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Field Article Figure 4: Quarterly distribution of RUTF to TFP from 2008- mid 2011, in metric tons. (Source: UNICEF) metric tons 1800 1600 1400 1200 1000 800 600 400 200 0 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 2008 2009 2010 2011 Quarter 1 Quarter 2 Quarter 3 Quarter 4 Figure 5: Source and amount (MT) of RUTF for TFP in Ethiopia (2008-2010) metric tons 80% 70% 60% 50% 40% 30% 20% 10% 0% 2008 2009 2010 Local RUTF (MT) Offshore RUTF (MT) Local% Figure 6: Delivery flow chart of RUTF for TFP/CMAM /TFP in Ethiopia UNICEF bonded warehouse RHB Warehouse ZHD Warehouse WoHO Warehouse Health Facilities (health posts, health centres and hospitals NGO imported RUTF NGO warehouse/ transport assistance RHB: Regional Health Bureau, ZHD: Zonal Health Department, WoHO: Woreda Health Office procurer and distributor of RUTF for most organisations to facilitate the importation processes. UNICEF procured and distributed a total of 11,472 metric tons of RUTF between January 2008 and September 2011 15 . Small scale local production of RUTF was piloted from 2004/5 by Concern and Valid Nutrition, using a small scale local producer and locally produced raw materials, except for the Dried Skimmed Milk (DSM) and mineral/vitamin mix which had to be imported. However, these pilots were unsuccessful as it proved difficult to ensure the quality of the product using small-scale producers. Success factors for local production In early 2007, larger-scale production was established following an initial investment from a US-based philanthropist (donating over 300,000 USD, to be repaid back to UNICEF through in-kind contribution by the local manufacturer once the production was up and running). Through the use of Nutriset’s franchise network (plumpyfield), a local company HILINA received the transfer of technology and skills from Nutriset that enabled local production of RUTF, of a quality that passed the expected standards of both Médecins Sans Frontières (MSF) and UNICEF. While the local producer was gradually scaling-up production, it was not enough to meet the needs of the expanded TFP during nutrition stress years (such as 2008). A large amount of RUTF still needed to be imported, although the proportion supplied by local production is encouraging. Between January 2008 and June 2011, approximately 39.3 million USD had been invested in the procurement of RUTF. This cost does not include the freight and distribution expenses. RUTF remains the most expensive component of the TFP; a cost analysis is currently being undertaken (together with the CMAM evaluation), which is expected to provide more information of the costing associated with the TFP in Ethiopia. Challenges with local production The local producer continues to procure all peanuts and oil from the local market, which positively contributes to the local economy and livelihoods of farmers. However, sometimes the quality of the RUTF has been compromised, with unacceptably high levels of aflatoxin contamination from poor handling and storage of peanuts. The local producer has taken several steps to ensure that levels of aflatoxin stay within acceptable recommendations. UNICEF has also instituted a system of testing each and every batch of RUTF for contamination. This has resulted in a two week lead time after completion of the production until aflatoxin test results are received from an independent laboratory in the UK. These efforts by the producer to improve the quality of the locally sourced raw materials have been showing results. Over the past 12 months, only one batch of RUTF has failed to comply with acceptable levels of aflatoxin in the final product. Distribution systems and structures for RUTF The in-country distribution of RUTF uses various routes to reach the health facilities. The bulky nature of the RUTF in both volume and weight that is required to ‘cure’ each severely malnourished child is considerably larger than the drug supplies usually needed for routine treatment of other lifethreatening conditions. As a result, pre-positioning several months worth of RUTF supplies has often been beyond the warehousing capacity of the health system. Additionally, the seasonal and sometimes drought-related rapid increases in admissions to the TFP, intensifies the pressure on the health service logistic system for ensuring timely deliveries of large volumes of RUTF. The FMoH uses the Pharmaceutical Fund and Supplies Agency (PFSA) logistic system for most medicines and supplies used within the health system. As described, RUTF is a bulky and heavy product, which has meant that it is beyond the current capacity of the PFSA system to handle distribution and storage. As a result, UNICEF and partners have been required to deliver the RUTF through the RHBs and ZHDs, indicated in Figure 6. UNICEF has distributed an average of approximately 2,800 metric tons of RUTF per year since 2008 to health facilities across Ethiopia. 16 Mostly it is delivered directly to the RHB warehouses although in times of emergency, UNICEF sometimes delivers to the zonal level or direct to woredas (dotted lines in Figure 6), to minimise the risk of damaging stock-outs. Re-supplying of the RUTF is based on official requests from the RHBs using the TFP reporting system, with re-supply levels based on the monthly reported caseloads. Major successes of the RUTF supply and distribution system The system has enabled rapid expansion of CMAM capacity to over 7,000 health posts. It is flexible and able to respond to emergency needs. Performance is strongly related to the technical persons implementing the programme, as they take the lead in requisitioning and distributing the RUTF. NGOs can access the RUTF from ZHDs or RHBs and support its delivery to health post level. UNICEF acting as the central procurement channel has considerably eased the burden on partners for importation and customs clearance Major challenges of the RUTF supply and distribution system The limited warehousing capacity of the regional and zonal health offices can sometimes affect the quantity of RUTF that can be delivered and stored safely. Late requests and inadequate forecasting of projected consumption compromise programming. Some misuse/ leakage of RUTF by clients has been reported (selling and sharing), using for moderately malnourished children and at times, adults. Some duplication can occur between partners, e.g. UNICEF, the Food By Prescription programme (FBP) and GOAL, creating difficulties for some facilities to track records of clients versus commodities. Coordination meetings have been established to assist with reducing duplication. CMAM transition in emergencies and development Management of SAM has traditionally been considered an emergency response, often implemented by NGOs. In the context of chronic food insecurity and seasonal hunger, programmes open based on emergency thresholds of SAM and GAM rates and then close as the situation improves, only to reopen in the next hunger season. The implications of this traditional emergency focus of CMAM include irregular and short-lived funding, inadequate resources for capacity building of the health system and delays in the emergency response. These delays have mostly been linked with the time needed to identify the affected woredas and conduct nutrition surveys, in order to justify the poor situation and hence access emergency funding from the various donors. This paradigm has resulted in additional costs of repeatedly phasing in and phasing out of programmes for the management of acute malnutrition in chronically affected woredas. The timeliness and adequacy of RUTF provision can be hostage to the declaration of emergency situations and resulting donor pledges. Hence there is a need for improved funding mech- 16 This is equivalent to over 217,000 cartons or over 32.5 million sachets per year 19
Field Article anisms, especially for on-going situations that may not be characterised as a humanitarian emergency. The extensive CMAM rollout in Ethiopia has enabled unusual access to longitudinal information on admissions of severely malnourished children to public health facilities over the past few years. Instead of waiting for nutrition surveys to be planned, undertaken and compiled, humanitarian actors can easily identify the progress or deterioration of a given nutrition situation, through surveillance of the monthly admissions to CMAM. The massive increase in coverage of CMAM services across the country has allowed access to first-hand information from wide areas. These constitute a considerable proportion of the country, especially if compared to the handful of woredas that were being reached through nutrition surveys. However, it must be noted that routine programming data, reports and anthropometric measurements will likely be of lower quality than standard nutrition survey data. Therefore, while the use of nutrition survey data remains relevant in specific situations, it is not necessarily the only tool available for decision making for action. In addition to nutrition surveys, hot-spot classification has been introduced in Ethiopia. The ‘hot-spot’ priority list provides the basis for the Relief Requirement Plan released by the DRMFSS in collaboration with all sector ministries and the UN. The use of the ‘hot-spot’ classification system has been a step forward from the sole reliance on the use of GAM and MAM thresholds, to decide when to start and stop interventions. Ways forward Integrated management of acute malnutrition at scale CMAM has integrated very well into the primary health care system of Ethiopia and is undoubtedly saving the lives of many vulnerable children. There has been demonstrated success when linking CMAM with the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) and ICCM initiatives. Encouragingly, many opportunities for the capacity building of frontline health workers continue to present themselves in Ethiopia. What is less clear is how the level of funding for integrated treatment for SAM will be sustained over the longer-term, since the supplies are expensive. There is an urgent need to strategise the possibilities of funding sources beyond humanitarian mechanisms. This could not only provide funding sources for ongoing needs, but would enable more equity of services, if severely malnourished children in ‘non-emergency’ woredas were able to have the same access to treatment as those living in identified hot-spot woredas. The cost analysis of the UNICEF/MOH CMAM evaluation (currently underway) is expected to provide useful insights on the cost effectiveness of investing in the management of severe acute malnutrition. The implementation of TFP/CMAM at scale calls for concerted efforts and investment in quality monitoring and improvement. CMAM quality improvement is contingent on many of the health system pillars 17 including service delivery, information systems, the health workforce, medical products, health financing and leadership. As a result, efforts to improve Tibebu Lemma/for UNICEF Ethiopia. Copyright UNICEF Ethiopia CMAM quality should be viewed from the health system’s perspective, and therefore contribute to overall improvements in the system. In addition, there is a need for improved linkages between TFP/CMAM, CBN and other direct nutrition interventions currently being implemented in Ethiopia to ensure that the maximum gains are being leveraged from the considerable investments being made by both government and partners. Operational research priorities Under the NNP, operational research is identified as crucial for developing our understanding of effective preventive and curative nutrition interventions. A number of research possibilities have been identified by FMOH/ EHNRI and partners, with priority operational research areas as follows: • Cost effectiveness study of TFP/CMAM in Ethiopia • Determinants of successful and lasting management of SAM through community based nutrition activities • Assessment of quality of nutrition data; flow, data utilisation, and validation • Study on the effectiveness, feasibility, acceptability and compliance of micronutrient powders (e.g. Sprinkles) to improve complementary feeding practices and reduce micronutrient deficiencies in children under 2 years of age. Conclusion The large numbers of severely malnourished children successfully treated over the last few years testifies to Ethiopia’s success in fully integrating the out-patient management of SAM into all levels of the routine health system. Importantly, across this vast land, services have Health Extension Worker, Habtam Byabel, attends to Seta Temesgen and her baby, Aynadis, inside the Geter Meda Health Post been decentralised to primary health care level to improve access and coverage. Based on our successful experience of scaling up TFP/CMAM in Ethiopia, countries that are considering starting TFP/CMAM could try to scale-up services to national level. Such actions save lives, both during emergency situations and as part of routine nutrition interventions. It is clear that the implementation of TFP/CMAM at-scale not only puts pressure on the health system, but also stimulates it to respond to the additional demands. This could be due to the fact that the programme is so visibly successful; it creates demand from within communities because of the rapid improvement in their sick malnourished children; when able to access appropriate treatment, the transition of their children - from listless and lethargic, to playful and energetic – can provide a powerful motivating force for the community. Ethiopia has learned that to successfully rollout TFP/CMAM, it is vital to ensure government commitment and to develop good coordination between government and development partners (especially for resource allocation). It is also crucial to create a wellestablished logistics system and well thought-out monitoring and evaluation systems, to ensure both quality and continuity of services. For more information, contact: Dr Ferew Lemma, email: ferew.lemma@yahoo.com 17 WHO. Everybody’s Business: Strengthening health systems to improve health outcomes: WHO Framework for action. 2007. (accessed at http://www.who.int/healthsystems/ round9.2.pdf 20
Page 1 and 2: July 2012 Issue 43 ISSN 1743-5080 (
Page 3 and 4: The overall aim of the Addis Ababa
Page 5 and 6: Editorial Éditorial A note on term
Page 7 and 8: Editorial Éditorial Haile Gebrsela
Page 9 and 10: Editorial Éditorial governance). S
Page 11 and 12: Editorial Éditorial incorporated b
Page 13 and 14: Editorial Éditorial the MoH and in
Page 15 and 16: Editorial Éditorial Filling RUTF j
Page 17 and 18: Field Article percentage points per
Page 19: Field Article sion for relevant sta
Page 23 and 24: Field Article Health and nutrition
Page 25 and 26: Field article Table 2: Number of he
Page 27 and 28: Field article MOH, Ghana MUAC measu
Page 29 and 30: Field article Box 1: Outline of the
Page 31 and 32: Field article Nutrition outcomes ar
Page 33 and 34: Field article feeding (IYCF) practi
Page 35 and 36: Field article other cluster activit
Page 37 and 38: Linear programming to design low co
Page 39 and 40: Research reporting rate sometimes r
Page 41 and 42: Field article Through twice yearly
Page 43 and 44: Field article Table 2: Chronology o
Page 45 and 46: Field article The following assessm
Page 47 and 48: Field article Brief history and bac
Page 49 and 50: Field article France and UNICEF sup
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Professional profile Dr Nadera Haya
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People in aid CMAM Conference, Addi
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