Download a PDF of this issue - Field Exchange - Emergency ...

Field Article
community understood that the service would
be provided once the supplies had arrived.
At health system level, the nutrition initiative
also made a positive contribution:
“The best thing is that nutrition became mainstreamed
in district health system of the affected
districts. Trainings on CMAM of community
level workers, LHWs and community based
organisations (CBOs), health care providers in
the facilities and involvement of district health
managers, it all resulted in a continuum of
raising awareness about nutrition, of which
no-one knew about previously”.
NGO Representative
Another positive aspect of the response was
that all the partners had a similar understanding
of roles and responsibilities.
“Everyone knew who will do what. What would
each one get in terms of training, finances and
logistics and who will ensure transportation of
supplies till the end distribution point. Previously
it had emerged as a big challenge to ensure
supplies at the district level, with very limited
means of distribution. This time the donor was
well aware that the delivery of supplies till the
last point will require additional assistance.
Previously the supplies were just delivered at the
district warehouse.”
Provincial Level Respondent from Health
Department
Although payments were usually paid to
government staff to monitor the programme,
“The district coordinators of National Programme
for FP and PHC and the EDO were given a fixed
per diem for the visits conducted against the
approved monitoring plan previously submitted”.
Provincial Level Respondent from Health
Department
During the initiation of training, each LHW was
provided with a mat and utensils etc. for the
strengthening of their health houses so that
they could conduct activities and demonstrate
good practices, such as hand washing. The
LHWs also received a per diem for their work,
which reportedly enhanced motivation.
Challenges for CMAM in Balochistan
The aforementioned shortage of doctors in rural
areas was a major constraint in effective implementation
of activities. Additionally LHWs are
not present in many rural areas and there are
some concerns about possible politicisation in
this province, because of the importance of relationships
with local tribal leaders.
A high turnover of government staff necessitated
frequent re-training. It was common to
find untrained staff providing CMAM services.
Frequent stock-outs of RUTF and other products
to treat acute malnutrition were
experienced due to difficulties maintaining an
uninterrupted supply chain.
The deteriorating security situation posed a
great challenge both to programme implementation
and monitoring. Some programmes had
to close down due to escalating security
concerns.
Another hurdle was engaging the medical
officers of the PPHI. These medical doctors,
despite invitations from the DoH, did not join
the training on facility-based CMAM. It was
assumed by the department of health that being
a non-state provider, the PPHI thought itself to
be a competitor. PPHI on the other hand had
71
basically no mandate for CMAM. Hence the
Basic Health Units (BHUs) could not be
engaged.
By virtue of their presence and roots in the
community, as well as their access to donor
resources, the local NGOs have an advantage.
They often understand local power structures
well and are able to manage the potential political
pressure from local power brokers. Their
ability to network can generate increasing
community demand for CMAM services.
“We found significant number of people coming
from villages, demanding for the ‘chocolate’
(RUSF) for their kids.”
NGO Representative
While NGO programmes are vital, particularly
during disasters, sustainability issues prevail at
all levels of programme implementation.
Lessons learned
The CMAM response in Balochistan has shown
that a timely emergency response is crucial in
order to contain rapidly deteriorating situations.
Ownership within the health department,
especially at district level, make a visible difference
for programme success, although it must
be recognised that payments for government
staff to provide services might compromise
longer-term programming, in terms of expectations
(implementation of CMAM programmes
resulted in additional per diem payments).
Involvement of the community in the screening
process resulted in better acceptance and
understanding of the programme. Local NGOs
were particularly successful in breaking the
substantial gender barriers in rural areas during
the disaster, engaging with the affected people,
especially pregnant and lactating women.
NGO staff tend to stay in positions longer,
probably due to the better remuneration packages
that NGOs are able to offer. Questions of
sustainability are repeatedly raised.
The structural factors and underlying socioeconomic
conditions will influence whether a
child is likely to relapse into acute malnutrition,
as remarked by a representative from a NGO
that implemented SCs but not OTP.
“We witnessed that kids referred from poor
socioeconomic households recovered from SAM
in the SC after admission and treatment and
went to their community but later returned with
the same set of complaints again for which they
were admitted earlier.”
NGO Representative
The future for CMAM in Balochistan
At present, the provincial team is concerned
that the post-18th amendment scenario will be
characterised by an immediate vacuum in
policy and technical assistance that formerly
came from federal level.
Additionally, the approach to date has
been highly donor dependent. While these
strategies provide short-term solutions for
nutrition problems, longer-term financial
support from donors is required to sustain
programmes and to develop a provincespecific
nutrition policy.
A family who had taken refuge in Sangarh
District, Sind. They had lost their crops in
the floods. The mother is pregnant.
Khyber Pakhtunkhwa (KPK): Scaling Up
at Home, Rolling out Elsewhere
Khyber Pakhtunkhwa (KPK) was in a relatively
better position to respond to the flood emergency,
due to prior experience of large-scale
emergencies and previous work on CMAM. At
the time of the 2010 floods, the DoH was able to
scale up existing operations rapidly. It is clear
that the previous capacity built in nutrition
response proved effective in facilitating scaleup.
Despite KPK being the worst affected
province, it performed better in terms of reduction
in SAM and GAM prevalence in
subsequent surveys, when compared with
other provinces, such as Sindh.
Although there was a disaster contingency
plan in place, it was not entirely successful due
to extensive damage to nutrition-related
commodities stored in a warehouse located on
the bank of the river Kabul, which was washed
away by the floods. The floods badly damaged
the health facilities, most of which were
submerged partly or wholly by the floodwater.
It was a considerable challenge to establish SCs,
the CMAM model was therefore modified.
Mobile teams were introduced and provided
services directly to villages.
“In Nuashehra Noushera and Charsadda the
population settled along motorway, roadsides,
schools and scattered pockets. Health facilities
became non functional and inaccessible. Therefore
Dr S Qazi, Pakistan