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Field article
MUAC measurement in a child in Gaza
province during the Child Health Week
The term CMAM was not well accepted in
Mozambique because it suggested that the
management of malnourished children is only
carried out in communities. The term ‘outpatient
treatment’ has therefore been used for this
element of the PRN. The PRN contains five
components:
(1) inpatient treatment for cases of SAM with
poor appetite and/or medical complications
(2) outpatient treatment for cases of SAM
without medical complications
(3) outpatient treatment for cases of moderate
acute malnutrition (MAM)
(4) active case finding and referral at the
community level, and
(5) nutrition education at the community and
health centre levels.
The main aim of the PRN is to reduce the
number of deaths due to SAM. In addition, it
aims to reduce the incidence of SAM by
improving early detection, referral and treatment
of children with MAM.
Linkages with other health and nutrition
interventions
The MoH actively promotes the integration of
services. In principle, nutrition is an integrated
component of reproductive and maternal and
child health, as well as HIV and AIDS and
tuberculosis services. Nutrition is also a component
of health promotion, community
involvement and school health activities. The
extent to which integration actually takes place
depends on the level of training and workload
of the staff involved. In 2010, the MoH
approved the broadening of the definition of
child health services to include children up to
the age of 15 years. Prior to this, children
between 5 and 15 years of age were treated
within adult health services (with the exception
of those living with HIV). The Ministry is
currently revising the protocols and guidelines
for all related programmes (in addition to
Volume 2 of the PRN), so that they are in line
with this new policy. This shift should help
strengthen nutrition interventions for children
in this age group.
Nationwide scale up of the PRN
Outpatient treatment for SAM without complications
was introduced in Maputo City in 2004
as part of treatment services for children with
HIV. It was incorporated into general health
services and expanded to other provinces in
2007. The health directorate of one district in
Nampula Province (Ribaue) initiated a full
package of treatment for acute malnutrition as a
Maaike Arts, UNICEF, Mozambique
pilot in 2007, with support from Save the
Children, Valid International and UNICEF. This
pilot was very successful and was subsequently
expanded to other districts in Nampula. By
2010, five districts in Nampula Province had
successfully established a pilot learning centre
where all five components of the PRN were
implemented. The lessons learned from the
pilot were incorporated into the revision of the
PRN manual, the Manual de Tratamento e
Reabilitação Nutricional (Volume 1, covering
children aged 0 to 15 years of age). The development
of the manual started in 2005 and was
completed in August 2010 with the approval of
the Minister of Health. The new WHO growth
standards (2006) have been incorporated in the
revised manual.
Community-based screening, referral and
follow up of SAM cases were introduced in
2006/2007 in the Nampula pilot. These have
since been gradually rolled out as part of the
PRN. The speed of this roll-out is increasing
since the approval of the PRN manual in
August 2010 and subsequent training in the
implementation of these components.
The treatment of MAM was included as an
integral part of the programme in the PRN
manual. MAM treatment programmes have
primarily used Corn Soy Blend (CSB) provided
by the World Food Programme (WFP). In 2011,
CSB was replaced with ‘CSB Plus’ which
contains additional micronutrients. Initially, the
protocol for treating MAM covered children
less than 5 years of age only. This was
expanded to children aged 0 to 15 years of age
in Volume 1 of the revised PRN manual.
Volume 2 addresses adults, including a specific
focus on pregnant and lactating women, and
this will be finalised in the near future.
Volume 1 of the PRN manual includes the
following procedures for community screening
and referral of malnourished individuals.
Community-based Health Workers (CHWs),
known as Agente Comunitário de Saúde (ACSs),
Agentes Polivalentes Elementares (APEs) and
activists, screen children aged 0 to 15 years of
age for acute malnutrition. This screening
involves taking measurements of mid upper
arm circumference (MUAC), checking for
oedema, and looking for signs of wasting.
Screening is also carried out annually during
the National Health Weeks (NHWs). There are
two rounds of NHWs, one of
which includes screening for
malnutrition. The CHWs refer
those who meet the criteria to
the nearest Health Centre (HC)
where they are then assessed
for acute malnutrition and
other health issues and
provided with the relevant
treatment according to the
protocols described below. In
addition, children in the ‘well
child check-ups’ who are
underweight or have growth
faltering are referred for screening
and can enter the
programme through this route.
Patients with SAM who have
good appetite and no medical
complications are treated on an
outpatient basis with Ready to
Use Therapeutic Food (RUTF).
Tina Lloren, Save the Children, Mozambique, 2009
Patients with SAM and additional complicating
factors are treated with therapeutic milks and
RUTF, before transitioning to outpatient treatment
to complete their recovery. Patients with
MAM are treated either with RUTF or CSB Plus,
depending on what is available at the HC. The
follow up is carried out during the ‘at-risk
child’ consultations (Consulta de Criança de Risco
or CCR).
Risks of scale up
A number of possible risks are associated with
scale-up, including:
• The rapid roll-out of the new PRN protocols
might compromise the quality of training
and subsequent implementation. Adequate
supervision will therefore be crucial.
• Sufficient funding for the training of staff in
all health facilities and related reproduction
of materials could also become a constraint.
The scale up of community screening, both
as a routine service and during NHWs, will
most likely lead to increased demands for
RUTF, CSB Plus and therapeutic milks.
However, the funding for these products is
not yet fully secured for the coming years.
Many of the donors have a limited mandate
in terms of target group, age group,
geographical coverage or type of intervention
(procurement, technical support, etc.),
which can complicate fundraising.
• The MoH’s recommendation to use RUTF
for MAM in places where no CSB Plus is
available could lead to shortages, since the
number of MAM cases is considerably
higher than the number of SAM cases.
Furthermore, the introduction of Volume 2
of the PRN Manual includes protocols for
the use of therapeutic milks and RUTF for
the treatment of SAM in older age groups.
These new protocols could also lead to
shortages of therapeutic products because
at present, the national supply only covers
children less than five years of age. The
vision is that rollout of Volume 2 will only
start after the availability of supplies is
ensured.
Nutritional products and local production
of RUTF and CSB
When outpatient treatment was introduced,
UNICEF imported RUTF from Europe. To
ensure in-country availability and to increase
national ownership of the product, Nutriset in
A child in PRN with her mother in
one of the pilot health facilities
in Nampula Province
47