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Field article
The implementation of the revised M&E system for
the PRN has been halted due to delays in the printing
and distribution of instruments required to collect
health centre-level data. It is expected that final
approved versions of the instruments will be printed
and distributed by the end of 2011, with collection of
data starting in earnest from January 2012.
Supplies and supply chain management
The primary supplies for the PRN are therapeutic
milks (F75 and F100), RUTF, CSB Plus, ReSoMal,
routine drugs (e.g. antibiotics, vitamin A, deworming
drugs, malaria prophylaxis, etc) and anthropometric
equipment (including MUAC tapes, weighing scales
and height/ length boards).
The MoH receives support from several partners to
procure the products required to treat acute malnutrition,
including F75, F100, RUTF and ReSoMal. As
mentioned, UNICEF and CHAI have been purchasing
imported RUTF for the programme, although this
support was phased out in 2010.
The WFP supplies CSB Plus to selected health
centres in the southern and central parts of the country.
Initially, this was done via NGOs but it is now
supplied directly to the provincial health directorates
(with financial support from WFP).
Supply chain management capacity at different
levels is limited. Stock-outs of RUTF, ReSoMal and
therapeutic milks are often reported. In most cases, it
is due to inadequate forecasting and communication
between the different levels (health facility-districtprovince-central
level). The weak and often late
reporting of numbers of children treated is a major
contributor to the forecasting challenges.
Community involvement
The community components of PRN in Mozambique
were initiated as part of the pilot in Nampula Province
in 2008 (see earlier). The pilot showed that the strategy
of encouraging active community involvement quickly
produced results. Health centres in the districts where
community activities were being implemented
(Memba, Eráti and Ribáué districts) experienced an
increase in the number of referrals. However, requirements
for RUTF resulting from the subsequent increase
in caseloads had not been properly forecasted. When
screening of acute malnutrition was integrated into
activities of the monthly health day at provincial level,
there were further increases in caseloads.
Following the success of the pilot, the programme
was expanded to other provinces including Sofala,
Zambézia and Gaza. Save the Children (the main
provider of technical assistance to MoH in this area)
partnered with other community-based programmes to
strengthen staff capacity. These staff have, in turn,
Table 2: Individual and programme level monitoring forms
Monitoring forms
1 Referral form (MUAC, oedema, other signs) used
by CHWs to refer cases to the health centres
2 Inpatient individual health card, called the
‘Multicard’ or Multicartão
3 Monthly reporting form (admissions,
discharges, mortality rates performance) for
inpatient care; from facility to district and
provincial health offices
4 PRN register book for outpatient care; SAM
and MAM
5 Malnutrition treatment card (Cartão do Doente
Desnutrido) given to the caretaker to keep
track of treatment and informing next
appointment date
6 Monthly reporting form (admissions,
discharges, performance) for outpatient care;
from facility to district and provincial health
offices
Level used
Community
Inpatient
Inpatient
Outpatient
Outpatient
Outpatient
supported the provincial and district health
services in the implementation of the
community strategies included in PRN.
Partner support has included training of
trainers on community mobilisation in the
context of PRN and home-based nutrition
care for people living with HIV/AIDS in
several provinces during 2011.
The experience of Nampula Province
showed that it is possible to develop a close
link between health professionals and
community groups. Monthly meetings were
conducted involving health professionals
and community groups, to discuss relevant
health issues. Health professionals now
recognise the importance of active community
involvement for wide dissemination of
health messages and of community sensitisation
to ensure early referrals, when the
disease process is at a less advanced state
and still relatively easy to treat. Many traditional
healers now also recognise that the
treatment of malnutrition is complex and
requires referral of the child to the health
centre for appropriate rehabilitation.
However, it has still proven to be challenging
to roll-out the community activities,
in part because the focus so far has been at
health facility level. There are a limited
number of experienced staff who can
provide technical assistance to the MoH’s
efforts at community level. This will
continue to be a problem unless additional
efforts and funding are geared toward this
gap. The delay in printing and distribution
Figure 2: Flow of the monitoring system
Inpatient
Multicard (Multicartão) completed by
nurses and/or doctors
Monthly report for inpatient treatment
compiled by nutrition technician and/or
MCH nurse responsible forPRN
Community
Health Facility
Referral form
completed by nurses
District Health Office
Provincial Health Office
MOH
Referral completed by CHWs
Figure 3: A snapshot of the PRN database to track admissions and outcomes
of materials used at the community level,
including reference forms, job aids, and
MUAC tapes, delayed implementation,
even in areas where training and mobilisation
were underway.
The MoH recognises the need to prioritise
community components of CMAM
within the PRN, and is committed to including
community-related activities into plans
of action. Support will be sought from various
organisations and donors. Linkages will
be established with the new cadre of CHWs
(APEs). In light of the current momentum to
establish large-scale nutrition programmes
in Mozambique, it is expected that more
communities will benefit from efforts to
improve community knowledge and skills
for the diagnosis, referral and follow up of
cases of acute malnutrition.
Coordination
The Nutrition Department of the MoH coordinates
the group of partners supporting the
PRN. This group meets weekly when
needed and less frequently where possible.
There is a division of labour between all
participants, which can be flexible when
required, but is based on each organisation’s
mandate and comparative advantage. A
formal description of this coordination
mechanism is currently being developed.
Results: caseload and outcomes
According to the data available to the MoH
(for many provinces only partial data are
available), by mid-2011 6,319 children
Outpatient
Register books for PRN in at-risk child consultations
and pediatric ART, completed by nurses
Monthly report for outpatient treatment
compiled by nutrition technician and/or MCH
nurse responsible for PRN
One inpatient report and one outpatient report,
aggregating data for all health facilities in their
jurisdiction, completed by the district statistics
technicians
Database disaggregated by district, completed
by the provincial nutrition technicians
Database disaggregated by province, completed by
the staff in the nutrition Department of the MOH
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