Introduction My name is.. ACF – Action Against Hunger, we work in the fields of nutrition, FSL and WASH. Today, I’m here to talk about our nutrition program in DRC, and specifically our approach to scale up Community management of Acute Malnutrition (CMAM).
To start with, few words about the country: DRC located right in the middle of Africa: 2 nd country by size in Africa (after Sudan), 64.000.000 habitants. Vast country then, mainly covered with forests which make access very challenging in most part of the country. In the past few years, all 6 of 11 provinces have been surveyed, mapping of acute malnutrition avalaible.
What is interesting looking at this map, is to see that contrary to a common perception of the situation in DRC, nutrition crisis are not necessarily related to the ongoing conflitcs.
So the situation as we find it is that. Based on that, there is a need to define a strategy that would adress the issues to allow scale up of CMAM implementation
A strategy that would help reach and treat a high number of beneficairies, and therefore be cost efficient
And be fully integrated within the Health system, in a sustainable manner, which is the spirit of the CMAM approach itself.
To achieve this, opportunities are numerous. … .. The question for us was: where are the needs? Where can ACF bring support, and complement what is already existing? Where can we act to actually make a difference?
After several years of experience on the field in DRC, lessons learnt from our programs, and understanding what works and what does not, we ended up with 3 simple strategic pilars I would liek to present to you today.
The old way of trying to achieve integration within the health system was for a long time about training of medical staff in local hospital. We would train, supervise the staff in charge, leave buffer stock of all sort of items needed to perform the treatment, and consider the mission accomplished. Working at the local level does not allow sustainability. Lack of supervision, staff turn over, lack of means.
Then we looked also into working with the central level. The development of new internationalprotocols was a good opportunity to initiate discussion with the central level for them to buy in and support its implementation in the country. But is become quickly clear that the central level needed to be involved in every step on the way in the design and the implementation of nutrition program, for them to be able to support them on the field, include them in their annual budget, and to roll them out.
And finally, one level we neglected to consider the longest is the provincial level, who has a role that is very similar to the one of local government in a federation. In DRC the provinvcial level is accountable for the activities that are going on at the local level to the central level, and it is the one who make sure that the policies and strategies decided at central level are implemented on the field. It’s role is crucial in the development of the CMAM strategy.
2 nd pillar: support all components needed for the actual implementation of the nutrition program. Technical training is essential but not sufficient to allow the CMAM program to happen.
There is a lack of resources at all levels to perform nutrition activities. The material support we provide is ….. This support is not necessarily directly directed to the nutrition program: ita iams at supporting the system as a whole. The objective of this material support is clearly to support the program to happen, but it is also an incentive. Medical treatment in DRC is provided through a Cost recovery approach, and severely manourished individuals and considered indigents (do not pay for treatment); no motivation from medical staff to treat them.
And lastly, there is a need to support the Organisational part of the program: what I call organisational part englobes all actions and ressources needed to allow an activity to happen. The strategy for the CMAM implementation has been designed at central level but need for plan of action, tools, indicators, RH and items management, tranportation and stock. UNICEF and WHO ensure that items are available for free, but need proper report on their use, program indicators, and propre order request.
The third and last pilars I would like to mention today: Our capacity to identify crisis and intervene in emergency. We developped a program: the PUNC= Nutrition Emergency pool Technical and support staff, anthropometric and health education material are prepositioned to be deployed for rapid interventions. Surveys are implemented when red flag Emergency interventions on a 3 months period. Exit strategies: handed over to an ACF / other NGO or to MoH Advocacy for neglected areas Overall resources: 75 technical nutrition personnel (100% national) 50 support staff (logistics, administrators, drivers etc.) Budget ~ 9 millions USD / year (not including the RUTF).
Concretely, what is the outcome of our programs In 2010: 41 nutritional evaluations (survey, rapid screening), 16 emergency interventions, 35 heath zones supported through regular programs, 3200 nurses, 250 medical doctors, 13.000 community health workers, 450 MoH management personnel and supported the treatment of reached more than 42,038 SAM beneficiaries.
Short funding cycles: difficulty to assess the sustainability of the approach Bottle neck for RUTF supply: RUTF still expensive, even if local production Turn over of medical staff: constant need to perform training The department in charge of nutrition is parallel to other departments within the MoH (primary health care, prevention, IMCI) Community workers are a key component of the CMAM approach, and overall their contribution has be great, but we are facing issue of lack of motivation, will to be remunerated for the time they spend of the program, overlap with other health services (immunization, etc). We wish we could develop a way to make the most of all data collected throughout the country Last but not least, we address SAM only, while CMAM is also about MAM. And beyond treatment of MAM, there is a need to implement programs for the prevention of SAM (FSL, health, etc). The way is still long, but some significant steps have been overtaken since the past few years, and t
Lessons in the Integration of CMAM & IMCI Activities_Whitney_5.12.11
Supporting CMAM Scaling up Democratic Republic of Congo 05/17/11 May 2011
Mapping of Acute Malnutrition <ul><li>EDS 2007 : All provinces MAG> 10% </li></ul><ul><li>Territory surveys 2009/2010: </li></ul><ul><li>100 territories surveyed, only 3 territories with MAG <5%. </li></ul>05/17/11
Mapping of Acute Malnutrition 05/17/11 Conflicts
Context 05/17/11 <ul><li>Acute malnutrition is present all over DRC </li></ul><ul><li>Causes are structural as well as contextual </li></ul><ul><li>Poor coverage of nutrition programs </li></ul>Scale up CMAM implementation
Context 05/17/11 <ul><li>Acute malnutrition is present all over DRC </li></ul><ul><li>Causes are structural as well as contextual </li></ul><ul><li>Poor coverage of nutrition programs </li></ul>Scale up CMAM implementation High cost efficiency
Context 05/17/11 <ul><li>Acute malnutrition is present all over DRC </li></ul><ul><li>Causes are structural as well as contextual </li></ul><ul><li>Poor coverage of nutrition programs </li></ul>Scale up CMAM implementation High cost efficiency Sustainable integration within health programs
Opportunities 05/17/11 <ul><li>From ACF </li></ul><ul><li>Professional and qualified technical personnel </li></ul><ul><li>Co facilitator of the national Nutritional Cluster </li></ul><ul><li>Provides technical guidance and support to the MoH </li></ul><ul><li>From MoH </li></ul><ul><li>Political will to address acute malnutrition </li></ul><ul><li>Policies, strategies implemented and updated </li></ul><ul><li>Effective and fruitful collaboration with ACF </li></ul><ul><li>From communities </li></ul><ul><li>Concerned by the problem </li></ul><ul><li>Will to take part into the program </li></ul>
ACF Strategy 05/17/11 Support all levels of management and implementation
ACF Strategy 05/17/11 Support all levels of management and implementation
ACF Strategy 05/17/11 Theoretical and on the job training, on going formative supervision Medical personnel, community volunteers Technical capacity Building Local level
ACF Strategy 05/17/11 Training of trainers and theoretical training, Update of protocols in line with international nutrition guidelines Technical capacity Building Local level Central level
ACF Strategy 05/17/11 Training of trainers, theoretical training, creation of provincial pools Technical capacity Building Local level Provincial level Central level
ACF Strategy 05/17/11 Support all levels of management and implementation Support all components of the nutrition program
ACF Strategy 05/17/11 Supply, equipment, logistic chains, cash, rehabilitation, Transport for supervision Technical capacity Building Material support Local level Provincial level Central level
ACF Strategy 05/17/11 Implication of partners from project design Stock maintenance, supply requisition, activity report, organizational charts, data analysis, communication with higher levels and suppliers & partners Technical capacity Building Material support Organisa- tional support Local level Provincial level Central level
ACF Strategy 05/17/11 Support all levels of management and implementation Support all components of the nutrition program Capacity to identify and address emergencies
Challenges still to be addressed <ul><ul><li>Short funding cycles </li></ul></ul><ul><ul><li>Bottle neck for the RUTF supply </li></ul></ul><ul><ul><li>High turn over of medical staff and managers </li></ul></ul><ul><ul><li>Lack of communication/integration of MoH main offices </li></ul></ul><ul><ul><li>Lack of leadership on Community workers management </li></ul></ul><ul><ul><li>Too little analysis of data generated (surveillance?) </li></ul></ul><ul><ul><li>Prevention of SAM (MAM, FSL, WASH), </li></ul></ul><ul><ul><li>… .. </li></ul></ul>