Community based treatment of severely malnourished children in Ethiopia

By Mulatu Yirba

Ethiopia is one of the developing countries where a great deal of public health problems are evident, and infant and child mortality rates are high. One of the main causes of the high child mortally rate is acute and severe malnutrition due to different infectious diseases and inadequate intake of nutrients. Child mortality as a result of severe malnutrition is high not only because health services are not available and accessible, but also there is a lack of clear treatment protocols and inadequate supplies in the health facilities, and lack of awareness in some communities about what to do when their children have such problems.

Mostly treatment of severe malnutrition is there when there is a nutritional emergency and mainly facilitated and implemented by non-governmental organizations. To get better treatment, one has to go to hospitals or therapeutic feeding centers (TFC), that are out of the reach of many who need the service, where some inpatient services are available and the child has to wait there for up to 30 days until he or she is fully recovered. Since many children are confined in the same room at TFC or hospitals, it is most likely that they are exposed to cross infections. Furthermore, the costs to the family of having to stay in the centre or hospital are very high. Caregivers, usually mothers, have to stay in centers or hospitals for several weeks leaving their other children and family members at home and rendering them unable to engage in daily activities.

To address the challenge of treatment of children with severe malnutrition and decrease child mortality, Concern Ethiopia, an international non-governmental organization where I used to work for before I came to U.S, started an initiative of pilot projects to institutionalize Community based Therapeutic Care(CTC) in the already existing ministry of health system to make it part of the routine services at all levels (hospitals, health centers and health posts). The concept of CTC was developed by Valid International and it is an innovative concept that mobilizes communities and supports local health services to rapidly and effectively treat those with acute malnutrition in their homes.

The ideal elements of CTC are: community mobilization, out-patient therapeutic care (OTP) for cases of severe acute malnutrition without medical complications, in-patient care for those with medical complications and supplementary feeding for those with moderate malnutrition to prevent them from becoming severely malnourished. But the main focus of the project where I was working was mainly outpatient treatment, community mobilization and referral of those few cases with medical complications (severe anemia, marasmic-kuwash, edema 3+, no appetite to RUTF (Ready-to-Use-Therapeutic-Foods), frequent diarrhea and vomiting, severe infectious diseases, etc.) to hospitals and TFC. This pilot program was totally implemented by ministry of health with initial minimal support from Concern and UNICEF which includes training of health professionals in health facilities and community volunteers (who are already volunteering for other health activities like family planning and expanded program on immunization (EPI)), and provision of drugs and other supplies like RUTF , routine medicines (anti-worms & antibiotics) and vitamin A.

Severely malnourished children are identified through screening of the affected population by community volunteers or self-referral. Once they come to the nearest health facility they are screened using three anthropometric measurements, such as Mid-Upper-Arm Circumference (MUAC), weight & height (to compare with the standard) and assessment of pitting bilateral edema (I am not sure whether this approach is changed now). Based on these measurements and assessment, a child between 6months-5 years (the program focuses more on these age groups) is severely malnourished if his or her MUAC is <11.0cm or wt/ht <70% or has bilateral pitting edema or any of these two or more combinations. In addition to these, the trained nurse asks parents or care givers of the child’s medical history and does thorough physical examination to detect any medical complications. Once they fulfill the criteria of out patient treatment (which is the case for more than 80% of severely malnourished children based on my observation), they get the necessary treatment and take RUTF home for one week. After that they come every week for medical assessment, anthropometric measurements and take RUTF for another week and continue like this until they are declared to be cured, non-respondent or referred to other places for the same treatment or for impatient care based on the treatment protocol.

Production of Ready-to-Use-Therapeutic-Foods (RUTFs) already started in Ethiopia and, I hope, this local product will dramatically lower its cost and increase availability which are the main challenges of the program. As I saw from its ingredient lists, the original spread RUTF recipe contains 5 ingredients: peanut butter, vegetable oil, powdered sugar, dry skim milk and a mineral vitamin mix. When I was there (2006/2007), RUTF production in Ethiopia had been challenged with difficulty of importing ingredients not available locally, particularly dry skimmed milk and the mineral vitamin mix. They were finding ways to produce from locally available ingredients (I do not know the status this time).

My role in this national CTC pilot program was mainly working with ministry of health, particularly, at the grassroots (Zonal and Woreda) level in providing training, supervising, monitoring and evaluation of the program activities. It was a great experience for me because I have observed many of those children, who would otherwise die without this CTC, have been surprisingly able to gain weight fast, their edema disappeared and was cured. I have seen the feelings of parents when they saw their children become happy, play, eat well and become healthy. One nurse told me, and I quote,” I feel proud of being a nurse; I am saving life” after he saw the dramatic changes of children in the program. My feeling was the same, if not more, than the nurse.

The effectiveness, based on my observation, is very promising to fully institutionalize CTC in the existing MOH (Ministry of Health) system and decrease children mortality and morbidity (illness) due to acute severe malnutrition, inclusion of acute severe malnutrition treatment as a main component within the minimum health services package. Ensuring that staff training and provision of treatment supplies will still need much work along with support from MOH and others like UNICEF. The need to address health financing policy issues to facilitate access to free treatment for severe acute malnutrition is also another issue which has economic implications and, I think, needs political commitment and policy adjustments. I mentioned these challenges because I believe they are keys to the sustainability of the program. In my opinion, even though it is not debatable that the availability of this treatment service saves the lives of many of those who are already severely malnourished, it is not by itself enough to solve problems of malnutrition; it needs to coordinate with other livelihood programs and tackle the route causes.

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