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Table 3: Facility-based mortality of children under 5
due to SAM 11
Year 2005 2006 2007 2008 2009 2010
Facility
based
deaths in
children
under five
due to
SAM
15.2% N/A 11.5% 10.5% 11.8% 9.3%
under-five were admitted for inpatient treatment
for SAM, of which 701 (11%) died. Just
over 900 children were referred to outpatient
care to continue their treatment and 5,854
received only outpatient treatment for SAM.
The low percentage of children going directly to
outpatient treatment is probably related to the
fact that training in the new treatment protocols
was only scaled up recently.
As reported by the Health Information
System, the percentage of facility-based deaths
due to SAM has been slowly reducing.
However, in 2010 percentage mortality was still
just under 10%, with wide regional differences
(ranging from 5 to 20%). This could be due to
high levels of complications and/or inaccurate
application of the protocols and/or inaccurate
reporting. This issue has yet to be studied in
detail. Mortality for the past years is shown in
Table 3.
In 2010, 31,503 children received a supplement
for MAM (of which 27,620 received CSB
Plus and 3,883 received RUTF).
Successes
The introduction and approval of outpatient
treatment of SAM with community involvement
has been a success in itself. In the
beginning, many paediatricians and other
medical practitioners were sceptical about the
possibility of treating children with SAM as
outpatients, particularly children with oedema.
The key decision makers have now been
convinced by the evidence from the pilot
programmes and are endorsing the new protocols.
However it has been stated that all cases of
oedema should still to be treated as inpatients.
The PRN is owned by the MoH and all partners
have aligned with its protocols and
implementation mechanisms, actively taking
part in the working group meetings.
Other successes include the development of
a set of PRN training and implementation tools
(job aids and registration forms and books),the
implementation of a pilot learning centre in five
districts in Nampula Province, continuation of
training and integration in the ‘at-risk child’
consultations (CCR), prevention of mother to
child transmission of HIV (PMTCT) services,
and triage in many health centres. Additionally,
in places where community leaders, practitioners
of traditional medicine and APE/ACSs have
been trained, there is increasing interest and
support from the communities.
A further success of the Mozambique experience
is the integration of treatment of
malnutrition for people with and without HIV.
The existence of one protocol and one national
programme aimed at treating malnutrition,
regardless of HIV status, has resulted in costsharing
and collaboration among partners and
donors who support the target group of children
less than five years and people living with
HIV. For example, PEPFAR-supported partners
are very active in supporting the
PRN programme.
Finally, there has been an
improvement of awareness on nutritional
support by many health staff
and those in district and provincial
health offices. This has led to increasing
numbers of patients receiving
nutritional assessments, counselling
and rehabilitation.
Challenges
A number of challenges remain in
the case of Mozambique that will
affect national scale-up:
Training
Questions remain as to how to maintain
the quality of training at all
levels using the ToT cascade model. Potential
solutions put forward include the development
of a training video, increasing the number of
other training tools and ensuring adequate
supervision where possible.
Implementation/service delivery
Close follow up is also required for effective
service delivery. This has not always been
possible due to capacity constraints. It is
expected that (where active), NGO clinical partners
can assist the government to follow the
programme closely, including via clinical
mentoring.
Recording and reporting
Insufficient capacity (including knowledge of
software such as Microsoft Excel), commitment,
and understanding of the importance of reporting
at all levels create challenges for achieving a
timely and accurate reporting system. The data
are rarely analysed or further scrutinised (for
example, for possible causes of high mortality
rates or increasing or decreasing caseloads).
This could be due to heavy work-loads of MoH
staff, but the barriers need to be identified in
order to improve the system.
Supply chain management
Lack of effective supply chain management,
forecasting and procurement create major
challen- ges to ensuring uninterrupted supply
chains. Capacity in this area is weak at all
levels, not only for nutrition supplies but for all
supplies managed by the MoH.
Therapeutic foods are difficult to transport
and store because they are heavy and bulky.
Weak logistic skills of health staff have led to
poor forecasting of the quantity of products
needed, resulting in frequent stock-outs.
Funding issues
The short funding cycles of donors and a lack of
financial resource commitment to support the
PRN at all levels hinders strategic long-term
planning. RUTF supplies are not yet secured
after mid-2013.
Other challenges include:
• The health infrastructure is undermined by
a lack of qualified staff and high turnover of
medical staff and managers. One approach
to address this problem would be to train
all health facility and hospital staff in
districts where PRN/CMAM operates.
• Issues of community access, e.g. distance
from health facilities, preference of the traditional
care system and shortage of community
mobilisation efforts.
• Poor understanding of malnutrition at the
Maaike Arts, UNICEF, Mozambique
Sign for the RUTF factory in Beira City
community level (malnutrition is not necessarily
perceived as a medical or dietary
problem, but rather as a spiritual problem),
which prevents communities from seeking
professional health care. This should also be
addressed through the strengthening of
community mobilisation and involvement
in the PRN activities.
The way forward
While the PRN can already claim success in
expanding the availability of CMAM, the
following steps are required to ensure a continued
and successful scale-up of the
implementation of the new protocol:
1. Finalise Volume 2 of the manual for the
treatment of acute malnutrition for adults.
2. Strengthen the quality of training, including
the development of additional training
tools and video-based training modules.
3. Produce and distribute job aids and materials
at all levels.
4. Develop a plan to support the implementation
of the protocols, once training of
health workers is finalised.
5. Establish supportive supervision systems
and ensure that they are routinely applied
(finalise the tools, implement the supervision).
6. Prioritise community involvement and
initiate this in places where it does not
exist. This should include building a cadre
of specialists who can provide technical
assistance on the community components.
7. Strengthen recording, reporting and analysis
of the data (promoting the triple A cycle of
assessment, analysis and action).
8. Strengthen supply management and logistic
systems.
9. Secure adequate and on-going funds for
supplies.
10. Consider the establishment of a technical
group focusing on community based work.
11. Investigate the causes of mortality in
children with SAM.
12. Design a plan for the introduction of the
new protocols in pre-service training of
health and nutrition workers of all levels.
For more information, contact: Edna Possolo,
Head of the Nutrition Department, Ministry of
Health. Email: epossolo@misau.gov.mz or
ednapossolo@gmail.com, Yara Lívia Ngovene,
email: yngovene@misau.gov.mz, Maaike Arts,
email: marts@unicef.org
11
Ministry of Health/Health Partners Group Performance
Assessment Framework, March 2011.
50