimentary feeding.

Community mobilisation. HOPE continued to support MNCH services in a network of peripheral health centres and community mobilisation for nutrition was integrated into these existing activities. Additionally, HOPE outreach teams, travelling to villages, integrated nutrition screening and counseling in these community visits and identified acutely malnourished children and transported them (with their mothers) to the appropriate health facility.

Outpatient Therapeutic Programme (OTP). HOPE provided limited OTP services at the level of the health facility. Children that were identified as having MAM (MUAC 11.5-12.5 cm) and SAM children without complications (MUAC <11.5 cm) received a meal and medical treatment when they presented at the health facility, while SAM children with complications were admitted to the Stabilisation Centre for inpatient care.

Ready-to-use Therapeutic Food (RUTF) was unavailable due to high costs so instead, low cost, locally available nutritious foods, such as Khirchri and Sooji (semi solid foods comprised of lentils, rice and wheat with some vegetable oil), were prepared daily. These foods were cooked by HOPE staff and fed to the children by their mothers or carers. Mothers were then instructed to prepare these foods at home daily (with the food they had in the household- no foods were given by HOPE) and return every two weeks for a follow up visit for the child.

Necessary medications for minor ailments such as cough, cold, diarrhoea, and vomiting were provided.

HOPE transported children back to their homes. Mothers were instructed to bring their children back in two weeks for a check up. As HOPE teams visited the villages every week they picked most of the children/mothers that needed to return to the programme.

Follow up visits included assessment of MUAC and weight, review of dietary history and provision of nutritional counseling. In cases of minor illnesses, medication was provided. For children who were not gaining weight, health facility staff counseled mothers and suggested feeding techniques.

SAM children (MUAC <11.5cm) with complications were taken to an inpatient hospital where their medical complications were treated. Nutritional treatment was based on the provision of khitchri, sooji, and sagodana (a rice based porridge). At the hospital mothers were given demonstrations on food preparations as well counseling on breast-feeding and IYCF practices. Patients were discharged based on > 15% weight gain and taken back to the villages by the CHWs in HOPE’s transport. Patients were encouraged to go to the nearest health facility (fixed OTP) for follow up on a monthly basis.

Programme performance

This reduced CMAM service project continued for almost a year, from April 2012 to March 2013. During this time a total of 9600 children with acute malnutrition were identified in the peripheral health facilities, see table below. Of the MAM children identified, 5616 (90%) were treated and recovered, though the default rate was high, 9.5% (593 children). Amongst the SAM children without complications, 1253 children (87%) recovered while 151 children (12%) defaulted.

During this period, 231 patients (13.8% of all SAM children) were admitted to the Stabilisation Centre. Of these, 137 (59.2%) recovered, while 32 patients (14%) defaulted (as they were unwilling to stay as inpatients). No change in weight was seen in 37 patients (16%) while 18 patients (7.8%) showed a loss in weight, .

An average duration of 5.4 months was needed to recover from MAM. Children with uncomplicated SAM stayed in the programme for an average of 6 months. Records show that 86% of children were followed up in their homes by the CHWs. It is recognised that the results for recovery of SAM children with complications do not meet the International Sphere Standards. This is though to be due to the limited nutritional support provided- there was no therapeutic milk (F-75 or F-100) or RUTF in the SC.

Challenges

The programme had many challenges.

• There was no external funding, HOPE ran the programme with their existing infrastructure, staff, and medical supplies.
• Personnel specifically dedicated to nutrition were few.
• RUTFs for the OTP or for the SC were not available and there was no F75 or F100 for inpatient care.
• Mothers were unwilling to stay in the hospital for a week or ten days because they had other children had home.

Costs

HOPE’s overall health programme cost was $68,000 for the year³. Nearly 35% of the budget went in staff remuneration, medicines 20%, logistics was 30% and nearly 15% on food. Based on HOPE’s experience, this amounts to about 40% of the costs of a similar-sized donor funded CMAM programme.

Conclusion

Due to limited resources, HOPE in consultation with their CMAM trained staff (pediatricians and nutritionists) designed and implemented a programme to treat acutely malnourished children using local ingredients, complemented by appropriate medical support for a year. While programme performance met international Sphere standards in terms of outpatient recovery, default was high and length of stay was much longer than recommended. In-patient SAM cases did not recover as per Sphere standards. However, community mobilisation continued as HOPE tried to foster behavior change to support positive health and nutrition practices in the absence of anything else.

While not an ideal situation, it is a situation that is often faced at the end of an emergency programme. Based on this experience, HOPE would urge donors to review their policy of short-term emergency funding to support nutrition programmes and advocate for longer term/flexible funding to enable programmes to continue beyond the emergency phase, particularly in high-burden, resource-poor, emergency prone contexts. In addition, HOPE supports the government to take ownership of nutrition services and encourages joint strategic planning to ensure sustainability.

¹The State of the World Children UNICEF 2013

²Chief Nutrition Coordinator, Nutrition Officer, Social Welfare Office and Communication Officer

³This includes the CMAM activities as well as the wider health activities. As the CMAM activities were integrated into the wider health activities it is not possible to identify the cost of just the CMAM activities.