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Field article
Children with HIV who are severely malnourished
are also treated using the national CMAM
protocols.
Access to CMAM supplies
UNICEF procures and provides anthropometric
equipment, Ready to Use Therapeutic Food
(RUTF), therapeutic milk (F-75, F-100),
Rehydration Solution for Malnutrition
(ReSoMal) and Combined Mineral and Vitamin
mix (CMV) for the programme. USAID is also
procuring RUTF, F-75 and F-100 to support two
regions and has committed funds for procuring
CMAM supplies to support scale up in 2012.
The RUTF and equipment are stored at the
National MOH/GHS warehouse. The supplies
are then requested by facilities at national,
regional and district level and distributed
through the existing GHS supply chain system.
Stock reporting has been incorporated into the
weekly tally sheets and monthly reports to
systematise and improve stock control and
reduce the risk of ‘stock-outs’ due to delayed
requests for re-supply. Health care providers
have been trained to use the system, whereby
they report on inventory levels on a monthly
basis and make requests to the DHD for
supplies when they reach a minimum stock
level.
Quality of CMAM services
Standardised treatment protocols and job aids
have been developed and are being used at all
CMAM operational districts, facilities and
communities. Adherence to the protocols is
high, although there are variations between
individuals and facilities. Experience to date
has indicated that the main determinants of
good adherence to standardised treatment
protocols are the intensity of supervision and
support received during the initial two to three
months of setting up inpatient and outpatient
care facilities from the national SAM SU and
regional SAM STs, and the level of training
received by the implementers.
The national SAM SU and regional SAM STs
provide monthly and quarterly supportive
supervision to the regions, districts and facilities.
The DHMT also carries out
weekly/bi-weekly supportive supervision. The
focus of the support and supervision is on
adherence to CMAM protocols, admission
procedures, use of the action protocol, the quality
of screening and assessment of malnutrition
using MUAC tapes, testing for bilateral pitting
oedema, and the quality of individual and service
data recording and reporting. The quality of
the management of SAM is high partly due to
this intensive supportive supervision.
The CMAM monitoring tools for care
include outpatient care treatment cards, tally
sheets, client registers and reporting forms, bin
cards or tally sheets for supplies, supervision
checklists for regional and district levels. There
is generally good record keeping and reporting
by the service providers. CMAM service
performance is reviewed monthly at all levels:
sub-metropolitan area, municipality, district,
regional and national levels. CMAM data are
currently managed by the nutrition officers and
not yet integrated into the Health Information
Management System (HIMS). Discussions are
ongoing with the Centre for Health Information
Management (CHIM) to review existing nutrition
indicators in the system to also include
CMAM indicators. CMAM data are collated at
the district level and the data are then sent to
the regional level where they are entered into
an Excel database before being submitted to the
national GHS/Nutrition Department.
CMAM service performance
Table 4 and Figure 3 provide a summary of the
total number of children who were managed
and some service performance indicators (from
inception to August 2011).
Cure rate: Overall, 71% of children were
discharged cured, which is below the recommended
Sphere target of >75%. The cure rate
was offset by the high default explained below.
Death rate: Overall, 2% of children died, which
is an acceptable rate for the management of
SAM and below the Sphere standard of