Tanzania: An Integrated Approach to Managing Severe Acute Malnutrition
Issue addressed
Despite the well-documented relationship between malnutrition and child mortality, nutritional interventions received little attention in Tanzania throughout the 1990s. During this ‘lost decade’, many health strategies focused on a single disease, and when efforts at integration were made – as through the integrated management of childhood illness (IMCI) approach – nutrition was the weakest component. By 2000, 43 per cent of children in Tanzania were stunted and 31 per cent were underweight. In addition, many suffered from micronutrient deficiencies, with vitamin A deficiency alone accounting for one in seven deaths of children between the ages of 6 and 59 months.
Tanzania’s national Demographic and Health Survey data released in 2005 indicated that there were approximately 40,000 severely malnourished children in the country, in addition to about 450,000 moderately wasted children and 2.4 million chronically malnourished children. Quality-of-care data show that curative services are failing these children. For example, the Joint Malaria Project found malnutrition services to be among the country’s worst, with many malnourished children dying before being registered and therefore not even counted in hospital statistics. In one major hospital in Dar es Salaam, WHO and Ministry of Health (MoH) staff estimated that severe malnutrition accounted for around 60 per cent of child deaths. More conservatively, a report released in 2006 by Research on Poverty Alleviation, a Tanzania-based NGO, found malnutrition to be at least an underlying cause of 60 per cent of child deaths in Tanzania.
Strategy used and actions taken
In view of the critical need to address child malnutrition, UNICEF began by raising awareness of the issue. It also trained, in May 2006, 80 clinicians and nutritionists on the international protocols for facility-based management of severe acute malnutrition (SAM).
Following this, since classroom training was not felt to be sufficient, field training sessions were organized for clinicians from 11 regional and district hospitals, who visited Ethiopia to learn about integrated management of SAM.
The third strategy was to support the importation of the therapeutic products needed for management of SAM, since these were not part of the essential drugs list and were therefore difficult to import.
Finally, UNICEF sought to ensure the sustainability of these measures by partnering with the Paediatric Association of Tanzania (PAT) and the International Food and Health Association (IFHA) to enable them to take over the training of clinicians, establishment of national standards and delivery of essential therapeutic products.
Results
To date, the 11 regional and district hospitals have begun piloting the integrated management of SAM strategy. The Paediatric Association of Tanzania is facilitating the process through on-the-job training, supervision, monitoring and evaluation. PAT will also support the elaboration of national protocols to include management of SAM and will revise the training curricula of medical and nursing schools accordingly. In addition, it will maintain a national database of performance indicators for each of the hospitals piloting the integrated strategy.
As a result of strong advocacy with the Tanzania Food and Drugs Authority (TFDA), therapeutic products for the management of SAM are now permitted. TFDA is processing the registration of such products (for example, F75, F100, Plumpy’nut and ReSoMal) to allow their importation, and IFHA is in discussion with Nutriset, the French makers of Plumpy’nut, to set up a local producer.
Each of the 11 regional and district hospitals will support the health clinics in implementing the outpatient treatment. It is expected that by the end of the first year, as many as 10,000 severely malnourished children will have been reached through these interventions, approximately 6,000 of whom would probably have died otherwise. Although some 500 children are expected to die even with these interventions, it is noteworthy that this initiative, operating through only 11 hospitals, is expected to save the lives of approximately 5,500 children in a single year.
Lessons learned
The international protocols for management of SAM have been available for a decade and have been successfully implemented in many African countries (Burundi, Chad, Ethiopia and Niger) as part of emergency relief. However, in non-emergency countries, the management of SAM has received far less attention, and hospital treatment practices are extremely outdated.
The SAM initiative in Tanzania has helped to highlight broader nutrition problems in the country and enabled clinicians and nutritionists to comprehend the full impact of a ‘silent emergency’ like malnutrition on the lives of its children.
The initiative has fostered partnerships between civil society (PAT), the public sector (MOH/TFDA) and the private sector (IFHA) that are a first step towards dealing with other nutrition issues, such as the management of moderate acute malnutrition and chronic malnutrition.
Remaining challenges
The key challenges ahead are: (1) finding ways to scale up the management of SAM to all hospitals and health clinics to ensure that every child has access to proper treatment, (2) finalizing and validating national protocols, and (3) mainstreaming the management of SAM in health policies and strategies.