Funding Proposal: Extended CMAM study: Zinder Distict, Niger

Introduction

This research aims to trial an adapted version of the Community-based Management of Acute Malnutrition approach to Severe Acute Malnutrition (SAM). The standard CMAM approach, now integrated widely into national nutrition protocols.The strategy combines outpatient treatment and community participation to enable home-based care for the majority of SAM children. The reduced demand on inpatient resources and on the community’s opportunity-costs means a huge increase in sustainability from previous models. However, full integration of CMAM into Ministry of Health activities still constitutes a huge challenge with a massive decrease in available health centre and outreach resources. The extended CMAM model to be piloted here aims to use Community Based Volunteers to implement in-situ treatment for beneficiaries thus significantly further reducing the demands on external resources and rendering the CMAM approach fully sustainable in a low resource environment.

Main Objective

Compare performance indicators and results of the roll out of (CMAM) Community-based Management of Acute Malnutrition by means of a randomised control trial located in two similar areas. The first area will be a control zone in which CMAM will be implemented in an Outpatient Therapeutic Programme (OTP) – known as CRENAS in Niger - and Stabilization Centres (SC) – known as CRENI in Niger. This is the standard implementation method recognised in the National Protocol. The second area (known as the intervention area henceforth) will use a decentralised CMAM implementation method for SAM without complications. This method will be implemented by Community-based Volunteers (CBV) – known as ASC in Niger in health posts.

Means of Verification

  • Coverage survey reports
  • Analysis of routine programme data and statistics
  • Reports from supervision visits
  • Final report on the study

Specific Objectives

Specific Objectives of Extended CMAM

  • Improve access to treatment for cases of Severe Acute Malnutrition (SAM) in a MoH run CMAM-style programme
  • Maximise the contribution of Community-based Volunteers in CMAM programmes
  • Provide a more sustainable treatment of severe acute malnutrition at community level

Specific Objectives of the Extended CMAM trial

  • Study the cost-efficiency of an adapted model for CMAM, as based on the method currently contained within the National Protocol; with a particular focus on cost versus improved mortality rates
  • Adapt and integrate CMAM activities into those of the Community-Integrated Management of Childhood Illnesses (C-IMCI) programme already being implemented by the Community-based Volunteers in Niger

Means of Verification

  • Coverage survey reports
  • Reports from supervision visits
  • Analysis of routine programme data and statistics
  • Documentation of the adapted protocol of extended CMAM
  • Training materials
  • Training and evaluation tools
  • Reports on the training of health centre staff

Background to the study:

NGO-lead Implementation of Standard CMAM Programme from 2005

Save the Children – United Kingdom (SC-UK) started operations in Kantche and neighbouring districts in August 2005 in response to the then nutrition crisis by establishing a CMAM programme. In line with national protocols and standard CMAM operations, the programme comprised three core components: an OTP, a Supplementary Feeding Programme (SFP) and community mobilization. These are briefly described below:

  • Outpatient Therapeutic Care:thisinvolves the home-based treatment of severe acute malnutrition and is targeted to malnourished children with an appetite and without medical complications. Children receive initial medical treatment in the outpatient centre followed by a weekly ration of Ready-to-Use-Therapeutic Food (RUTF) until the desirable weight gain is achieved. The RUTF is distributed from outpatient centres, where the child’s progress is also checked, and then administered at home.
  • Supplementary Feeding: this component is targeted to moderately acutely malnourished children who receive a fortnightly take-home ration made of a cereal blend and oil until the desirable weight gain is achieved.
  • Community mobilization:Essential in a community-based nutrition programme, this element includes the collection of information concerning community networks, health-seeking behaviours and understanding of the programme, as well as the sensitisation of the community to the programme (including screening and referral issues) via existing communication networks and key-informants.

Phase-out of NGO support and integration of CMAM programme

The CMAM programmewas run in an "emergency" mode for about 3 years. This meant that, although the CTC sites were located next to the health centres/posts there had been little involvement of the local Ministry of Health (MoH) staff in nutrition activities which were implemented by SC-UK mobile teams. Due to a change in the policy environment andfollowing concrete steps taken by the MoH towards the integration of the treatment of acute malnutrition into the health system, SC-UK has recently reviewed its nutrition strategy and, from January 2009, has started to integrate OTP activities into MoH operations in all the health centres in Kantche district having phased out SFP inDecember2008. A MoU on integration between the Regional and District Health Authorities was signed in November 2008. Initial plans involveSC-UK support of the integration process for a year and progressive transfer of responsibilities to the MoH over this period of time. The integration experience will be reviewed on a regular basis and support from SC-UK will be adjusted according to the reviews’findings. The quality of the programme will be a key element in determining the degree of support and the timing of SC-UK’s phase out.

Rationale for Locating Pilot Study in Kantche:

The Continuing Impact of Malnutrition in Zinder

The most recent national survey carried out by INS/UNICEF/WFP in June 2008 estimated the national prevalence of Global Acute Malnutrition (GAM) at 10.7% with 9% GAM in girls and 13% in boys. Significant differences in GAM levels were observed across the different regions of Niger with the lowest prevalence in Niamey (7%) and the highest in Zinder (16%). It was noted that there had been no overall improvement, as compared to June 2007, with a national figure of 11% GAM. Furthermore, the GAM prevalence in children 6-35 months was found to be alarmingly high with 15% at the national level and up to 21% in Zinder region.

On the other hand the prevalence of severe acute malnutrition was estimated at 0.8% at the national level with 0.6% in girls and 1.1% in boys with regional variations and the highest level in Zinder with 2% SAM. The prevalence of severe acute malnutrition was found to be much higher in children below 35 months than in older children with 1.3% and 0.1% respectively at the national level and 2.9% and 0% respectively in Zinder region.

The Implication of CMAM Integration for Programme Sustainability

Given Zinder’s position as the district most severely affected by the high rates of GAM and SAM, considered alongside the absence of any significant reduction in both rates since 2007, it remains a priority to treat those children affected with an efficient and effective programme. Of all the regions in which CMAM has been implemented, this is particularly important in Zinder given the regions vulnerability in this regard. As discussed above, SC-UK are currently in the process of a staggered phase-out their own support for CMAM in the region during which time they are supporting integration of the method into MoH activities. Despite the significant efforts being made by SC-UK to support integration and activities being undertaken by the MoH to ensure that CMAM activities are fully maintained, ensuring programme sustainability in a development context is an enormous challenge. Among other things, this is because the level of community outreach supported by emergency NGO programmes is not feasible in a MoH-run programme. In addition, numbers of staff available for running distribution centres are greatly reduced as NGO operations are phased out and any staff assigned to this work must deal with a heavy workload from their other areas of responsibility. In short, following the implementation of an NGO emergency level response, maintaining the same level of activities after a comprehensive integration process is unfeasible if using a standard CMAM approach. As has happened in many other country contexts, the pilot integration of one health-centre in Kantche during 2008 demonstrated some of the problems associated with reduced resource input and lead to many beneficiaries switching to a distribution centre still being fully run by SC-UK. Integration in this centre was temporarily reversed ahead of full integration while efforts were made to alleviate the adverse affects of integration. It is expected that the implementation of Extended CMAM will play a key role in rendering continued CMAM activities sustainable in this heavily food-insecure context.

Expected Results

  • CBV in the intervention zone are trained and capable of carrying out extended CMAM activities
  • At least 50% of cases of SAM in the intervention zone identified and receiving adapted treatment
  • Recovery rate in the intervention area is similar to that of the control area and greater than 80%
  • The defaulter rate in the intervention area is less than that in the control area and under 5%
  • The rate of referral to inpatient care (CRENI) in the intervention area is less than that in the control area

Risks and Hypotheses

  • The two areas identified for the study remain both similar and comparable for the duration of the study
  • The provision of supplies (RUTF and medicines) for the management of SAM remains regular and reliable without any rupture to stock
  • There are no sharp increases in the malnutrition rate in the two implementation areas for the duration of the study giving rise to the need for an emergency intervention
  • The partners currently operating within the two implementation areas do not change for the duration of the study

Study Activities

Planning Phase

  • Identification of the areas for implementation of the study (control and intervention areas) according to criteria established by the research protocol
  • Implementation of two nutritional surveys: one in the intervention area and the other in the control area
  • Preparation of a tailored protocol, adapted from the current national CMAM protocol, for the management of SAM by the CBV in the intervention area (extended CMAM)

Set up stage

  • Training / refresher training in CMAM for health centre personnel
  • Training / refresher training of CBV based in the control area in current national CMAM protocol and standard CMAM activities
  • Training and refresher training of CBV based in the intervention area in the adapted CMAM protocol and in the management of CMAM activities in health posts, with an emphasis on diagnosis (Middle Upper Arm Circumference (MUAC) and presence of oedema), the prescription and administration of RUTF, and in the referral of cases to the OTP or the SC
  • Training / refresher training of the CBV in the intervention area in C-IMCI activities
  • Training of village health committees in the management of RUTF stocks
  • Implementation of two coverage surveys in the two areas of operation (the intervention and control areas). These surveys should be conducted during the final phase of the study.

Implementation Stage

  • Supervision of routine activities carried out by the CBV in the intervention area with an emphasis on growth monitoring activities
  • Supervision of routine adapted CMAM activities carried out by CBV in the intervention area with a focus on: activities, performance, results, observation of protocols and criteria
  • Supervision of CMAM (OTP) activities being conducted by health centre staff in the two zones with a focus on: activities, performance, results, observation of protocols and criteria
  • Analysis of routine data produced by the programme both with regards to the general performance of the extended CMAM programme and to the specific study being conducted
  • Monitoring of the quality of programme registers and documentation

Final Phase

  • Analysis of the final programme data and evaluation of the results
  • Implementation of the two coverage surveys in the two areas of operation to be compared to those implemented at the beginning of the study
  • Drafting of a report on the research carried out and the results obtained

Inputs

  • Preparation of extended CMAM protocol
  • Preparation of training tools for CBV, other community actors (eg. village health committee) and OTP staff
  • Training of CBV
  • Training of health centre/OTP staff
  • Preparation of management tools (individual follow-up forms, data collection forms, decision making flow-charts) for extended CMAM activities
  • Preparation of tools for the evaluation and analysis of the variables to be monitored during the study

Outputs

  • Objective and comprehensive data obtained regarding the quality of the extended CMAM programme
  • In the intervention area, the CBV will be trained in extended CMAM protocols and therefore able to assure the sustainability of the management of SAM in the area
  • Report analysing the results of the research with a detailed evaluation of the extended CMAM strategy’s efficiency

Budget

See attached spreadsheet

Timeline

The provisional timeline presented in the below table is based on a data collection period of one year

Activité / T1 / T2 / T3 / T4 / T5 / T6 / T7 / T8 / T9
Formalités administratives
Réunions d'information
Formation des équipes
Supervisions formatives
Collecte des données
Supervisions évaluation
Saisies des données
Analyses des données
Rapport Final
Publications