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Monitoring change: one-to-one tuition is transforming the skills of health extension workers in Ethiopia Elissa Jobson

CMAM monitor shows health extension worker how to read weighing scales at Shekosh health post

SOMALI REGION, ETHIOPIA 25 July 2013 – Ali Hassan visits Sheykosh health post in Degahbur every six weeks or so. Each time he goes, he spends the whole day working closely with local health extension workers Ifrax Mukhtar and Rumaan Axmed, providing them with much needed advice and support as they administer treatment to the acutely malnourished children living in the area.

“I give them on the job training,” says Ali. “I’ve shown them how to weigh each child, how to take the MUAC [the middle-upper arm circumference used to diagnose severe wasting], how to correctly fill in the patient cards, and when and how to give routine medicine. Every day I come, I assess what’s missing and how to fill the gap until my next visit.”

Ali is one of a cadre of monitors being trained and deployed by UNICEF, with support from ECHO, the European Commission Directorate-General for Humanitarian Aid and Civil Protection. His mission: to give vital one-to-one mentoring for health extension workers – the frontline in the community management of acute malnutrition (CMAM) programme.

Why are the monitors needed?
“Before Ali started coming to my health post I used to enrol every child with oedema into the out-patient treatment programme (OTP), but I learnt from him that oedema does not necessarily mean that a child has malnutrition,” Ifrax says. “He has also shown me how to measure oedema properly and explained that some of the oedema cases will need referral to the health centre.”

Health extension workers should have this basic information at their fingertips when running CMAM programmes but Ifrax fell pregnant during her CMAM training and was unable to finish the course. “I missed some of the sessions and had forgotten some of what I had learned when I returned to work,” she explains. Unfortunately, many other health workers also have gaps in their knowledge which can compromise the quality of the life-saving outpatient treatment they administer.

This is not to suggest that CMAM is not effective. It clearly is: since 2008 more than 1 million Ethiopian children have received treatment through the programme, which utilises the country’s extensive network of health posts (each serving one kebele or sub-district with a population of around 5,000 people) and its growing army of health extension workers to provide community-based care for children who are dangerously malnourished. According to some analysts, CMAM, with a cure rate of around 84 per cent, has contributed substantially to Ethiopia’s rapidly declining child mortality, which dropped by 40 per cent in the five years to 2012.

But, as Sylvie Chamois, a nutrition specialist at the UNICEF Ethiopia office, explains, the speed with which CMAM has been introduced means that the supplementary support provided by the monitors is sorely needed: “The monitors are important because the scale-up of CMAM to the health posts has been very rapid. In 2008 there were less than 100 sites and as of today, just five years later, there are over 11,000 health posts operating outpatient therapeutic programmes. So you need good supportive supervision in the field to ensure that the quality of service and treatment is high.” This is particularly true for Somali region, she continues, where CMAM is very new and the rollout of the health extension programme only started recently.

UNICEF supports the Government roll-out of CMAM since 2003 with technical and financial assistance (development of guidelines, trainings and quality assurance) as well as supply procurement and provision (therapeutic foods, drugs, anthropometric equipment, etc). ECHO is currently contributing to the support of CMAM services in 39 woredas in Afar, Amhara, Oromia, SNNPR and Somali regions.

Putting theory into practice
The classroom-based training the health extension workers receive on malnutrition, while providing a good basic grounding, is sometimes difficult to translate into reality at the busy health posts.

Star pupil Radia Mohamed, aged 24, outside her office at Garman health post

“When I first came to Sheykosh, Ifrax couldn’t even fill in the OTP card,” says Ali. “She said that she had received training but it was only theoretical – she had never actually filled in a card before! So I showed her practically how to do it and watched her fill in the card.”

Ali believes that the one-to-one support he gives is essential. “With theoretical learning the health extension worker may capture only a few pieces of information, but when you show her practically how to take the weight of a child, for example, she will do it perfectly and she will never forget,” he insists.

And Ifrax agrees: “Ali comes to the health post on the OTP day and stays with me the whole day. He helps me check the weight and the MUAC. He doesn’t just come, check my documents and leave. He explains and spends some hours with me and engages in my activities.” She says that she would like to receive more of this kind of in depth training and mentoring, adding: “Every time the monitor comes I gain more information. I want to continue and increase the amount of support he gives us.”

The monitors offer a different kind of support for experienced health extension workers like Radia Mohamed, 24, who runs Garman health post in Shinile zone. She works with former nurse turned CMAM monitor Abdi Mohamed, aged 28. “When I see a very severe case I call Abdi and ask him what do to. Sometimes the children are so wasted that it can be scary but I am 100 percent more confident since Abdi started visiting,” she says.

The result on the ground
The difference that the monitors are making is clear to see. Based on nine strict criteria[1], such as each health post is assessed on the quality of the CMAM service it is providing. When Ali first visited Sheykosh health post its scorecard was just 62 per cent. Four months later it had risen to 89 per cent. This kind of transformation has been witnessed across Somali region in those health posts where the monitors are working.

[1] Criteria assessed are Community mobilisation; Management of admissions and discharges; Referral and management of complications; Weekly follow-up; Treatment management; Recording and reporting; Supply and logistics;Supervision and Water, sanitation and hygiene practices.And this improvement in the assessment scores is being turned into real results on the ground, as Ifrax illustrates: “At the beginning, because all the children were small I used to give out equal amounts of Plumpy’nut [ready to use therapeutic food (RUTF) used in the treatment for acute malnourishment]. But Ali brought a calculation table and showed me that I should use the weight of the child so that there is not uniform distribution of the Plumpy’nut.” When she started giving the correct number of RUTF sachets she realised that the children were recovering more quickly. “Providing that a child doesn’t have any other illness, the majority recover within 4 weeks. In the past they were staying on average seven weeks. This is a big change.”



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