Vulnerability assessment and nutrition survey in 2009
Training CHWs to reinforce further their capacity in screening and actively identify malnourished children, recognition of danger signs and referrals to appropriate services – HF and community ; deliver BCC community outreach services -community assessment-community mobilisation-active case finding and referralcase follow-up; behaviour change communication. Train CHWs in active and passive case findingScreen for MAM and SAM using MUAC,Management of acute moderately malnourished child (PD/Hearth and Community Kitchen)Care groups and CHWs include prevention of malnutrition in BCCReinforced community health servicesC-IMCI Training of CHWs on screening with MUAC and referral for malnutrition reinforced by the CMAM programIntegration of CHWs as nutrition volunteersUse of Care Group and local leaders trained in C-IMCI BCC dissemination to include nutrition messages on prevention OTP supervision and follow up by MoH district supervisors and MAM supervision in the community by nutrition staff in charge of health centres
Creating a linkage with health facilities for severe cases and complications by training Health facility staff on management – OTP/Stab, supervision of CHW in additionHealth facility IMCI- curative under fives – assessment of nutrition status- referrals for complications
Contributed to advocacy for national level policy (technical working group included CMAM treatment in national protocol )MOH Government of Rwanda have made CMAM part of their health service delivery Supply chain for materials for the CMAM program have been integrated with the routine medical supply chain (although improvement is still needed in storage and avoiding stock-outs).
A Rwanda-specific protocol for CMAM has been developed and approved for implementationCMAM services reached more than 8,000 acutely malnourished children through active case finding and referral, outpatient therapeutic services, community based nutrition activities and inpatient treatment services.Awareness of acute malnutrition was raised among personnel across central, regional, district, and village levels (low in the health agenda). Screening for acute malnutrition during the mother and child health weeks appeared to increase program reach in remote areas (but not necessarily uptake due to distance, mutuelle health insurance and cultural perceptions about malnutrition causes)Close collaboration between the Government of Rwanda, EIP and UNICEF, through provision of technical input and support.
Emergency plan to eradicate malnutrition - The plan is a national effort to identify and treat every young child identified as acutely malnourished and then implement strategies that attack the problem district by district across the countryTechnical and policy working groups - provided strategies and policies, guidelines, protocols, capacity building and data systems in CCM-IMCI, Malaria and nutrition -Decentralization – given the district health team autonomy in programming
with lower levels of acute malnutrition but where a constant case load of malnourished children needs management through existing services. Officially recognised CHWs – mobilize govt resources and supplies – spported the motivation Com PBFMade it easier to promote management of acute moderate in the community This is likely to be a result of the emphasis of the programme being on treatment, rather than on prevention. Treatment of acute severe and moderate malnutrition need to be presented within the context of malnutrition prevention as multi-sectoral strategy.
A number of reasons for this were identified, including distance of travel to OTP sites, lack of sensitization of traditional healers, national insurance membership, stigma associated with poverty, and the attitudes of some health centre staff. Harmonize CMAM data reporting and to fully integrate with the community Health information System (Com-HIS)Collaborate with international and national level donors to fill the gap in appropriate, cost-effective responses to moderate malnutrition within the context of an integrated approach with agriculture & livelihoods, education & HIV and AIDSDesign and implement a communications strategy that addresses socio-cultural obstacles to accessing services for malnourished children
RWANDA EXPANDED IMPACT CHILD SURVIVAL PROGRAM- Integrating CMAM with C-IMCI A Partnership of Concern Worldwide, International Rescue Committee and World Relief CORE group meeting - May, 2011
1/5 of the total population Over 300,000 children under five years
Direct Beneficiaries of the Program CHW-binome Mother Child Health center Manager /HC providers
Strategic Objective Reduce childhood mortality and morbidity using community-based integrated case management of diarrhoea, pneumonia (ARI), fever (malaria), and nutrition (added later) reinforced by social mobilization and behaviour change strategy (Care Groups)
Why Integrate Nutrition? Malnutrition is known to be a contributing factor in over 35% of all child deaths in Rwanda 52% of children are stunted, one in five are underweight, and 4.6% are wasted Access to acute malnutrition services was poor MoH recognized the need to identify and address the management of acute malnutrition in the community
Integration at the Program level-Health Facility
Management of Acute Malnutrition flowchart Community Health facility CHW conducts home visit/community growth monitoring and assess child with MUAC SAM (Severe Acute) Moderate (MAM) SAM without complications SAM with complications PD hearth/ Community kitchens Refer to health centre for OTP Referral to district hospital for stabilization
NATIONAL PROTOCOL FOR THE MANAGEMENT OF MALNUTRITION Kigali, on May,2009 REPUBLIC OF RWANDA MINISTRY OF HEALTH P.o. Box 84, Kigali www.moh.gov.rw
Impact to Date A number of positive elements emerged from integration of the CMAM approach with Com-IMCI Added value to CSHGP expanded impact National nutrition protocol CMAM services reached and treated over 8,000 Acute Malnourished children Awareness of acute malnutrition (baseline- low in the health agenda) Increased donor funding and available technical support MUAC screening included national vaccination campaigns
Elements & Factors that Facilitated Integration Strong Government commitment - “Emergency Plan to Eradicate Malnutrition” launched in May 2009. Existence of mobilized community network (30,000 non-salaried Community Health Workers)- 2 per village Existence of strong national level technical and policy working groups led by the MOH. Decentralized structure of governance maximized community involvement and mobilization to support integration.
Learning Highlights 1. Although CMAM was developed for emergency settings, it has proven to be equally effective in non-emergency 3. Network of CHWs integrated into the formal health system and implementing CCM 4. CSP strategy provided natural base for CMAM 5. No significant improvement in prevalence of acute malnutrition (baseline vs end of project nutrition survey)
What Needs to be Done to Improve Integration Data reporting and integration into national community HIS Collaboration to address the main problems causing malnutrition in the context of integrated approach Design strategies to address barriers to accessing services for malnourished children
Welcome to the Land of Thousand Hills!Thank You