Group 5 Nathan Chimbatata Liao Sha Zhao Yuxin Wang Ying Yin Xiaoxu

1. Proposal for Community Based Interventions for severe acute malnutrition in Oromiya Region in Ethiopia Group 5 Nathan Chimbatata Liao Sha Zhao Yuxin Wang Ying Yin Xiaoxu

2. Proposal for Community Based Interventions for severe acute malnutrition in Oromiya Region in Ethiopia • Background • Preparation • Project implementation

3. Proposal for Community Based Interventions for severe acute malnutrition in Oromiya Region in Ethiopia

4. Background • Severe acute malnutrition (SAM) is defined by WHO as a child having “very low weight for height…by visible severe wasting, or by the presence of nutritional edema,” which is a form of body swelling caused by severe protein deficiency in the body. WHO. Guideline: Updates on the management of severe acute malnutrition in infants and children . Geneva: World Health Organization; 2013.

5. Background • Malnutrition is a major global health problem • About 10 million children are estimated to be malnourished globally Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt M, Saboya M, Walsh A: Key issues in the success of community-based management of severe malnutrition. Food Nutr Bull 2006, 27:S49–S82.

6. Background.......

7. Background..... • Globally there are about 2.2 million deaths due to malnutrition annually • Greatest number of children suffer from stunting • Africa has the highest prevalence of malnutrition Key issues in the success of community-based management of severe malnutrition.Steve Collins, Kate Sadler The sustainability of Community-based Therapeutic Care(CTC) in non-acute emergency contexts .Valerie Gatchell, Vivienne Forsythe and Paul-Rees Thomas

8. Background.... • UNICEF estimates that 126,000 children are in need of urgent therapeutic care for severe malnutrition in Ethiopia • In Oromiya Region, in particular, 34.4% of all children under-five are underweight

9. Background....... • Prevalence of malnutrition in Ethiopia is at an alarming level • Ethiopia is ranked the sixth worst country in terms of nutritional outcomes worldwide. • Literature shows that 51 % of children under five years of age are stunted and chronically malnourished. • About 53 % of all under five deaths in Ethiopia are due to malnutrition Collins S, Sadler K, Dent N, Khara T, Guerrero S, Myatt M, Saboya M, Walsh A: Key issues in the success of community-based management of severe malnutrition. Food Nutr Bull 2006, 27:S49–S82.

10. Background...... • Prevention of Malnutrition remains a priority in many settings. • Ethiopia is implementing a decentralised service delivery platform/health extension programme to promote universal PHC access • Health extension workers are used in the programme and this has improved health and nutrition care practices

11. Background..... • Facility based and community based (RUTF) are the treatment modalities currently used to manage severe acute malnutrition • Challenges for facility-based treatment are: # The shortage of skilled health workers and health infrastructure # Infections transmission # Poor accessibility (physical and economic) to these facilities # Travel costs incurred by the mother (or caregiver) getting to, and staying at, the health center with her child. Key issues in the success of community-based management of severe malnutrition.Steve Collins, Kate Sadler The sustainability of Community-based Therapeutic Care(CTC) in non-acute emergency contexts .Valerie Gatchell, Vivienne Forsythe and Paul-Rees Thomas

12. Background..... • Studies show that community based treatment modality of acute malnutrition has more advantages over the other strategies Key issues in the success of community-based management of severe malnutrition.Steve Collins, Kate Sadler The sustainability of Community-based Therapeutic Care(CTC) in non-acute emergency contexts .Valerie Gatchell, Vivienne Forsythe and Paul-Rees Thomas

13. Case

14. Community Based Interventions (CBI) for severe acute malnutrition management

15. Target population Case identification Criteria for diagnosis Outline Community mobilization Mornitoring Treatment Referral OTP Follow-up Programme appropriateness Evaluation Programme effectiveness Programme coverage

16. What we need to ensure the implementation of the interventions?

18. Human resource Health service package for SAM Medical staff Outreach workers Volunteers Management team Community commissioners Government Ministry of Health Private companies The foundation

19. Financial resources The Phil and Linda Bates Foundation • Production of RUTF • Advertisement • Health system strengthening • Subsidy for workers • Referral …….

20. Material resources RUTF Private companies Produced locally patent  Food and Drug Administration Government Local food producers import

21. Other material resources • Posters and brochures for this programme • Suits for the outreach workers and volunteers • Anthropometric tools for each community • Transport

22. Target population Case identification Criteria for diagnosis Outline Community mobilization Mornitoring Treatment Referral OTP Follow-up Programme appropriateness Evaluation Programme effectiveness Programme coverage

23. Case Identification(Screening) • Target population SAM Children aged between 6 - 59 months • Diagnostic method Mid-upper-arm-circumference(MUAC),bipedal edema Tools: color banded strap A review of methods to detect cases of severely malnourished children in the community for their admission into communitybased therapeutic care programs.Mark Myatt, Tanya Khara and Steve Collins

24. Criteria: MUAC < 115 mm OR the presence of bipedal edema Assessment of outpatient therapeutic programme for severe acute malnutrition in three regions of ethiopia.T.Belachew and H.Nekatibeb,East African Medical Journal,december 2007,577-588

25. Case Identification（Mobilization） medical staff and volunteers parents education self-referrals outreach wokers and volunteers household seeking who active case finding health education health care workers and mother mother to mother how

26. Self-referrals How to achieve self-referrals? 1.Give training and health education about SAM and treatment to parents 2.Distributed brochures and pictures to parents Participants: Medical staffs, volunteers and parents Location 1. Health posts, schools, and during the screening 2. Distribute brochures to the streets and every household

27. Active case finding How to find cases actively and quickly？ 1.Point-to-point to look for cases 2.Give children a simple measurement 3.Health education to parents Participants: Volunteers and outreach workers Location Households in their own community

28. Mother to mother How to promote other mothers? 1.Medical staffs recommend treated children’s mothers to promote other mothers 2.Treated mother share experience and benefits of treatment with other mothers Participants: Medical staffs, volunteers , outreach workers and mothers Location patients’ villages and poor shelters

29. Target population Case identification Criteria for diagnosis Outline Community mobilization Mornitoring Treatment Referral OTP Follow-up Programme appropriateness Evaluation Programme effectiveness Programme coverage

30. Treatment In a health post, through the examination by health-care workers with appropriate training Cases found through identification Cases classification • Have any of the following conditions: • With complications • Severe oedema (+++) • Poor appetite • With one or more IMCI danger signs • Meet all the following conditions: • Without medical complications • Pass the appetite test • Clinically well Collaboration with other programmes Referral to inpatient treatment Outpatient therapeutic programme with RUTF Follow-up Discharge from the programme MUAC ≥125 mm and have had no oedema for at least 2 weeks Follow-up after discharge

31. Outpatient Therapeutic Programme (OTP) • Admission: • basic condition evaluation • Provision of RUTF and routine medicine • Education of the carer • Fill the patient monitoring cards Continuous and sustainable availability of RUTF and medicine supplies A health post Child for OTP High level health-care facilities Follow-up between two clinical visits weekly or every-two-week visit for check-ups and more supplies of RUTF

32. Key education messages

33. Follow-up during treatment Assessment of medical condition and care environment Outreach workers or volunteers to arrange Non responders a skilled health-care worker in a nearby clinic or in the community Child for OTP • Children during the first two weeks after admission into the OTP • Children who are losing weight or whose medical condition is deteriorating • Children whose carers have refused to inpatient treatment, though they were suggested to Responsers

34. Target population Case identification Criteria for diagnosis Outline Community mobilization Mornitoring Treatment Referral OTP Follow-up Programme appropriateness Evaluation Programme effectiveness Programme coverage

35. Monitoring and evaluation Aim ----- provide useful information that can form the basis for decisions to adjust programme design to better tailor implementation to the context specific factors.

36. Monitoring and Evaluation Programme Evaluation Process Monitoring Quality of RUTF Availability of RUTF Coverage Treatment Information Appropriateness Effectiveness

37. Process Monitoring Quality of RUTF The monitoring team will cooperate with the local health and food supervision department, make quality standards of RUTF, randomly sample and monitor the quality. Availability of RUTF The monitoring team will communicate with the health centers every week to ensure that there are sufficient RUTF for SAM children.

38. Process Monitoring Treatment Information In a CBI programme, children will move between the components (SC, OTP, SFP) as their condition improves or deteriorates. They may also move between the decentralised OTP distribution sites. It is therefore important to be able to track children between the programme components and distribution sites.

39. Process Monitoring Treatment Information Firstly, this project will establish a patient monitoring cards for every children. Health workers should examine the clinical cards at monthly meetings to identify children with static weight, weight loss or those not recovered after thee months. Secondly, this project will establish a numbering systemto ensure that each patient receives a unique registration number when he/she is first admitted into the programme. At last, on admission to the CBI all children should receive an identity bracelet with their patient number written in indelible ink. Based on this, it will be easy to track and exchange treatment information on individual children

41. Programme Evaluation Appropriateness The target populations and client’s perception of the programme should be monitored regularly and programme design and implementation adjusted accordingly. Two kinds of community-level monitoring can be used: focus group discussions and key informant interviews. To shed light on: Coverage, Access, Recovery, Service delivery, Cultural appropriateness, Lessons learned.

42. Appropriateness • Coverage- whether there are individuals or groups in the community who could be in the programme but are not, the reasons why and how it could be changed. • Access-whether there are barriers preventing people from accessing the programme and what might be done about them. • Recovery- whether carers perceive changes in children treated in the programme and whether anything can be done to strengthen the recovery process. • Service delivery- whether beneficiaries are happy with the CBI services they receive and the means of delivery, and whether they could be improved. • Cultural appropriateness- whether the programme is culturally sensitive or doing anything inappropriate. • Lessons learned- what should be done differently and what should be replicated in future programmes.

43. Programme Evaluation Effectiveness Routine treatment monitoring data will be used to evaluate the programme effectiveness. Measurement indicators: • Total number of children admitted in the programme • Cure rate • Non-recovery rate • Default rate • Average weight gain and length of stay • Relapses (readmissions after discharge) rate • Case fatality rate • Additional information, such as Cause of death, Reasons for default, etc..

44. Programme Evaluation Programme coverage We calculate two estimates of coverage from the data: the point coverage estimate and the period coverage estimate. Period coverage calculation Number of respondents attending the programme Number of cases not attending OTP + Number of respondents attending OTP Point coverage calculation Number of children in OTP with MUAC still < 115mm Total number of children with MUAC < 115mm The period coverage estimate shows how well the programme has been doing in the recent past whilst the point coverage estimate tells you how well the programme is doing at the time of the survey. X 100 X 100

45. Budget

46. How to achieve the sustainability of CBI ? • Political will • Community participation • Parents education • Women empowerment • Seeking external support • ……..

47. THANKS!