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Table 5: UNICEF Nutrition Food supplies in 2007 and
2011
Year Commodity
F-75 F-100 RUTF
2007 1000 kg 6000kg 2,670 cartons (36.8 MT)
2011 8960 kg 8658 kg 35,312 cartons (487.3 MT)
Freetown for larger consignments. Stock allocations
aim to ensure that there is a minimum of
two months stock at the PHU level, a four
month stock at the DHMT level, a three month
national buffer stock in Freetown and a one
month emergency stock at all times, shared
between Freetown, Makeni and Kenema stores.
UNICEF hires transporters to move supplies
from the Freetown warehouse to the districts.
The districts are then responsible for taking the
supplies to the PHUs. UNICEF quite often faces
a shortage of supplies, for example from April -
June 2008, March – June 2009, Dec 2010 and
from January – June 2011 due to the long procedures
involved when clearing goods from the
port of entry to the central warehouse. In addition,
incidents such as no road-worthy vehicles
or fuel shortages for the DHMT to transport
therapeutic foods from the district headquarter
to the PHU or poor road networks (especially
during the rainy season) have contributed to
pipeline breakdown.
UNICEF initially used the PUSH system
where food was sent equally to all PHUs.
However, to increase the efficiency of food
supply and minimise stock-outs, UNICEF
adopted the PULL system in 2011 whereby food
is issued to a PHU based on the caseload of
malnourished children. This system is still new
and only instituted in August 2011 but will be
reviewed.
To further increase the efficiency of the
supply chain, district nutritionists together
with other DHMT members have been trained
in storekeeping and monitoring of supplies. At
present there is a great deal of work in progress,
aiming to integrate the supply chain management
for all medical supplies of the MOHS,
including nutrition supplies. Encouragingly,
therapeutic foods have very recently been
included in the essential drugs list of MOHS.
Supplementary food supplies from WFP
include CSB, oil and sugar, which are premixed
prior to distribution to beneficiaries. The food is
all purchased abroad and received at the
Freetown port. Some food supplies are stored in
two warehouses in Freetown, with the balance
of food commodities then forwarded to the
WFP sub-offices in Tonkolili and Kenema
districts by commercial transporters and WFP
trucks. WFP trucks, light vehicles and NGO
trucks sometimes assist in getting the food to its
Figure 3: Discharge profile for children with MAM and SAM, 2010
Number of children
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
97.1%
98.7%
1.4% 0.8% 0.4% 0.1% 1.1% 0.3%
Cured Deaths Defaulters Non Recovered
Indicators
SAM
MAM
final destination. The very poor road conditions
in rural areas (especially during the rainy
season) again provide considerable logistical
challenges.
Results
Successes of CMAM
The efforts towards scaling up CMAM have
resulted in the realisation of results in different
areas of investment. Overall, the number of
SAM children treated has greatly increased
from 2,950 in 2007 to 35,000 in 2010. Admissions
in 2012 were higher (105%) than the planning
figures. The cure rates of children with MAM
and SAM remain impressive, at 98.7% (MAM)
and 97% (SAM) (see Figure 3).
Other successes are:
• The integration of CMAM as part of the
basic package of essential health services.
• Integration of therapeutic food as part of
the FHC.
• Development of national policy and
guidelines for treatment (CMAM guidelines
and IYCF).
• Government leadership of the CMAM
programme with the support of UN and
partners.
Staff capacity development has been notable. To
date, Sierra Leone has 150 trainers of CMAM
with 1,080 health facility staff trained at all
levels. Similarly, the MOHS has increased the
number of district nutritionists to nine and
created two new national positions on CMAM
and IYCF, for better coordination and oversight.
Challenges
The following challenges have been identified
during scale-up of CMAM:
Inadequate numbers and skills of health staff:
Despite the numerous efforts made to develop
the knowledge and skills of MOHS staff on
CMAM, the required level for effective service
delivery has not yet been attained. This affects
the health facilities, especially where there is
high staff turnover with staff transfers and
replacements without CMAM knowledge
transfer. The quality of service delivery is also
affected by the high burden of work, especially
after the introduction of the FHCI as more
people seek care. It is important therefore that
pre-service CMAM training is included in institutions
including those of universities, to
ensure health staff are graduating with knowledge
and skills for CMAM to ensure
sustainability of quality services.
Inadequate community mobilisation and referral
system:
As reflected upon earlier, most caregivers are
not aware of the programme, thus malnourished
children are not recognised or identified
which in turn leads to low coverage.
Inadequate management of logistics
and supplies:
The stock out experienced is likely
to have a major negative effect on
programmatic results, especially
defaulter rates. A major cause of
this pipeline breakdown was the
privatisation of the port, which
resulted in delays due to new clearance
procedures and hence
disruption of the whole supply
chain in the country. Leakage of
RUTF to non-target populations is
also a major concern. Some moth-
ers sell rations and even use it to prepare family
food. Mass sensitisation is ongoing in all
districts to inform communities that RUTF is
specially designed for the treatment of
malnourished children and that it contains
medicine. An information sheet has been
produced for community members on the
correct utilisation of RUTF.
Inadequate service delivery and access:
Malnourished children are not receiving
adequate attention due to the distance of some
OTP facilities (as identified in the SQUEAC 5
2011) and lack of comprehensive care in some
centres. This is due to the following:
• SFP services are not provided at all OTPs.
• The CMAM programme is not understood
as a comprehensive protocol to treat acute
malnutrition. SC/OTP and SFP are still
considered as two different programmes.
For many community members, as well as
some health workers, UNICEF-MOHS is
understood as having the RUTF
programme and WFP the SFP programme.
• Under and over rationing of food. For
example, children may be enrolled longer in
a programme than is necessary, i.e. more
than 12 weeks in an OTP and more than 2
months in SFP after the child is cured. Some
children are given smaller rations than indicated
due to stockout.
• Anthropometric equipment is unavailable
in some facilities.
• The updated National Protocol for CMAM
has not yet been disseminated widely.
Monitoring and evaluation (M&E)
At the national level, the MOHS has developed
tools, guidelines, checklist for field visits, protocols
and reporting formats for use by district
implementers. Monthly reports are submitted
to the national or central level by the district
nutritionists. Quarterly reports are written by
NGO CMAM partners (where they are active)
and shared during the MOHS coordination
meetings. Joint monitoring visits are also
conducted with the MOHS, UNICEF and WFP
every quarter. The MOHS also conducts spot
visits. At the community level, the NGOs (in
their working areas) monitor the work of the
CHVs.
Currently, data from CMAM sites on the
number of children who receive therapeutic
food has been integrated into the HMIS, in the
Directorate of Planning and Information within
the MOHS. However, the system sometimes
double counts children undergoing treatment,
so there is a need to review and train DHMT,
nutritionists and health staff to monitor better
the number of children with SAM and MAM,
rather than placing too much reliance on
national surveys. UNICEF has also created a
database to track CMAM supplies.
At the district level, the nutritionists conduct
joint supportive supervision with stakeholders
to PHUs and receive reports on a monthly
basis. During the district coordination meetings,
the district nutritionist also receives
updates regarding planned activities from
NGO partners. Staff from the Community
Health Centre (CHC) supervises the Maternal
and Child Health Post (MCHP), who in turn
supervise the government CHVs.
5
Semi Quantitative Evaluation of Access and Coverage
43