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Table 2: Chronology of training on CMAM, OTP and SC components
Date Staff trained Content Sponsor
June 2007 National/district health staff, Management of SAM
UNICEF with Valid International
paediatricians, nutritionists
2008 PHUs staff Management of SAM UNICEF with Valid International
& MOHS
2009 PHUs staff Integration of IYCF to support UNICEF with Valid International
CMAM
June-
August
2010
National/district & PHU staff Integrated training on the revised
national protocol for CMAM
New WHO growth standards
UNICEF with Valid International,
WHO, WFP, HKI
February-
April 2011
March
2011
June – Oct
2011
One DHMT member/ district
District Health Sister, NGO & other
government staff in each district
SC staff
Outpatient Therapeutic Programme (OTP)
The OTPs were scaled up from 20 in 2007 to 245
in 2011. The decision to open more OTPs was
taken based on availability of trained staff at the
PHUs, community needs and financial
resources. The scale-up from 2008 to 2011 per
year is shown in Figure 1. The large increase in
2010 followed a major training of staff from all
existing PHUs, with financial support from the
WHO, UNICEF and WFP. While the scale-up to
date has been impressive, it still represents only
20% of all PHUs. The scale-up should be gradually
continued until OTPs are established at all
PHUs; a difficult undertaking as some chiefdoms
are very large and many PHUs are
difficult to access due to very poor infrastructure
in some rural areas.
Stabilisation centres (SCs)
In 2007, there were only three treatment centres
in the whole country, located in the Western
area, Bombali and Bo. These Therapeutic
Feeding Centres (TFCs), admitted all SAM children
for 2 to 3 months until they achieved 80%
weight for height. In 2007, following the shift to
CMAM programming, the TFCs were transformed
into SCs, admitting SAM children with
complications only and discharging them to
OTP to complete their treatment once the
complications had resolved. From 2007, the
three SCs were scaled up to eight by 2009, then
14 in 2009 and finally 19 in 2010. Each district
currently has at least one SC, with plans to open
more as and when resources allow. WFP
provides food for mothers/caregivers of admit-
On-job training on how to
conduct CMAM coverage survey
On-job coaching and mentoring
in OTP skills
On-job training on how effectively
to implement the SC component
of CMAM
UNICEF with Valid International
UNICEF and Valid International
UNICEF
Table 3: Chronology of training on CMAM SFP component
Date Staff trained Content Sponsor
2008 Maternal and Child Health (MCH) aides Orientation on SFP
WFP
and district nutritionist in the Western Area
2009 MCH Aides, zonal supervisors, nutritionist Orientation on SFP
WFP
and nutrition focal points in Western area
and Moyamba
2010 MCH Aides in Bo, Pujehun and Bonthe Orientation on SFP WFP
May 2010 MCH Aides and Comunity Health Officers Comprehensive training in SFP
WFP
(CHOs) in Moyamba District
June-July Civil society staff (‘Health for all’ coalition) Orientation on SFP with basic concepts of WFP
2010
malnutrition to facilitate monitoring of the
programme
2010 District councillors – health committee Orientation to SFP with basic concepts of malnutrition
WFP
to facilitate monitoring of the programme
July 2010 MOHS nutrition focal points and WFP field
monitors
Comprehensive training in SFP
WFP
June-
August
2010
December
2010
Joint cascade training of PHU staff nationwide
Training of district Nutritionists
ted children at some of the SCs. In 2010, the
number of SCs supported by WFP was 10, up
from eight in 2008. One of the key challenges
faced by these eight SCs is the lack of food for
caregivers and so they refuse admissions to
avoid the high associated cost.
Supplementary Feeding Centres (SFCs)
Supplementary feeding for MAM children has
been implemented for many years, even before
the war. In 2007, the supplementary feeding
cycle for MAM lasted for three months in Sierra
Leone. This changed in 2011 to a minimum of
60 days to align with the reviewed CMAM protocol.
In 2008, 385 PHUs were covered by SFCs in
12 districts, increasing to 440 in 2009 and 521 in
2010. The scale-up was based on the prevalence
of SAM and MAM and availability of NGO
partners. In Sierra Leone, 43% of all PHUs are
currently providing SFPs, however not all OTP
sites are covered (67 OTP sites do not have a
SFP). This followed the suspension of SFPs in
four districts due to funding constraints. The
Nutrition Programme will make a formal
request to WFP to ensure that all OTPs are
covered by the SFP for the continuum of care to
prevent relapse after rehabilitation.
In 2007, community mobilisation was mostly
done by health staff through outreach services,
such as the Expanded Programme on
Immunisation (EPI). The children were
screened and identified malnourished cases
referred for treatment. Some PHUs had CHVs
Comprehensive training in SFP, SC, & OTP including
assessment, management and reporting
Comprehensive training on WFP processes and
procedures
WFP,
UNICEF,
WHO
WFP
Figure 1: Scale-up of OTPs
No. of OTPs
300
250
200
150
100
50
0
1 2 3 4 5
Year
Figure 2: Number of CHVs trained
3000
2668
2500
2000
1500
1000
500
420
442
90
50
0
1 2 3 4 5
Year
Number of CHVs trained
Number
attached to them (approximately one per PHU)
to support the outreach services.
To boost active case finding, from 2007
Project Co-operation Agreements (PCAs) were
developed and signed between UNICEF and
international and local NGOs to support
community mobilisation for the implementation
of CMAM. By 2011, a total of eight local
NGOs and three INGOs were involved across
all districts, except Koinadugu where the
USAID funded Multi-Year Assistance
Programme was being implemented by
International Medical Corps (IMC). A series of
community mobilisation messages were developed
by UNICEF.
Additionally, CHVs were trained by the
MOHS and NGOs at the district level. The
CHVs hold periodic meetings with the community
and screen children house-to-house on a
quarterly basis, referring identified malnourished
cases to the PHUs. They also make
follow-up visits at home for referred and
discharged children. The number of CHVs has
been scaled up progressively over the years,
with a total of 3,670 trained between 2007 and
2011 (see Figure 2).
All CHVs trained in 2010 and 2011 remain
active. Training is conducted for 3 to 5 days by
NGO staff with support from the District
Health Management Team (DHMT). The
national CMAM protocol for training CHVs in
early case finding and social mobilisation is
used. However, as observed during the CMAM
coverage survey in 2011, a large number of
mothers with SAM children reported that they
were not aware of the programme. This
provides clear evidence that community mobilisation
in CMAM remains weak. However,
since the bulk of the CHVs were trained in 2011,
it is hoped that this trend may be reversed as
long as the CHVs remain active.
Supplies and logistics
Since 2007, UNICEF has supplied the therapeutic
food and routine medicines required for OTP
and SC, including F-100, F-75 and RUTF. In
2008 and for most of 2009, nutrition supplies
were sent to the regional stores in Freetown,
Makeni and Kenema for distribution to the
district every two to three months. Since
December 2009, supply mechanisms were
simplified by sending them directly to the
districts, using a new food warehouse in
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