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Postscript
Postscript
cIYCF in Zimbabwe
By Fistum Assefa
Fitsum Assefa is currently working as UNICEF
Nutrition Manger, in Zimbabwe.
Zimbabwe has a high prevalence of
stunting (32%) and low prevalence of
wasting/acute malnutrition (3%)
(DHS 2011). The trend in stunting
suggests deterioration as compared to the early
90s, while the prevalence of acute malnutrition
remained the same or slightly improved. Of
note, the national average masks the prevailing
disparities across geographic regions and
wealth status, for example, there are districts
with stunting prevalence of over 40% and both
stunting and acute malnutrition are much
higher among the poorest segment of the population
as compared to the wealthiest.
CMAM services in Zimbabwe were initiated
as of 2006, with rapid expansion from 2009 (see
Figure 1). Due to the low acute malnutrition
context and existing health care infrastructure 1
it has been possible to integrate the management
of severe acute malnutrition (SAM) in
Zimbabwe with the existing curative and
preventive health care delivery system.
Currently over 70% of the 1600 health facilities
provide inpatient and outpatient SAM treatment
on a routine basis.
To help fill an existing gap, training materials
to support integration of infant and young
child feeding (IYCF) in CMAM were developed
at international level in 2009 2 and piloted
in Zimbabwe (2010), However, this approach
has failed to show any impact on prevailing
IYCF practices. This is partly related to the fact
that it is unrealistic to expect a rare situation
(90% of infants and young children
with poor IYCF practices). Also, CMAM offers
no contact with newborns and generally speaking,
with infants in the first six months of life.
On the contrary, we find our cIYCF initiative as
a key opportunity to ensure access and compliance
to other health and nutrition services,
including treatment of SAM.
The cIYCF assessment and counselling service
initiated in Zimbabwe is one of the many
solutions we are pursuing simultaneously to
ensure optimal IYCF is practiced. These include
improving policy, guidelines and tools for use
Figure 1: Growth in CMAM services in Zimbabwe,
2006-2011
1000
1000
800
600
400
448
608
at different levels of management and service
delivery, addressing the socio-culturaleconomic
barriers that take account of the role
and influence of others/gatekeepers within the
family/community (grandmothers, elders,
fathers), addressing the health workers’ and
managers’ knowledge and skill gaps, and advocating
for longer term commitment, integration
and resources for IYCF programming.
The missing elements in previous IYCF
promotion efforts (e.g. through world breastfeeding
week (WBW) communications, and the
WHO 40 hours training to master trainers, facilitators
and health workers) is lack of vision and
accountability mechanisms that link the training
to provision of counselling service and
changes in IYCF practices. A typical ‘cascade’
approach in IYCF training takes 8 – 10 people at
a time as ‘master trainers’ (who are not always
trained through a competency based approach),
who in turn train ‘facilitators’ (training usually
undertaken in a hotel or a training facility,
mainly theoretical, with little skills based training),
who then are expected to further train the
frontline facility staff and VHWs. Often when
country training action plans are drafted, after
regional or national TOT, the cost and time
implications are unrealistically huge that
discourage national decision makers and
donors.
Because of resource and logistical challenges,
training of frontline workers typically
lacks quality and coverage. Such an approach
results in a few ‘trained’ health workers spread
thinly throughout the country. This means that
those who are not trained or are trained using
earlier guidelines outweigh those trained using
more recent guidelines. The few newly trained
staff often cannot exhort significant influence
and their skills, knowledge and passion slowly
dies off.
Zimbabwe has attempted to address this by
finding a means for efficient and rapid expansion
of knowledge, skills and tools covering a
whole district at a time (within a week) and
attaching trained people to real cases that they
follow, starting with pregnancy/early infancy
Figure 2: Pre and post test results (responses to 15
questions) for Gwanika, Gokwe South district
training
100
80
60
40
to about two years of life. In our approach,
quality of training is emphasized and the
trainer/trainee ratio is 1:4/5, as per evidence of
the ideal ratio that can facilitate skills based
training. Valuable tools are included in the
training package for pre-post assessment that
determine improvement in knowledge and
skills. An example of the impact of training in
one location is shown in Figure 2.
To date, 14 districts have been covered by
this initiative, resulting in over 2,000 CCs and
over 20,000 mothers/infants accessing counselling
services on an on-going basis (1CC:10
mother/infant pairs). In addition, these 20,000
women take part in supporting other mothers
and access peer support themselves, as every
trained health worker facilitates the establishment
of at least one mother-to-mother support
group in their village.
During the trainings and supportive supervision
visits, it is emphasised that assessment
and counselling on IYCF is one of the key interventions
towards addressing undernutrition in
Zimbabwe and that the role of VHWs is pivotal
to the current momentum in the country to
address stunting as a matter of urgency (e.g.
SUN movement, National Food and Nutrition
Security Policy, etc.). We encourage a sense of
accountability by each VHW towards ensuring
optimal IYCF practices and to contribute to
further understanding of barriers and facilitation
of IYCF practices in their catchment
community. Accountability is increased
through location training reports that record
who has trained who, the contact details of
trained VHWs (including cell phone numbers
where available) and who is following up
which infant/mother pair. This will allow
determination of any pattern of training and
service provision outcome that can be
explained by quality of training and support.
So far, the VHWs appear motivated and
inspired to identify pregnant mothers from the
early days of pregnancy (which is also required
by other initiatives such as Maternal Mortality
Reduction, PMTCT 3 , etc.) and provide IYCF
counselling. They are also motivated to keep a
record of how feeding practices are evolving
with each infant/child over time. This can
easily be linked to nutritional outcomes, given
the demand for a growth monitoring and
promotion service in Zimbabwe. Such a system
of ongoing identification, assessment and counselling
of mothers will serve as an opportunity
to promote use and compliance of other health
and nutrition services and serve as a backbone
to build on additional interventions in IYCF,
such as home fortification of food. This in turn
can improve the demand and effectiveness of
community level IYCF counselling services.
Zimbabwe hopes to share experiences in
relation to results of this initiative on IYCF
practices and nutritional outcomes in future
issues of Field Exchange.
For more information, contact: Fitsum Assefa,
email:fassefa@unicef.org
200
0
101
17 27
2006 2007 2008 2009 2010 2011
Stabilisation centre
Total sites
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
% pre-test results % post-test results
1
Though weakened by the recent crisis, it is in the process
of recovery/being rebuilt stronger.
2
Integration of IYCF support into CMAM, Oct 2009. ENN, IFE
Core Group, Nutrition Policy Practice. Funded by the Global
Nutrition Cluster (IASC).
3
Prevention of Mother to Child Transmission of HIV
97