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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
Field article MOH, Ghana MUAC measurement of a child with SAM in Nyakrom hospital, Ghana highly motivated by the rapid clinical improvement of children with SAM. The approach of training most CHNs at the learning sites, as opposed to training only two or three CMAM focal people, enhanced team work and support for the programme. It maximised the chances of continuity of care and helped to convince implementers that CMAM is a government-owned intervention with a longterm perspective that requires the involvement of all health care providers. Ensuring intensive and close monitoring and mentoring of implementers by adopting frequent supportive supervisory visits at initiation of services was a successful approach. It contributed to good quality service provision and also proved to be an effective motivator for staff implementing the programme. Distribution of RUTF during the start of the programme used the same channels as other health supplies (employing the same transport and warehouse). This reinforced GHS ownership, minimised perceptions of the intervention as ‘vertical’ and increased the likelihood of the distribution system being sustained. The CMAM programme did not select new volunteers, but used the same CHVs as for other health programmes. This minimised the risk of volunteers requesting a special motivation scheme and enhanced the integration of active SAM case finding with their activities. Mother-to-mother sensitisation was used successfully, based on the ideas of ‘positive deviance’ whereby mothers/caregivers of recovering children are encouraged to sensitise caregivers of malnourished children to the existence and effectiveness of CMAM. The CHNs initiated the use of new information technology (SMS messages and telephones) to communicate with the CHVs prompting them to conduct follow-up activities. This helped to increase the proportion of defaulters who returned. At the district level, collaboration between managers of different interventions within the DHMT ensured the integration of trainings and sensitisation meetings. For example, resources for the National TB programme and NIDs were used to sensitise community workers on CMAM and/or provide refresher training to community volunteers. This kind of synergy optimised the output of the programme, ensuring that more communities were sensitised and more volunteers trained than the available CMAM budget allowed. Challenges Despite the successes of CMAM implementation, some challenges and/or weaknesses have been identified (either through the CMAM review or through internal review) that need to be addressed: • There is a lack of funding to support scale up to all the Phase 2 regions. • Community mobilisation did not specifically target the traditional medicine practitioners (TMPs). As such, children with SAM who are taken to these informal providers first, due to the belief that SAM is a spiritual problem (‘evil eye/curse’), are not identified and referred. • The defaulter rate is high. This is because some of SAM cases come from districts that have not initiated CMAM, making followup difficult once clients go back to their districts of origin. • It has been observed that volunteer fatigue sets in after a while, particularly in the urban areas. There is a need to find ways of sustaining the enthusiasm and commitment of volunteers. • Not all SAM cases being managed at the outpatient care facilities receive routine medication. This is because although treatment is supposed to be free to children under-five years, some health facilities are not able to provide free treatment to the children who are not registrants of the national health insurance (NHI) scheme. • Initial attempts to produce RUTF in-country failed after management issues with the selected company led to the inability of the company to meet conditions for start up. Risks to scaling up At present, there are a number of risks to the scale up of CMAM in Ghana. Although regional and district SAM STs help to reduce the workload of the national SAM SU, as CMAM expands nationally, the SAM SU will not have sufficient staff to successfully manage this phase of scale up. Inadequate funding for training, mentoring and supervision is a constraint, especially in Phase 2 regions that are not the focus of development partners. This will require continuous advocacy for resource mobilisation to support the scale up. Ensuring adequate and sustained availability of CMAM supplies (RUTF, F-75, F-100) remains a challenge. The high quality of CMAM service might be compromised if initial supportive supervision is not maintained during Phase 2 scale up. Way forward The next steps for CMAM activities in Ghana are to: • Develop a five-year CMAM scale-up strategy (2012–2016). • Integrate CMAM into pre-service training curricula for medical, nutrition, dietetics and nursing students. • Conduct a coverage survey to determine the extent of SAM within the community, the current access and uptake of CMAM services and the barriers to access and uptake that exist. • Include CMAM supplies, especially RUTF and CMV, into the national essential medicines list and hence the NHI drug list. • Develop linkages between CMAM and informal health systems such as the TMPs. • Conduct a capacity assessment to identify and prioritise the introduction of CMAM activities within Phase 2 regions (Western, Eastern, Volta, Ashanti and Brong-Ahafo). • Strengthen Social Behaviour Change and Communication (SBCC) for CMAM and link with IYCN, using quality improvement tools and systems at the community level. • Facilitate the involvement of civil society organisations (CSOs) to strengthen the community outreach component of CMAM. • Continue to advocate for national production of RUTF. For more information, contact: Mr Michael Neequaye, email: mikeneeq@yahoo.co.uk Ghana Health Service: http://www.ghanahealthservice.org/ MINISTRY OF HEALTH 26
- 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 and 20: Field Article sion for relevant sta
- Page 21 and 22: Field Article anisms, especially fo
- Page 23 and 24: Field Article Health and nutrition
- Page 25: Field article Table 2: Number of he
- 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
- Page 51 and 52: Field article Table 3: Facility-bas
- Page 53 and 54: Field article Article de terrain Ba
- Page 55 and 56: Field article Article de terrain th
- Page 57 and 58: Field article Article de terrain Fi
- Page 59 and 60: News UNICEF/NYHQ2008-1649/Pirozzi,
- Page 61 and 62: News specialists, CMAM programme ma
- Page 63 and 64: News Integration of the management
- Page 65 and 66: Conference on Government experience
- Page 67 and 68: News Update on Minimum Reporting Pa
- Page 69 and 70: Field Article Table 1: Nutrition si
- Page 71 and 72: Field Article Table 5: Experience f
- Page 73 and 74: Field Article six mobile teams were
- Page 75 and 76: Field Article different programmes,
<strong>Field</strong> article<br />
MOH, Ghana<br />
MUAC measurement <strong>of</strong> a child with<br />
SAM in Nyakrom hospital, Ghana<br />
highly motivated by the rapid clinical improvement<br />
<strong>of</strong> children with SAM.<br />
The approach <strong>of</strong> training most CHNs at the<br />
learning sites, as opposed to training only two<br />
or three CMAM focal people, enhanced team<br />
work and support for the programme. It<br />
maximised the chances <strong>of</strong> continuity <strong>of</strong> care and<br />
helped to convince implementers that CMAM is<br />
a government-owned intervention with a longterm<br />
perspective that requires the involvement<br />
<strong>of</strong> all health care providers.<br />
Ensuring intensive and close monitoring and<br />
mentoring <strong>of</strong> implementers by adopting<br />
frequent supportive supervisory visits at initiation<br />
<strong>of</strong> services was a successful approach. It<br />
contributed to good quality service provision<br />
and also proved to be an effective motivator for<br />
staff implementing the programme.<br />
Distribution <strong>of</strong> RUTF during the start <strong>of</strong> the<br />
programme used the same channels as other<br />
health supplies (employing the same transport<br />
and warehouse). This reinforced GHS ownership,<br />
minimised perceptions <strong>of</strong> the intervention<br />
as ‘vertical’ and increased the likelihood <strong>of</strong> the<br />
distribution system being sustained.<br />
The CMAM programme did not select new<br />
volunteers, but used the same CHVs as for<br />
other health programmes. This minimised the<br />
risk <strong>of</strong> volunteers requesting a special motivation<br />
scheme and enhanced the integration <strong>of</strong><br />
active SAM case finding with their activities.<br />
Mother-to-mother sensitisation was used<br />
successfully, based on the ideas <strong>of</strong> ‘positive<br />
deviance’ whereby mothers/caregivers <strong>of</strong><br />
recovering children are encouraged to sensitise<br />
caregivers <strong>of</strong> malnourished children to the existence<br />
and effectiveness <strong>of</strong> CMAM.<br />
The CHNs initiated the use <strong>of</strong> new information<br />
technology (SMS messages and telephones)<br />
to communicate with the CHVs prompting<br />
them to conduct follow-up activities. This<br />
helped to increase the proportion <strong>of</strong> defaulters<br />
who returned.<br />
At the district level, collaboration between<br />
managers <strong>of</strong> different interventions within the<br />
DHMT ensured the integration <strong>of</strong> trainings and<br />
sensitisation meetings. For example, resources<br />
for the National TB programme and NIDs were<br />
used to sensitise community workers on<br />
CMAM and/or provide refresher training to<br />
community volunteers. This kind <strong>of</strong> synergy<br />
optimised the output <strong>of</strong> the programme, ensuring<br />
that more communities were sensitised and<br />
more volunteers trained than the available<br />
CMAM budget allowed.<br />
Challenges<br />
Despite the successes <strong>of</strong> CMAM implementation,<br />
some challenges and/or weaknesses have<br />
been identified (either through the CMAM<br />
review or through internal review) that need to<br />
be addressed:<br />
• There is a lack <strong>of</strong> funding to support scale<br />
up to all the Phase 2 regions.<br />
• Community mobilisation did not specifically<br />
target the traditional medicine practitioners<br />
(TMPs). As such, children with SAM who<br />
are taken to these informal providers first,<br />
due to the belief that SAM is a spiritual<br />
problem (‘evil eye/curse’), are not identified<br />
and referred.<br />
• The defaulter rate is high. This is because<br />
some <strong>of</strong> SAM cases come from districts that<br />
have not initiated CMAM, making followup<br />
difficult once clients go back to their<br />
districts <strong>of</strong> origin.<br />
• It has been observed that volunteer fatigue<br />
sets in after a while, particularly in the<br />
urban areas. There is a need to find ways <strong>of</strong><br />
sustaining the enthusiasm and commitment<br />
<strong>of</strong> volunteers.<br />
• Not all SAM cases being managed at the<br />
outpatient care facilities receive routine<br />
medication. This is because although treatment<br />
is supposed to be free to children<br />
under-five years, some health facilities are<br />
not able to provide free treatment to the<br />
children who are not registrants <strong>of</strong> the<br />
national health insurance (NHI) scheme.<br />
• Initial attempts to produce RUTF in-country<br />
failed after management <strong>issue</strong>s with the<br />
selected company led to the inability <strong>of</strong> the<br />
company to meet conditions for start up.<br />
Risks to scaling up<br />
At present, there are a number <strong>of</strong> risks to the<br />
scale up <strong>of</strong> CMAM in Ghana. Although<br />
regional and district SAM STs help to reduce<br />
the workload <strong>of</strong> the national SAM SU, as<br />
CMAM expands nationally, the SAM SU will<br />
not have sufficient staff to successfully manage<br />
<strong>this</strong> phase <strong>of</strong> scale up. Inadequate funding for<br />
training, mentoring and supervision is a<br />
constraint, especially in Phase 2 regions that are<br />
not the focus <strong>of</strong> development partners. This<br />
will require continuous advocacy for resource<br />
mobilisation to support the scale up. Ensuring<br />
adequate and sustained availability <strong>of</strong> CMAM<br />
supplies (RUTF, F-75, F-100) remains a challenge.<br />
The high quality <strong>of</strong> CMAM service might<br />
be compromised if initial supportive supervision<br />
is not maintained during Phase 2 scale up.<br />
Way forward<br />
The next steps for CMAM activities in Ghana<br />
are to:<br />
• Develop a five-year CMAM scale-up strategy<br />
(2012–2016).<br />
• Integrate CMAM into pre-service training<br />
curricula for medical, nutrition, dietetics<br />
and nursing students.<br />
• Conduct a coverage survey to determine<br />
the extent <strong>of</strong> SAM within the community,<br />
the current access and uptake <strong>of</strong> CMAM<br />
services and the barriers to access and<br />
uptake that exist.<br />
• Include CMAM supplies, especially RUTF<br />
and CMV, into the national essential medicines<br />
list and hence the NHI drug list.<br />
• Develop linkages between CMAM and<br />
informal health systems such as the TMPs.<br />
• Conduct a capacity assessment to identify<br />
and prioritise the introduction <strong>of</strong> CMAM<br />
activities within Phase 2 regions (Western,<br />
Eastern, Volta, Ashanti and Brong-Ahafo).<br />
• Strengthen Social Behaviour Change and<br />
Communication (SBCC) for CMAM and<br />
link with IYCN, using quality improvement<br />
tools and systems at the community level.<br />
• Facilitate the involvement <strong>of</strong> civil society<br />
organisations (CSOs) to strengthen the<br />
community outreach component <strong>of</strong> CMAM.<br />
• Continue to advocate for national production<br />
<strong>of</strong> RUTF.<br />
For more information, contact: Mr Michael<br />
Neequaye, email: mikeneeq@yahoo.co.uk<br />
Ghana Health Service:<br />
http://www.ghanahealthservice.org/<br />
MINISTRY OF HEALTH<br />
26