BasicNutrition Services Package for Somalia

In recent years, nutrition partners in Somalia have made significant progress in the geographic scaling-up ofa basic curative nutrition package, virtually reaching SPHERE standards for coverage. Essentially the common point of almost all nutrition interventions in Somalia is that they involve the management of acute malnutrition. The nutrition partners, whilst recognizing this achievement in very challenging circumstances, now agree that a new challenge awaits them. The overarching objectives for the nutrition programme can now be summarized as:

  1. Maintenance of geographic coverage of programmes and expansion of client coverage.
  2. Incremental improvements in the quality of curative nutrition services.
  3. Expansion of access to evidence-based and feasible nutrition and nutrition related services, available through the existing nutrition service infrastructure to include preventative interventions and interventions linking nutrition to health, WASH, and livelihoods programming.

This document is intended to promote consensus around guiding principles for the implementation of this programme and guidance on what a basic nutrition services package would include at various levels of the Health System and throughout the lifecycle.

  1. Some interventions are considered to be immediately feasible in all areas of Somalia as International and National guidance and resources are available.In the table, these activities are labeled as Minimum.
  2. Some interventions, which are also considered as minimum requirements in a basic services package, maycurrently only be feasible for certain agencies to implement based on agency capacity, international guidance and experience of their adaptation to conditions in Somalia. Whilst other agencies may consider themselves not yet competent or ready to implement these types of interventions. Nutrition partners will endeavor to ensure that training and resources are developed to scale-up these interventions to achieve universal coverage in as short a time as possible. In the table, these activities are also labeled as Minimum and have an asterix in order to distinguish them.
  3. Finally, some interventions are evidence-based and should be part of a basic nutrition service package,but effective use of these interventions in Somalia may still require considerable adaptation, piloting and development of required resources. Nevertheless, partners may begin implementing these approaches as part of the development process. In the table these activities are labeled as Additional.

Guiding Principles:

  1. Nutrition Partners agree to support the Do No Harm principles in their work
  2. Nutrition partners agree to support the development and rollout of an essential package of nutrition services.
  3. Nutrition Partners agree to strive to work together to increase the quality of the delivery of the essential package of nutrition services, through collaboration, coordination and communication.
  4. Nutrition partners strive to integrate their services with those of health, water/sanitation, and livelihoods in order to comprehensively address the causes of malnutrition.
  5. Nutrition partners engage to support capacity building of communities and local partners to assist in knowledge and skill transfer.
  6. Nutrition partners agree to use nationally endorsed guidelines or, where they do not exist, internationally supported protocols. This will help ensure that a minimum of programme quality is respected.
  7. Nutrition partners engage to respect national reporting and monitoring formats and deadlines. Additionally, they strive to evaluate the impact of their programs, especially for new initiatives.

The essential components of the package include:

Essential components / Justification
Management of acute malnutrition / Contributes to reducing mortality and morbidity
Micronutrient supplementation / Reduces micronutrient deficiencies and contributes to reducing morbidity/mortality, contributes to improving growth & development, helps prevent neural tube defects, and helps ensure quality of breastmilk
Immunizations / Reduces morbidity and risk of malnutrition
Deworming / Reduces micronutrient deficiencies and morbidity
Promotion and support for optimal IYCF / Ensures optimal nutrient intake and contributes to reducing childhood morbidity/mortality and micronutrient deficiencies. Contributes to growth and development and reducing chronic and acute malnutrition. Also contributes to health of the mother
Promotion and support for optimal maternal nutrition and care / Prevents maternal undernutrition/micronutrient deficiencies and reduces likelihood of low birth weight babies. Helps maintain ability to breastfeed and ensure high-quality milk.
Prevention and management of common illnesses (anemia, malaria, diarrhea, pneumonia, and kalazar where appropriate etc) / Contributes to reducing mortality and risk of malnutrition.
Fortification (Home-based and food vehicles) and promotion of appropriate food fortification / Increases dietary quality and reduces micronutrient deficiencies. It also assists in targeting of harder to reach vulnerable groups such as women of child-bearing age or the elderly
Monitoring and surveillance / Supports program decision-making and ensures an up-to-date understanding of needs and programs to support resource allocation.
Common – should be targeted to all stages / Childhood / Infancy & post-natal mother / Pregnancy / Women of child-bearing age
COMMUNITY
Minimum /
  • Community mobilization on nutrition, malnutrition, and its identification
  • Identification (MUAC & oedema) and referral of cases of acute malnutrition. As well as follow-up of those who have defaulted from a nutrition program
  • Basic promotion forconsumption of nutritious locally available foods
  • Identification and referral of cases of diarrhea, respiratory tract infections and fever
  • Promotion and support for handwashing with soap, ash, or sand
  • Promotion and support for household drinking water treatment
  • Promote consumption of iron enhancers (ie. Lemon)
/
  • Promotion of appropriate feeding of the sick child
  • Basic promotion and support for optimal complementary feeding and continued breastfeeding for children 6-24 months*
/
  • Basic promotion of maternal nutrition
  • Encourage regular attendance at MCH and infant growth monitoring
  • Support and counseling services for early initiation and exclusive breastfeeding until 6 months *
  • Post-partumn vit A supplementation (through TBAs)
/
  • Promotion and support of early initiation and exclusive breastfeeding
  • Basic promotion of maternal nutrition
  • Encourage regular attendance at MCH and community-based services (ie. CHDs)
  • Promotion of deworming
/
  • Promotion of consumption of iron, folate, and vit A rich foods

Additional /
  • Promotion for consumptionmicronutrient fortified or enriched foods (ie. Flours, oil, sugar)
  • Specialized promotion for cultivation and consumption ofnutritious locally available foods
  • Support for formation of relevant support groups (ie. Breastfeeding, complementary feeding, etc).
/
  • Specialized promotion and support for optimal complementary feeding and continued breastfeeding, focusing on locally available foods/recipes
  • Promotion for child stimulation and play
/
  • Support for reduced workload and nursing breaks so that women have time for exclusive breastfeeding and care
  • Revitalize Umul period to help support proper care of newborn
  • Specialized promotion of maternal nutrition
/
  • Support for reduced workload and rest
  • Specialized promotion of maternal nutrition

Indicators /
  • # of community members sensitized and trained on identification of acute malnutrition
  • # of cases of acute malnutrition identified and referred by the community
  • # of community members trained on identification and referral of diarrhea, respiratory tract infection and fever
  • Increased awareness of locally available nutritious foods
  • Increase % of people using soap/ash/sand in hand washing
  • Increase % of households using home-based drinking water treatment (aquatab or boiling)
  • Increase number of households consuming enriched or fortified foods
  • Increase proportion of households cultivating and consuming nutritious locally available foods
  • Number of relevant support groups formed and active
/
  • Increase in appropriate feeding of the sick child
  • % increase in consumption of nutrient-rich foods in children 6-24 months
  • % increase in appropriate introduction of complementary foods for children 6-24 months
  • Improved hygiene behaviours when feeding children 6-24 months
  • % increase in number of mothers breastfeeding until child is 24 months
  • % of caregivers aware of key appropriate IYCF practices
/
  • # of women counseled in maternal nutrition
  • % increase in utilization rates at MCH
  • Increases in participation and understanding of growth monitoring
  • % increase in number of women report having time and support to exclusively breastfeed
  • % of caregivers aware of key appropriate IYCF practices
  • # of community-based breastfeeding counselors trained and giving correct advice
  • # of women supported with breastfeeding counseling
  • Prevalence of exclusive breastfeeding
  • Prevalence of initiation of breastfeeding within 1 hour of birth
  • # of sensitization sessions to revitalize tradition maternity care period (Umul)
/
  • # of pregnant women counseled in early initiation and exclusive breastfeeding
  • # of women counseled in maternal nutrition
  • # of sensitization sessions to promote attendance at facility and community-based health and nutrition services
  • % increase in utilization rates at MCH
  • % increase in number of women report support of reduced workload during pregnancy
/
  • Increased awareness of iron and folate rich foods among women of child-bearing age
  • # of newly-wed packages distributed
  • # of women reported taking multiple micronutrients

Common – should be targeted to all stages / Childhood / Infancy & post-natal mother / Pregnancy / Women of child-bearing age
OUTPATIENT or OUTREACH
Minimum /
  • Community mobilization….
  • Treatment of moderate and uncomplicated severe acute malnutrition (OTP & SFP)
  • Referral of complicated cases of SAM to inpatient facility (SC)
  • Identification and management of diarrhea with zinc and ORS
  • Identification and treatment of common illnesses ( anemia, malaria, and pneumonia)
  • Nutrition education
  • Nutritional monitoring and reporting
  • Provision and promotion of ITNs
  • Supervisor visits performed regularly for outpatient/outreach sites
/
  • Vitamin A supplementation
  • Deworming
  • Basic counseling and support for optimal complementary feeding behaviours *
  • Multimicronutrient supplementation
  • Measles vaccination or full immunization
/
  • Vitamin A supplementation of post-partum women (6 weeks)
  • Deworming of the mother
  • Micronutrient supplementation for lactating women
  • Referral of infants not gaining weight or not suckling/breastfeeding well to inpatient facilities
  • Support and counseling services for early initiation and exclusive breastfeeding until 6 months *
/
  • Multiple micronutrients supplementation
  • Deworming (from 2nd trimester only)
  • Promotion of early initiation and exclusive breastfeeding
  • TT immunizations *
/
  • Multiple micronutrients supplementation *
  • TT immunizations *
  • Education on IYCF and importance of appropriate child care

Additional /
  • Provision and/or promotion of fortified foods or supplements (ex. Sprinkles, LNS)
  • Adapted and specialized nutrition counseling focusing on locally available foods or products
  • Distribution of household drinking water purification materials
  • Growth monitoring
/
  • Full immunization coverage
  • Specialized promotion and support for optimal complementary feeding, focusing on locally available foods/recipes
/
  • Referral of complicated cases to a higher level care facility

Indicators /
  • # of malnourished cases admitted into SFP and OTP
  • Sphere Standards for coverage and exit indicators for SFP & OTP
  • # of complicated cases of SAM referred to SC
  • % of caregivers with knowledge where to access services for management of acute malnutrition
  • # of children with diarrhea treated with zinc (for at least 7 days) and ORS
  • # of children with common illness identified and treated
  • # of caregivers participating in nutrition education sessions
  • # of monthly reports completed and submitted
  • # of regular supervisory visits conducted
  • # of nutrition counseling sessions conducted
  • # provided with fortified foods or supplements
  • # of ITNs distributed
  • Promotion materials disseminated and used in facilities
  • Increased consumption of nutritious locally available foods
  • Increases in treatment of number of households treating drinking water
/
  • # of children receiving vitamin A every 6 months
  • # of children dewormed
  • # of women receiving counseling on optimal complementary feeding practices
  • # of children receiving measles vaccine
  • # of children receiving full immunization coverage
  • Increases in optimal child feeding behaviours (timing, food choice, hygiene, etc)
/
  • # of post-partum women supplemented with vitamin A
  • # of mothers dewormed
  • # of lactating women receiving micronutrient supplements
  • # of infants appropriately referred to SC
  • # of breastfeeding counselors trained and active
  • # of women receiving breastfeeding counseling
  • Prevalence of exclusive breastfeeding
  • Prevalence of initiation of breastfeeding within 1 hour of birth
/
  • # of pregnant women receiving multiple micronutrients
  • # of pregnant women dewormed
  • # of pregnant women counseled in early initiation and exclusive breastfeeding
  • # of pregnant women receiving TT immunization
  • # of women with complications referred to a higher level care facility
/
  • # of women receiving multiple micronutrients
  • # of women receiving TT immunization
  • # of women participating in IYCF promotion sessions

INPATIENT – STABILIZATION CENTRES
Minimum /
  • Medical and nutritional management of complicated severe acute malnutrition
  • Psycho-social , emotional support
  • Nutrition education, including breastfeeding and IYCF
  • Linkages with outpatient services
/
  • Catch-up immunizations
/
  • Relactation services
  • Management of infants not gaining weight at home
  • Support for the feeding of infants who cannot be breastfed
  • Provision of ITNs for discharge*
/
  • Referal to MCH on discharge

  • # of SAM cases admitted to SC
  • # of cases transferred to OTP once stable
  • % mortality
  • # of centers providing psycho-social and emotional support services
  • # of beneficiaries receiving psycho-social, emotional services
  • # of monthly reports completed and sent
/
  • # of women relactated
  • # of infants admitted to SC
  • # of infants admitted
  • who cannot breastfeed

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DRAFT BasicNutrition Services Package for Somalia