Madagascar is prone to food insecurity and nutritional crises, mainly because of its vulnerability to environmental factors such as recurrent floods, drought and insect infestation that exacerbate an already precarious situation. About half a million children are affected by acute malnutrition, with wasting prevalence as high as 13 per cent among children under five. There is a shortage of nutritional rehabilitation services – only 36 are available in hospitals throughout Madagascar – and access to basic health services and utilization rates are low.
In 2005 and 2006, the country experienced a nutrition emergency in two regions, affecting about 150,000 people, including 24,000 children and 4,500 pregnant and lactating women. In the affected regions, characterized by remoteness and scattered populations, acute malnutrition rates rose above 20 per cent.
Strategy used and actions taken
To respond to this emergency, UNICEF and partners opted for ambulatory treatment of both moderate and severe acute malnutrition cases, implemented for the first time in Madagascar in an emergency context. This strategy was chosen to ensure appropriate coverage rates by alleviating the difficulties faced by communities in accessing health facilities. Therapeutic feeding centre or supplementary feeding centre (TFC/SFCs) services were set up in five fixed sites at existing health facilities and at 28 ambulatory sites that were visited by staff from the fixed sites on a weekly basis.
The existing community nutrition network was reinforced: All of the ambulatory SFC/TFC activities were carried out in existing community nutrition sites, and community workers were actively involved in the weekly sessions with the visiting health staff. The community workers carried out home visits to provide follow-up for children receiving special food treatment and conducted health education sessions for emergency response workers.
The operation was carried out by the national government and NGO partners, with formal and on-the-job training, close follow-up, technical support and regular supervisory visits ensuring the quality of both medical and nutritional services. UNICEF provided strong technical assistance for the design and implementation of the nutritional response, assisted the regional coordination team, and provided coaching for field staff. Special attention was given to promoting and supporting national leadership in emergency management through support to coordination, joint supervisory visits and continued technical assistance.
Close to 90 per cent of the affected children were treated and 82 per cent of those were discharged as cured. An anthropometric nutrition survey using the SMART (Standardized Monitoring and Assessment in Relief and Transition) methodology confirmed that the acute malnutrition rate dropped from 20.4 per cent in December 2005 to 10 per cent in April 2006.
Key factors that contributed to this success include:
This experience confirmed the relevance and efficiency of ambulatory treatment for acute malnutrition and the potential for extending this approach to routine management of acute malnutrition through existing community nutrition sites. As a result of the lessons learned from this operation, the National Nutrition Office, Ministry of Health and Family Planning, and UNICEF updated the national nutrition protocols and management tools to include a transitional TFC phase and incorporated guidelines on the ambulatory treatment of severe acute malnutrition and home-based treatment.
The experience also increased collaboration between public health staff and community nutrition workers, who worked hand in hand on the screening, diagnosis, treatment and follow-up of malnourished children. Building on this, the Ministry of Health is considering implementing a community-based therapeutic care (CTC) approach at community nutrition sites. Since the mid-1990s, the country has been developing community-based nutrition networks in the most at-risk areas, and there is a plan to increase coverage. The lessons learned from the implementation of ambulatory treatment of SAM, including the vital role that community health workers can play in the absence of facility-based care/treatment, will inform the scaled-up CTC approach. In addition, the national nutrition alert system is being modified to strengthen growth monitoring data at community nutrition sites and use the data for early warning: an increase in underweight prevalence should automatically activate an anthropometric nutrition survey.
UNICEF will be supporting the Ministry of Health throughout 2007 as it pilots the revised early warning system and the CTC approach in six locations during an initial 12-month period. This initial phase will allow for fine-tuning the strategy for implementation at scale, defining policy as well as coordination mechanisms and specifying roles and responsibilities of community workers, basic health facilities and hospital-based therapeutic feeding centres.
Activities will aim at (1) strengthening the collection and analysis of data on growth monitoring to determine the prevalence and trend of underweight in the community and to identify a cut-off point for activating the alert system; and (2) capacity-building of community nutrition workers and facility-based health staff on community-based therapeutic care (CTC) to improve families’ access to appropriate care at reduced costs and with minimal inconvenience.