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Field article
France and UNICEF supported the establishment
of a RUTF factory as part of the Nutriset
‘plumpyfield’ network. The factory was set up
in Beira City in the centre of the country,
managed by the non-governmental organisation
(NGO) Joint Aid Management (JAM).
Planning and construction of the factory started
in 2006, with equipment arriving in mid-2008.
The factory was certified for local procurement
by UNICEF at the end of 2009 and officially
inaugurated in February 2010.
Sugar and oil are procured locally, as are
increasing amounts of the peanuts. The remaining
ingredients are imported. The factory
produced small quantities of RUTF packaged in
jars until it obtained a sachet line in mid-2011.
Sachets are preferred over jars because of their
longer shelf life, they are easier to prescribe (the
content of the jars is 220g) and easier to handle
by the patients (no spoon is needed).
The Clinton Health Access Initiative (CHAI)
procured a proportion of the country’s RUTF
needs for 2011 from the local JAM factory via
the UNITAID Programme. It is expected that
the sales of locally procured RUTF will increase
in the future.
CSB has mostly been imported, with the
exception of small quantities procured from
JAM in 2010. In 2011, WFP expanded its work
with JAM to increase the volume of locally
produced CSB.
Partnerships and funding
The Ministry of Health and its partners
The MoH is responsible for the management of
health facilities in the country. Non-government
actors are not leading any health facility.
The drafting and revision of protocols and
guidelines is the responsibility of the MoH.
Clinical and technical partners provide technical
support to health services. At present,
these include various PEPFAR 10 supported partners
such as CARE, the Elizabeth Glaser
Paediatric AIDS Foundation (EGPAF),
Vanderbilt University’s Friends for Global
Health (FGH), Family Health International
(FHI), and the International Centre for AIDS
Care and Treatment Programmes of the
Columbia University (ICAP), as well as the
CHAI, Médecins Sans Frontières (MSF) and
Save the Children. Several of these organisations
also cover the costs of in-service training
and supervision for staff of selected districts or
provinces.
Several organisations, including EGPAF,
FANTA-2/FHI360, Save the Children, UNICEF,
USAID, WFP and WHO, provide technical
support at central level. The cost of training and
reproduction of training materials and job aids
has been shared by several of the PEPFAR clinical
partners, FANTA-2/FHI360, UNICEF,
USAID and WFP.
Health Directorates come from both central
level and donors.
Since 2008, CHAI has procured the vast
majority of RUTF for the country, with UNICEF
filling gaps where needed. Therapeutic milks
and other products for the treatment of SAM
are in principle procured by MoH, with
UNICEF filling gaps where necessary (which
included large amounts of therapeutic milks in
2009, 2010 and 2011).WFP provides CSB Plus
but the coverage is not nationwide (in 2010, the
programme covered selected districts in five
provinces). The contribution to training and
reproduction of materials is described above.
Implementation
Geographical coverage
In principle, the coverage of the PRN is
national, although it will take some time to
achieve full roll out across the country. As of
mid-2011, 191 out of about 1,280 health facilities
in the country (from primary to the fourth level
of health care), provide inpatient treatment for
SAM and 229 provide outpatient treatment.
However, as yet, not all facilities or districts
have been trained in the updated 2010
protocols.
Training
In the time between the introduction of outpatient
treatment for SAM using RUTF and the
official approval of the new PRN protocols,
numerous health workers were trained in draft
versions of the protocol that were under development.
Outpatient treatment was initiated for
the rehabilitation phase of SAM treatment and
for the relatively small number of SAM cases
that presented without complications.
Since the end of 2010, three regional (north,
central and south) Training-of-Trainer (ToT)
workshops for the new protocols have been
conducted, reaching a total of 112 people. The
training was rolled-out in a cascade manner
starting with the three regions, followed by
replication trainings at provincial level and
finally, at facility and community levels. To
date, each province has undertaken at least one
training session for district staff (reaching 376
people). Attempts are always made to include
either a trained MoH staff member or a member
of a clinical partner organisation to facilitate
and/or supervise some of the sessions. Training
materials for Mozambique were developed by
adapting WHO-recognised scientific guidelines
and practices to the national context. The materials
were updated and improved using
post-training feedback.
The complete PRN training library includes
three ‘packages’, each consisting of an orientation
training package, facilitators´ guides and
hand-outs for participants. Complementary
training materials on HIV and nutrition are
provided at community level.
Box 1: Flow of data in the programme and from
health facility to provincial level
Once a person has been screened for acute malnutrition,
community health workers (CHWs) refer them to
a health centre using a standardised referral form
that includes MUAC measurements, presence/
absence of oedema, and any other notable signs. The
health centre staff conduct further diagnostic tests to
ascertain if the person has acute malnutrition.
Cases of SAM with complications are referred to
the nearest inpatient facility, where treatment is
tracked using the ‘multicard’ (multicartão). At the end
of each month, the health centre staff report the
admission and discharge statistics using the inpatient
monthly reporting form.
Cases of SAM without complications or MAM cases
are admitted into the outpatient programme, and
their information is recorded in the PRN register book.
The beneficiary or the caregiver for the beneficiary is
given a malnutrition treatment card that contains
important information regarding the treatment,
including a log of the medicine/products given and
an indication of when they should return to the
health centre. The name of the CHW is also included
on the card, and the beneficiary/caregiver is advised
to seek the CHW when they return home. At the end
of each month, the health staff complete the outpatient
monthly reporting form and send it to the district
health office. These forms are then compiled and sent
to the provincial health office.
At the provincial health office, the inpatient and
outpatient monthly reports provide the information
that is entered into the PRN database (Figure 3). The
databases have been designed specifically for the
PRN and are intended for use throughout the health
system from health facility to central level.
The database spreadsheets automatically link to
charts showing trends over time, supporting straightforward
interpretation and reporting of the results by
the provincial point person for nutrition to the
central MoH in Maputo. Some of the results that can
be derived from the analysis of data generated
include the frequency of referral of new cases of
acute malnutrition according to food availability,
season, disease epidemics and various other factors.
planning and logistics, orientation to tools
and databases for the PRN programme.
There are plans to initiate supervision activities
within health facilities to observe the quality of
implementation and to provide refresher
sessions where needed. A supervision checklist
is currently under development.
Recording and reporting
Several tools were developed for programme
monitoring, including individual and
programme level monitoring forms, a database
to track admissions and outcomes and a database
to manage the stocks of RUTF, CSB Plus
and therapeutic milks. The PRN individual and
programme level monitoring forms are
summarised in Table 2 with the flow of the
monitoring system illustrated in Figure 2 and
outlined in Box 1.
Particular emphasis is being placed on the
quality of data recording and reporting, as this
has been identified as a weak aspect of the PRN
for a number of years. A specific data-handling
training course was developed alongside the
new protocol training. To date, 34 staff have
participated in a dedicated five day monitoring
and evaluation (M&E) training that focused on
the PRN database and the related reporting
mechanisms. The general PRN training package
also includes a section on M&E.
A strong focus is placed on training of the
Funding
full PRN package. The number of days training
for each level of participants is as follows:
In 2011, the MoH’s annual budget was USD 360
million, of which approximately half was
• Facility-based health workers: 5 days.
provided through external funding sources.
• CHWs: 2 days, plus an additional 2 days
There is a Common Fund for the Health Sector,
for training on community-based nutrition
to which 16 donors contribute. The Nutrition
and HIV for CHWs and home-based care
Department’s budget for 2011 was approximately
USD 260,000, although this amount does
volunteers.
• Community leaders and traditional healers: 1
not include the vertical funds provided by
day covering the basics of the programme.
UNICEF, WHO, USAID, WFP and other partners
who support the implementation of
• Provincial-level health staff: hands-on 3-day
training covering monitoring, evaluation,
10
specific activities. Funds for the Provincial U.S. President's Emergency Plan for AIDS Relief
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