Concept Paper on a proposed IMAM programme in Mogadishu, Somalia
Introduction
Estimates of Severe Acute Malnutrition (SAM) in Somali urban contexts are currently estimated to be 5.1% (Source: Somalia Nutrition Cluster data). There are no reliable estimates of the SAM rate in Mogadishu although anecdotally the situation is considered to be “Very Critical” (Source: FSAU report Feb 2009).
Currently in Mogadishu there are 7 OTP sites (3 MSF-E & 4 ACF) operating through static and mobile sites serving 7 districts. While caseloads are high in these locations the geographic positioning of the centres often does not indicate local access to services since this is moderate by clan boundaries. In addition there are few functional health facilities offering other health services such as maternal and child care.
The current concept is to rehabilitate 16 MCH buildings in Mogadishu and establish OTP sites to treat children with SAM. The rehabilitated MCH units will provide a platform for yet more health services to be integrated through other partner organisations. A primary focus will be put up on capacity building.
As part of a wider IMAM approach a supplementary feeding programme to treat Moderate acute malnutrition will be instigated. Discussions with WFP are being finalised regarding the availability of food commodities and, where possible, the SFP programme will be implemented prior to the OTP programme as a matter of prioritisation to prevent deterioration of more cases to SAM. Where RUTF is not available to SAM children they will be enrolled in the SFP programme and given double rations of Ready to Use Supplementary Food as a bridge to therapeutic care.
Consultation with UNICEF has received commitment of RUTF supplies to treat the children with SAM. Thus the MCH units will provide a location for additional nutritional support as part of the wider IMAM approach.
Currently SAACID is running 16 wet feeding centres with considerable success. Children with SAM have to this point been identified through MUAC screening and referred to ACF inpatient units where only those SAM cases with severe complications are able to be treated. The addition of the OTP services at the MCH will enable the proper treatment of children with SAM without complications.
Agencies active in Somalia including ACF, MSF, Medair, Concern Worldwide and technical fora such as FSAU and the Somali Nutrition Cluster have been consulted during the programme design process to ensure protocol harmonisation.
The methodology of implementing IMAM (or CTC) through local NGO partners through capacity building is also currently operational in other challenging contexts; Oxfam Novib is implementing CTC via local organisation in 4 provinces in Afghanistan with technical support and training provided by Valid International and will soon be evaluated for expansion to another 4 provinces.
Objectives
Treat 1400 children with severe acute malnutrition < 5 yrs as identified with MUAC <11cm (assumption SAM rate = 0.8%, Coverage =50%) after 6 months and up to 8000 children (assumption SAM rate = 5.1% as defined by WHO growth standards W/H <-3Z scores, coverage =50%) after 12 months
Operational environment
Security: All project staff will be recruited from local communities to staff OTP and trained in security procedures according to SAACID security policy. Additional technical and managerial staff will be trained in and adhere to Oxfam Novib / SAACID security policies. Mitigation of security risks will be ensured through the inclusion of local community representatives and key leaders from all targeted districts of Mogadishu in planning the placement of the MCH units. Representatives of IDPs (which form a large segment of the population in some districts) will be included in this process. Sites will be selected with attention to providing equitable access to OTP sites in relation to geographic distribution and accounting for clan boundaries. Provision of guards at OTP sites will provide additional security during distribution days. A major contributor to the provision of a safe operational environment is the SAACID methodology of site selection through negotiation with key leaders from across Mogadishu. Such negotiation has contributed significantly to the success of the wet feeding programme currently operating and will be duplicated for the site selection for MCH units.
Logistics: RUTF and routine medications required for the treatment of SAM will be provided by UNICEF with local contractors taking responsibility for safe storage and delivery to OTP sites. Adequate storage facilities already exist in Mogadishu. Buffer stocks of RUTF will be positioned at OTP sites to mitigate temporary breakages in the supply chain. It has been noted (Source: UNICEF) that basic facilities for a cold chain for measles vaccination already exists in Mogadishu. The OTP may be conducted with a minimal water supply (for RUTF appetite test) at worst. However the full functionality of the MCH will require a water supply. It is planned to install elevated tanks in the MCHs or bladders where needed as an interim measure. Water supplies will be trucked for tank / bladder filling
Interagency collaboration
Oxfam Novib will recruit a programme Manager for IMAM in Mogadishu. Local staff on the ground will be selected from candidates proposed by the community and appointed by SAACID to work in this programme. As far as security constraints allow, the Oxfam Novib project Manager will work directly with the field based nutrition advisor and SAACID field staff. Training and further technical support will be provided by Valid International. EC and UN partners will provide supplies and funding for rehabilitation of MCH units and the treatment of malnutrition respectively.
Oxfam Novib continues its representation on the Somalia Nutrition Cluster and with the appointment of the programme manager will continue to contribute to the development of nutritional programmes in association with partner organisations.
Planning figures and assumptions
A pre-requisite for programme implementation will be an adequate supply of RUTF. Initially the OTP may be started using RUTF borrowed from stock in country. Since supplies will be limited targeting will be strictly limited to those at high risk of mortality using MUAC. Assuming coverage of 50% may be attained this would result in the treatment of approximately 1400 children less than the age of 5 yrs. With programme maturation, adequate supply and staffing the targeting will be changed in line with WHO growth standards. The caseload for the same coverage would be expected to reach 8900 children treated in OTP for SAM. These figures may vary based on the assumptions of 50% coverage and that district population estimates from June 2008 remain valid and were accurate at the time of estimation.
Building costs will vary according to the size of the MCH; estimates vary from small MCH-USD10,000; medium MCH-USD15,000 and large MCH-USD 25,000. At the time of writing the senior community leaders are in negotiations to identify suitable sites for the OTPs and the cost estimates for rehabilitation (Expected to be in the region of USD 400,000 including administration costs. Consultation relating to coordination with the presently existing OTPs of MSF and ACF has been conducted and will account for barriers to access at the existent locations.
Operational phases and activities
The first phase of the operation will consist of rehabilitation of the MCH departments with the sites being selected by the community representatives themselves during a workshop organised by SAACID. The indicated time for rehabilitation is approximately 6-8 weeks. However the programme will require that the MCH units become available in 2 phases of 8 to allow programme expansion over 2-4 months.
When the first 8 MCH units have been completed the first phase of OTP implementation will begin. Roll out of the programme will be completed upon completion of the final 8 MCHs. In the interim between site selection and building completion clinicians will be trained in CTC at a remote location (Somaliland) to ensure trainers have access to a suitable training environment with access to operational OTP sites for practical experience. A mid term evaluation and coverage survey will determine the appropriateness of staffing, supplies and security to recommend expansion of the targeting to enrol many more children in the programme (caseloads may multiply by 5 times).
Data collection and analysis
Building works: SAACID will provide contracts of work, photographs and GPS locations of the building sites. Design specification will be provided by Oxfam Novib
OTP: SAACID staff will collect individual patient progress data via the OTP treatment card and supply monthly reports in standard unicef format to the programme supervisor (Oxfam Novib-field based) and the programme manager (Oxfam Novib-Nairobi based) for integration into the HMIS data management system. Remote technical support from Valid International will be provided on an as needed basis. When security conditions allow, the Nairobi based programme manager will visit the operational site for direct monitoring visits. When this is not possible evaluations may be conducted through meeting with staff at a remote location with the OTP cards to assess adherence to protocols and other indicators which may suggest a need for improvement in practice. When security allows direct evaluation on the ground will be conducted by Valid International.
SAACID staff will supply monthly data reports; Oxfam staff will provide monthly data reports and quarterly progress reports; Valid will provide Assessment, training and set up, mid term evaluation, final evaluation reports.
Sustainability
Skill transfer and the provision of MCH units make this programme potentially more sustainable although Somalia is likely to be dependent on donor aid for the foreseeable future. The provision of the MCH units however does provide a platform for the integration of other health services presently unavailable in Mogadishu. While the operational environment remains insecure and uncertain, the SAACID methodology of community engagement has provided other operational sites with relatively safe spaces to deliver humanitarian aid. This methodology will underlie the provision of other nutrition and health services.
Risk management
Financial exposure to the local organisation SAACID will be mitigated through regulated cash transfer procedures, rigorous on financial accountability procedures and as much as possible transfer of support as supplies rather than in cash. Much of the suppliers will come from UNCIEF and WFP.
SAACID is a long term partners of Oxfam Novib and has managed large projects with large portfolio over the years. Oversight support will also be provided via SAACID Australia which has operation and technical support commitment to SAACID Somalia. A SAACID operations director based in Nairobi will also closely work with Oxfam Novib to assure quality and efficiency.
Oxfam Novib will maximise possibilities of expert staff travelling to the field. For this Oxfam Novib has currently engaged a security consultant to revise the security procedures and guidelines with a view to enhancing its ability to operate and run programmes in insecure contexts.
Outputs
16 functional MCH units
8900 children <5 yrs with SAM treated in OTP at 16 sites at 12 months
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