Ghana: Integrated Nutrition Action Against Malnutrition (Innovation)
Major Area: Young Child Survival and Development
The Upper West Region (UWR), located in northern Ghana, is one of the country’s most deprived regions and has high child malnutrition and mortality rates according to the 2003 Ghana Demographic Health Survey (GDHS). In May 2007, UNICEF, in collaboration with Catholic Relief Services (CRS), initiated an Integrated Nutrition Action Against Malnutrition (INAAM) Project in the UWR with the aim of reducing severe acute malnutrition (SAM) among children under three years of age. The project, executed by the Ghana Health Service (GHS), provides Plumpy’nut® – a ready-to-use therapeutic food (RUTF) – to a targeted 2,000 children, along with intensive behaviour change communication (BCC) to their mothers with the help of Community-based Health Volunteers (CHVs).
The initial lessons learnt are that: 1) provision of Plumpy’nut® is a simple, quick and efficient means of reducing SAM in children under three in Ghana in the short to medium term; 2) community-based out-patient treatment of SAM using Plumpy’nut® improves adherence among mothers; and 3) a strong partnership with an efficient NGO is key to the success of the project.
This is the first time Plumpy’nut® was used in Ghana to treat SAM. Children receiving Plumpy’nut® in various in-patient nutrition rehabilitation centres (NRCs) were able to recover quicker than with other treatment regimes, enabling early return home. Children with SAM identified through GHS monthly growth-monitoring sessions in project communities could be effectively treated in their own homes, without the need for admission to in-patient care; mothers had the opportunity to learn from peers how to take better care of their children through the positive deviance approach. The project is innovative in that it provides the opportunity to complement the CRS and World Food Programme (WFP) feeding programmes, enabling children with SAM to recover to the “moderate stage”, and then continue receiving supplementary foods (corn-soy blends and vegetable oil) until they recover fully. The project also provided an effective means to reach children with SAM even in the most remote parts of the region.
This project has provided the opportunity for NRC managers, community health volunteers (CHVs), and mothers to work together to implement a simple and rapid-results strategy (combined Plumpy’nut® and BCC) to manage SAM, even in remote parts of the region. GHS officials in the region are now calling for the inclusion of more communities in the project. A national workshop conducted by GHS in June 2007 on the treatment of SAM created a tremendous awareness about Plumpy’nut® across the country. This national workshop now calls for making the product available for severely malnourished children in other parts of the country. The use of Plumpy’nut® to address SAM in Ghana has also gained strong interest among development partners, including USAID.
As a result, there is great potential for scaling-up the INAAM Project through GHS. Already, USAID, in collaboration with GHS, is planning to utilize Plumpy’nut® in a similar project during the first 8 months of 2008. UNICEF and USAID (through the FANTA Project) have initiated efforts to promote production of Plumpy’nut® locally in Ghana. Initial in-country investigation by both Nutriset (France, Aug 2007) and UNICEF confirmed that Plumpy’nut® production in Ghana is feasible. A number of potential producers have been identified, and a comprehensive plan for full-scale local production by December 2008 has been drawn up.
According to the Ghana DHS 2003, 26% of U5 children in the UWR are underweight (weight-for-age z-score < -2), over a third (34%) are stunted (weight-for-height z-score < -2), and 11% have acute malnutrition or are wasted, (weight-for-height z-score, WHZ < -2), of which nearly one of every four (24%) have severe, acute malnutrition (WHZ < -3). In comparison, the rates of child underweight, stunting and wasting in Ghana as a whole are 22%, 30% and 7%, respectively. Child mortality rates in the UWR (208 per 1000 live births) are also almost double the national average (111 per 1000 live births).
Reducing the persistently high malnutrition rates in the UWR demands new strategies. A successful approach will increase child survival rates in the region and the country, since malnutrition probably accounts for over 50 per cent of all child mortality in Ghana. The use of Plumpy’nut® in combination with BCC in the UWR was informed by the reported efficacy and success of Plumpy’nut® in the treatment of SAM in other African countries.
The INAAM Project used three strategic components: (i) facility-based rehabilitation, (ii) community-based rehabilitation and (iii) the positive deviance (PD)/Heath approach to behaviour change communication. In the first component, children admitted to all six NRCs in the UWR received Plumpy’nut®. Community-based rehabilitation took place in 102 communities in four districts (out of eight), where either CRS or the World Food Programme runs a supplementary feeding program. In these communities, children aged 6-to-36 months with SAM (mid upper arm circumference (MUAC) ≤ 12 cm) identified by GHS during monthly growth-monitoring sessions received two packets of Plumpy’nut® daily (1000 kcal/d) for five weeks; their mothers attended weekly intensive health and nutrition education sessions. In all, 13.8 metric tons of Plumpy’nut® was made available for approximately 2,000 eligible children. The PD/Health approach was implemented in six communities in two districts of the UWR. This approach empowers communities to address malnutrition by affirming positive local cultural practices (discovered during community-based positive deviant studies) and delivering nutrition education based on social learning theory and adult learning principles.
CRS was chosen as a partner for the following reasons: (i) their success in partnering with GHS over several years, (ii) their experience implementing child survival and nutrition programmes in the region, (iii) their logistical and human resources (including trained CHVs), and (iv) their capacity to and interest in scaling-up the project.
The first three months were used to procure supplies and equipment, conduct a baseline survey, train CHVs, and develop monitoring and evaluation systems. Available data as of November 2007 indicate that 563 children with MUAC ≤ 12 cm, out of 6,125 screened (9.2%), in 68 communities received Plumpy’nut®. Nearly 67% of these children were successfully rehabilitated (MUAC > 12.5 cm) within five weeks. Incomplete data from four NRCs show that 84 children on admission were successfully treated with Plumpy’nut® and were discharged within five weeks. Field interactions with mothers and the NRC managers reveal that the Plumpy’nut® was very well accepted by children. Mothers and NRC managers attested to the remarkably quick improvements in the health status of children consuming Plumpy’nut®. Trained CHVs provided intensive nutrition education to more than 500 mothers of children receiving Plumpy’nut® at the community level. Full results are expected in June 2008, when a formal impact evaluation will be completed.
Facilitating the establishment of a Plumpy’nut® production unit in Ghana is the next first logical step toward reducing or eliminating the huge freight costs associated with importation and allowing production to be controlled in-country to respond to current needs, such as emergencies. Fortunately, there appears to be substantial enthusiasm among development partners and potential investors to make this happen. Another step is to create more demand for the product through awareness-promotion within the Ghana Ministry of Health and among mothers, as well as to mobilize funds for purchase of Plumpynut® by the poor families who need it most.
Maintaining the gains already achieved in the INAAM Project communities is a challenge, since those communities still remain vulnerable, particularly to food insecurity. Plumpy’nut® is too expensive for poor families and has to be provided free of charge. It is also a challenge to scale up the project within the region (and beyond) due to inadequate resources compounded by poor infrastructure. Above all, the proportion of children with SAM is the tip of the iceberg; addressing the wider problem of moderate malnutrition is a far greater challenge.