Integrated Management of Acute Malnutrition

inMogadishu

Training report

Burao, Somaliland

July 2009

Valid International

El Hadji Issakha Diop CTC/CMAM Advisor

()

Séverine Frison (

Table of content

Acknowledgements

Abbreviations

Executive summary

1.Introduction

1.1.Nutritional situation analysis in Mogadishu

1.2.Project Background

1.3.Objective of the mission

2.Assessment of IMAM selected sites

2.1.Criteria used for the selection of the IMAM sites

2.2.Catchment’s area population, distances and expected case load

2.3.Logistics, equipment and supplies

2.4.Staffing pattern

3.IMAM model in Mogadishu

3.1.Community mobilisation

3.2.Supplementary feeding programme

3.3.Outpatient therapeutic programme

Admission criteria

3.4.Stabilisation centre

4.Training

4.1.Participants

4.2.Classroom training

4.3.Field based training: mentoring in OTP and SFP sites

4.4.Organization of the sites

4.5.Pre and post test

5.Monitoring and supervision

6.Conclusion and recommendations

Annexes

Acknowledgements

We would like to offer our sincere thanks to the staff of Oxfam Novib and SAACID for their support during the preparation and throughout the duration of the training. We would like to thank Peter Kamalingin (Humanitarian Programme Officer Oxfam Novib) for his support. Many thanks also to Tony Burns (Director,SAACID-Australia), Bashir (Finance Officer, SAACID-Somalia) and Oumar Sheik (Oxfam Novib’s Logistician in Hergeisa).Thanks also to all the SAACID team we trained; it was a very dynamic and involved group which made us extremely hopeful that this programme will be succesful. Many thanks to Medair for allowing us to spend 5 days at their OTP and SFP sites for the purposes of field training.

We would like to thank in particular Fatuma Abdirahman (Nutrition Program to Humanitarian Programme Officer) who was of great help during the preparation of the mission and training. Finally, we are grateful to Christy Sprinkle (Programme Manager SAACID) for her enthusiasm and participation in the training.

Abbreviations

ACF
CM
CSAS
DRC
ECHO
FSAU
GAM
IASC
IDP
IMAM
IRIN
MAM
MCHN
MSF-H
MUAC
NCHS
OCHA
OTP
P&LW
RUSF
RUTF
SAM
SFP
SQUEAC
TFC
UNDP
UNICEF
W/H
WFP
WHO / Action Contre la Faim
Community Mobilisation
Centric Systematic Area Sampling
Danish Refugee Council
European Commission Humanitarian Aid Office
Food Security Assessment Unit
Global Acute Malnutrition
Interagency Standing Committee
Internally Displaced Person
Integrated Management of Acute Malnutrition
Humanitarian News and Analysis Service of OCHA
Moderate Acute Malnutrition
Mother and Child Health and Nutrition [Clinic]
Médecins Sans Frontières - Holland
Mid Upper Arm Circumference
National Centre for Health Statistics
UN Office for the Coordination of Humanitarian Affairs
Outpatient Therapeutic Programme
Pregnant and Lactating Women
Ready to Use Supplementary Food
Ready to Use Therapeutic Food
Severe Acute Malnutrition
Supplementary Feeding Programme
Semi Quantitative Estimation of Area Coverage
Therapeutic Feeding Centre
United Nations Development Programme
United Nations Children’s Fund
Weight for Height [percentage of the median]
World Food Programme
World Health Organisation

Executive summary

Although reliable data to estimate the population sizeandthe prevalence of acute malnutrition is lacking, it is possible to say that the nutrition situationin Mogadishu is expected to deteriorate, perhaps drastically,mainly due to persistent conflict and population movements. In fact anecdotal reports by SAACID-Somaliaindicate that food scarcity and security are two of the key concernsbeing facing by the population. In addition there are recent report from the Food Security Advisory Unit (FSAU, February 2009) indicating that the nutritional situationis “very critical”.

Currently in Mogadishu, Integrated Management of Acute Malnutrition (IMAM) is being operated by Action Contre la Faim(ACF)in Hodan and Waberi Districts and Médecins Sans Frontières, Espagne(MSF-E) in Karaan District. However,the vital community component is currently lacking from the ongoing IMAM and, as such, there is likely to be poor coverage and a high defaulting rate. In January/February 2009 Valid International,in collaboration with Oxfam Novib and SAACID, conducted a pre set-up assessment for 16 sites in Mogadishu (1 per district)2. Following the plan of action designed arising from this mission; the set-up was planned to begin in 8 sites. However, since both ACF and MSF-E are already operating in some of these districts, further consideration needs to be given before OTP sites are opened here for two reasons: to avoid double registration leading to more RUTF being sold on the market and , in addition,to ensure good relationships with partners.

Technical assistance (classroom and field visit) was providedthroughout the IMAM training conducted by Valid International in Burao, Somaliland in July 2009. The community outreach component was also addressed during the same mission period by a Valid Social & Community Advisor (see Mandalazi E, CM report).The training itself focused on enabling participants not only to be familiar with IMAM in theory but also to understand that it will be essential to adapt IMAM to the context of Mogadishu, where unfortunately we have not been to support the step-by-step implementation.Instead, participants of this training, conducted away from the programme’s target area, will need to transfer what they have learned in Burao following this training to the target area in Mogadishu.

Field training involved five days of on-site work in which participants were trained in screening, measuring, key messages, filling out record cards and medical examination. In addition trainees each took responsibility for at least one OTP admission and also dealt with the issue of liaising to arrange follow ups on SFP cases. They did not all participate in SFP admissions due to the challenges experienced due to a degree of poor organisation at the Medair sites.

For the initial roll out of this programme, we agreed to limit the admission criterion to MUAC < 11.0cm (which targets children at the highest risk of mortality) to minimize the risk of overwhelming the programme with large numbers of beneficiaries. Additionally it is not appropriate to increase to < 11.5 cm when an adequate and consistent RUTF supply is not readily available.

Discussions throughout the training following the field visits (Medair’s sites) highlighted some of the ways in which the organisation of IMAM activities could be improved when being transferred to the Mogadishu context. For instance there existed some confusion about the process of admitting a child to OTP. This was principally due to some weaknesses in the organisation of the reception process: follow up cases and new admissions were not separated in different lines;no priority was given to very severe sick cases which were consequently being referred later than necessary;and upon arrival to the OTP site carers did notreceive sufficient orientation from Medair’s staff and were consequently confused.

Clearly the fact that the training for the Mogadishu IMAM programme has been conducted remotelyis likely to create some challenges. However, after comparing pre and post test results and the significant improvements made by the participants during the training; and taking into consideration suggested solutions addressingthe weaknesses in the Burao programme;there is goo evidence that trainees will be able to transfer reasonably the field experience gained in Burao in the context of Mogadishu.

Key issues & recommendations

Participants in this training are now equipped with the necessary knowledge to return to Mogadishu and begin the roll out of the community based IMAM programme on which they have been trained. They will need to follow the recommendations laid out in detail in this report and made during their training to establish a successful programme in the first 8 sites to be targeted. The fact that participants have received training in a different location and not on the job in Mogadishu will make this process challenging but feasible if recommendations are followed thoroughly.
Essential to IMAM is the provision of RUTF. Given this, agreements with UNICEF and WFPconcerning supplies must be signed to allow this program to go ahead.Furthermore, logistics for transport and distribution of RUTF to the OTP sites should be carefully planned to avoid shortages.
ACF is running OTP sites in Hodan and Waberi, thus SAACID should only open SFP sites in these areas. If, after few months, evidence shows that opening other OTP sites in these districts would have a positive impact then this should be reconsidered at this stage.The opening of OTP in Karaan site should be discussed with MSF and will depend on their activities.
The MUAC criteria could be widened to < 11.5 cm as soon as the caseload is stabilized and a reliable plan for the provision of resources is in place. However, introducing W/H z score criteria may not be relevant in this context. Studies have shown that W/H z-score may not be the best criterion to identify SAM due to the specific body shape (anthropometric differences) of Somali populations,partly because they are mainly agro-pastoralists and pastoralists. Additionally the introduction of W/H z-score for Somali populations will considerably increase the caseload with huge human resources implications.
Organisation of the sites is crucial. During the set up the important points discussed throughout the training should be thoroughly taken into consideration (provision of shade in the waiting area whenever possible; crowd control while beneficiaries are waiting to be seen; availability of drinking water; organisation of queues according to need (newattendants returnees); prioritisation of severe cases).

1.Introduction

The combined effects of persistent conflict, civilian displacement, the failure of the main “gu”rains in 2009across 70 percent of the country, high staple food prices, and the worsening drought in key pastoral areas in central and northern regions of the country have worsened the food security situation in Somalia in recent months. Over 3.2 million people, more than 40 percent of the country’s population, require emergency humanitarian assistance and livelihood support (FEWSNET, June 2009).

Already, roughly 60% of the population in the central regions (Galgadud and Mudug) isclassified as either in Acute Food and Livelihood Crisis or in a Humanitarian Emergency situation due to drought, hyperinflation and conflict which have affected rural, urban and Internally Displaced Person (IDP) populations. Recent nutrition surveys (May ’09) confirm that the nutrition situation currently remains above the emergency threshold for all livelihoods and is classified as Critical, with Global Acute Malnutrition (GAM) rates of between 15.3 - 18.0% and Severe Acute Malnutrition (SAM) rates of between 2.6 - 5.5% (FSAU, February 2009).

In this context, the implementation of a programme using an Integrated Management of Acute Malnutrition (IMAM) approach (elsewhere known as Community based Therapeutic Care (CTC) or Community management of Acute Malnutrition (CMAM)) is both a timely intervention and coherent. With a view, therefore, to supporting the roll out of CMAM, Valid International conducted a pre set-up assessment for 16 sites in Mogadishu(1 per district) in collaboration with Oxfam Novib and SAACID in April 2009. According to the plan of action designed during this set up, the set-up will first start in 8 sites.Consequently, technical assistancewas given during the IMAM training for the set-up of the 8 initial sites during sessions conducted in Burao, Somaliland in July 2009. Although ideally this training would have taken place in the target area itself, security issues prevented this from happening and the training sessions were therefore conducted remotely.

1.1.Nutritional situation analysis in Mogadishu

Reports of nutritional data from urban centers in Somalia indicate a GAM prevalence of 20.1% and a Severe Acute Malnutrition SAM prevalence of 5.1% as measured by World Health Organisation (WHO) growth standards. There is no data available specifically for Mogadishu.

Estimations of prevalence were made by extrapolating data from other areas of Somalia with particular reference to urban areas which showed close similarities with the target area. Anecdotal reports gathered by the Somalia Nutrition Cluster suggest that the situation in Mogadishu is worse than in otherareas and this was also taken into account.

Nutrition services in Mogadishu are currently provided by Action Contre la Faim (ACF) and Médecins Sans Frontières Espagne (MSF-E) in the form of Outpatient Therapeutic Care sites (OTPs) in seven districts and oneTherapeutic Feeding Centre (TFC). No Supplementary Feeding Programme (SFP) is currently available. A wet feeding programme is currently operated by SAACID, a Somali National Non-Governmental Organisation (NGO) in 16 districts in Mogadishu. The wet feeding programme has been earmarked for closure in October 2009.

Table 1: Estimation of SAM in 16 districts of Mogadishu by MUAC & WHO weight for height z-score(Binns P, IMAM pre-set up report, April 2007)

Table 2: Estimation of Moderate Acute Malnutrition in 16 Districts in Mogadishu by MUAC & WHO weight for height z-scores(Binns P, IMAMpre-set up report, April 2007)

1.2.Project Background

Oxfam Novib contracted Valid International in order to provide technical assistance in the setting-up of 16 IMAM sites in 16 districts in Mogadishu. The implementation of the IMAM in Mogadishuwill be managed by SAACID in collaboration with Oxfam Novib. A Valid consultant came to Nairobiin January/February 2009 to assist on the pre set up assessment.

The present mission lasted from the 14th July to the 1stAugust. The first few days of the visit were spent in Nairobidiscussing issues regarding the context in which the programme will be implemented agreeing on the timetable and training materials. The trainingitself was then conducted in Burao, Somaliland from the 20th to the 30th of July. Two Valid consultants lead the technical/nutrition components of the IMAM training while an additional Valid advisor conducted the community mobilization section of the training. The practical training was carried out using Medair’sexisting sites in Burao.

After the training, conducted off-site, the actual set-up will start in Mogadishu in August.

1.3.Objective of the mission

This mission aimed to provideOxfam Novib with the necessary technical support to ensure an effective training for SAACID staff along with the production of guidelines to form the basis for the set upin the 8 IMAM sites earmarked for the initial roll out in Mogadishu.

More specifically, this mission focused on the following activities:

Classroom training on the key aspects of IMAM implementation (5 days)
Field based training on the practical implementation of IMAM (5 days)
Technical support for the organization of the set up

2.Assessment of IMAM selected sites

Sixteen (16)sites(one per district) were selected for the implemention of IMAM programmes in Mogadishu. This was based on the planthat 8 Mother and Child Health and Nutrition (MCHN) clinics will be rehabilitated initially and that the remaining 8 will be ready for operations in the near future. Because of the current unstable/unpredictable situation in Mogadishu, the training was held in Somaliland and the advisors consequently didn’t visit the sites but some pictures were available and, judging by these, the rehabilitated structures seemed to offer the possibility of well organized sites.

2.1.Criteria used for the selection of the IMAM sites

MCHN clinics have been targeted to hold OTP sites. Part of the reason for this decision was that it was decided to rehabilitate government structures which provide a platform for sustainable health interventions. Moreover, the presence of a permanent structure fosters a sense of community ownership and provides somestoragecapacity for routine equipment and ready to use food rations.

The sites were chosen according to the following criteria:

-Security

-IDP camp concentration

-Government site/structure

-Community agreement

-Site located at least 1km away from existing partners’ sites.

Regarding the last criterion, we would usually advise having at least 2 to 3 hours walk from another partner’s site. The 16 districts cover a total area of only 8km by 13km and the security situation makes it very difficult for the population to cover even the shortest distance. At this point it is unclear how far peopleare either able or willing to walk.One challenge is that the district borders are not well known and the GPS points collected in the field did not always match the available maps so it was difficult to know exactly how far the sites were from each other. Although the context is very complex, it seems clear that a 1km distance between sites does not seem farenough.

ACF is presentin 2 districts, Hodan (OTP,SC) and Waberi (OTP) and MSF is present in Karaan (OTP). It was therefore agreed thatthe sites being opened by Oxfam Novib/SAACID in Hodan and Waberi would only run SFP to avoid double registration and the risk of releasing more RUTF onto the market. This will also ensure a good relationship with ACF.This situation will require thorough collaboration between partner organisations: ACF’sdischarged OTP beneficiaries will be followed up in SAACID’s SFPs and most of the malnourished children with complications from the area of intervention will be sent to ACF’s SCs (see paragraph 3.4).

Regarding the presence of MSF in Karaan, at the time of this visit, it was notcertain whether the organisation were still intervening in that district and a decision will be taken after further discussions with MSF. However, if MSF is found to still be running an operational OTP in this district, we strongly recommend that SAACID do not open an additional OTP in Karaan.

2.2.Catchment area population, distances and expected case load

In the context of this programme, where insecurity presents a real barrier, it is almost impossible to accurately estimate the catchment area and the notion of distance is itself elusive. As mentioned earlier, we do not have a clear picture regarding how long people are willing to walk. As far as the expected caseload is concerned, there is no survey data or reliable population estimate for Mogadishu. Several reports make estimates of population size although, even in recent months, there have been displacements from Mogadishu but also population movements into Mogadishu and between districts.