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Published on March 6, 2014
Author: malaria_consortium
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L EARN I N G PA P E R Integrating severe acute malnutrition into the management of childhood diseases at community level in South Sudan
BACKG ROUN D Learning paper series Since starting operations in 2003, Malaria Consortium has gained a great deal of experience and knowledge through technical and operational programmes and activities relating to the control of malaria and other infectious childhood and neglected tropical diseases. Organisationally, we are dedicated to ensuring our work remains grounded in the lessons we learn through implementation. We explore beyond current practice, to try out innovative ways – through research, implementation and policy development – to achieve effective and sustainable disease management and control. Collaboration and cooperation with others through our work has been paramount and much of what we have learned has been achieved through our partnerships. This series of learning papers aims to capture and collate some of the knowledge, learning and, where possible, the evidence around the focus and effectiveness of our work. By sharing this learning, we hope to provide new knowledge on public health development that will help influence and advance both policy and practice. South Sudan Malaria Consortium Office Capital Active projects SUDAN Upper Nile AWEIL Unity Northern Bahr el Ghazal Warrap ETHIOPIA Western Bahr el Ghazal Jonglei Lakes CENTRAL AFRICAN REPUBLIC Western Equatoria JUBA Eastern Equatoria KENYA DEMOCRATIC REPUBLIC OF CONGO UGANDA
Contents AUTHOR Emily Keane ICCM Nutrition Programme Coordinator, Malaria Consortium South Sudan CONTRIBUTORS Andrea King Programme Manager, Malaria Consortium South Sudan Anthony Awira M&E Manager, Malaria Consortium South Sudan Lucy Koyaki Programme Officer- Nutrition, Aweil, Malaria Consortium South Sudan ADDITIONAL INFORMATION AND TECHNICAL REVIEW Ruth Allan Country Director, Malaria Consortium South Sudan Helen Counihan Regional Programme Coordinator, CIDA ICCM, Malaria Consortium Miatta Zenabu Gbanya Country Technical Coordinator, Malaria Consortium South Sudan Dr Prudence Hamade Senior Technical Advisor, Malaria Consortium Madeleine Marasciulo-Rice Case Management Specialist, Malaria Consortium Salim Nakueira Programme Coordinator, Malaria Consortium South Sudan Dr. James Tibenderana Africa Technical Director, Malaria Consortium EDITOR Diana Thomas Senior Communications Manager, Malaria Consortium DESIGN Transmission Art direction & design Andrew Lyons Cover illustration Cristina Ortiz Map illustration CONTACT firstname.lastname@example.com Citation: Keane, E (2013) Integrating severe acute malnutrition into the management of childhood diseases at community level in South Sudan, Malaria Consortium Learning Paper Series: www.malariaconsortium.org/pages/learning-papers.htm COPYRIGHT Malaria Consortium PUBLISHED Autumn 2013 2. Introduction 4. ection 1. S Childhood diseases and malnutrition 4. Context, current interventions 6. ombined approach, policy environment C 8. Section 2. The volunteers 12. Incentives and motivation 14. Training 15. Service delivery 16. Treatment protocol 18. overage, admissions, monitoring C and evaluations 20. Routine reporting 24. Prevention strategies 25. Stock and supply management 26. Section 3. Key lessons learned 28. Conclusion 30. Recommendations 32. About Malaria Consortium © 2013 This learning paper was produced by Malaria Consortium and is licensed under a Creative Commons Attribution No-Derivs 3.0 Unported Licence. It is permitted to copy, distribute and transmit the work commercially or otherwise under the following conditions: the work must be attributed in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work; the work may not be altered, transformed, or built upon. These conditions can be waived if permission is granted in writing by Malaria Consortium. For other details relating to this licence, please visit http://creativecommons.org/licenses/by-nd/3.0/. For any reuse or distribution, please make clear the licence terms of this paper by linking to it via www.malariaconsortium.org/resourcespublications/add-type/learning-papers Learning Paper 1
BACKG ROUN D Introduction Despite several advances towards Millennium Development Goal 4 (MDG4) to reduce childhood mortality, the diseases of poverty – pneumonia, diarrhoea and malaria, together with under-nutrition – remain among the leading causes of child mortality across the world. It is estimated that globally there were 6.9 million deaths in children under five in 2011.1 Of these deaths, it has been recognised that over a third are due to under-nutrition. Children suffering with severe acute malnutrition (SAM), a particular form of undernutrition, are some of the most vulnerable and have a greater than nine-fold increased risk of dying than children who are well nourished. South Sudan ranks 15th highest in the world in terms of mortality rates for children under five1. Malaria is the leading cause of illness in all age groups, with 100 percent of the population at risk. It also accounts for approximately 30 percent of all hospital admissions. Up to 35 percent of children under five had suffered from a fever during the two weeks preceding the 2009 Malaria Indicator Survey (MIS). Broadly speaking, the leading disease pattern contributing towards deaths in children under five in South Sudan is similar to global trends, with pneumonia, diarrhoea and malaria being the leading causes. Malnutrition is widespread throughout the country with 28 percent of children under five being underweight, 31 percent stunted and 23 percent wasted.2 Since December 2010, Malaria Consortium has been implementing an innovative approach to community management of SAM, 'piggy-backing' onto an existing integrated community case management (ICCM) programme in the Republic of South Sudan. This learning paper considers Malaria Consortium's experience of this combined approach in a highly complex context and shows whether the management of SAM is an effective, acceptable and feasible component of ICCM programming. Integrated community case management The term integrated community case management (or ICCM) generally refers to an integrated approach for assessing and classifying signs and symptoms of pneumonia, diarrhoea, and malaria in children under five years old, and providing homebased treatment or referral for these diseases. The approach also normally includes health promotion and preventive activities such as sleeping under a net and hand washing. This care is provided by volunteers in the community who are trained by health workers on the ICCM approach A mother and her son wait their turn at a community outpatient therapeutic feeding centre in Hong village, Aweil West 1. Levels & Trends in Child Mortality Report 2012 www.unicef.org.uk/Documents/UNICEF%20Child%20mortality%20report%202012.pdf 2. South Sudan Household and Health Survey, 2010 2 Learning Paper
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SECTION 1 Childhood diseases and malnutrition In an extremely resource-limited setting such as South Sudan, there is a double challenge: a high burden of childhood disease and death, coupled with limited healthcare services to treat these diseases. There is a clear association between under-nutrition and the leading diseases (malaria, diarrhoea and pneumonia) causing deaths in children under five. Children suffering from these diseases are more likely to enter into a vicious cycle of becoming malnourished through poor absorption of nutrients, while those already malnourished are more likely to die from these diseases due to a compromised immune system. These challenges require innovation in programme delivery models in order to address the needs with the resources that are available. Context Decades of conflict have led to collapse of basic infrastructure across the country including health clinics, schools, roads, government offices, communication systems and water and sanitation supply. Despite the efforts of the government, donors, international and national non-governmental organisations, South Sudan still faces numerous challenges. The lack of infrastructure is overlaid with a range of acute crises resulting from flooding, disease outbreaks and renewed localised and international conflicts resulting in large population movement and displacement. The Government of the Republic of South Sudan's austerity measures has also required a re-prioritising of limited national financial resources and already low commitments to basic services have been further reduced. Renewed hostilities with the Republic of Sudan, driven by a stalemate on post-secession arrangements, led to the decision at the end of January 2012, to shut down oil production, which the World Bank suggested would force economic collapse, as oil revenue accounted for 98 percent of the government's budget. Health facility use is low in South Sudan. Outpatient visits are only 0.2 visits per person per year despite 44 percent of the population being settled within a fivekilometre radius of a functional health facility3. Even five kilometres can be an impossible journey in parts of the country, especially in the rainy season where floods and swollen rivers may make any access to services impossible. Access to treatment for common childhood disease still remains low. Only 39.6 percent of children under five have access to anti-malaria treatment within 24 hours of fever onset; 54.6 percent of the children with diarrhoea are treated with oral rehydration salts4 and 38.5 percent treated with appropriate antibiotics according to treatment guidelines.5 This low service use is the result of lack of human resources and qualified staff, shortage of drugs and medical supplies, cultural 3. South Sudan Health Facility Mapping 2011 4. EPI Coverage survey 2011/2012 5. Lot quality assurance sampling community-based survey 2011 4 Learning Paper and financial barriers, long distances to health facilities with poor roads and transport, a dysfunctional referral system and limited or no ambulance service. While pneumonia, diarrhoea and malaria are still the main cause of death for children under five, they result from a range of causes closely linked to poverty and are all preventable. Pneumonia, diarrhoea and under-nutrition can result from a lack of access to health services, poor hygiene practices, poor infant and child feeding practices. These include low exclusive breast feeding practices for six months, lack of suitable nutritious weaning food for infants and young children, a poor care environment, living conditions, lack of access to vaccination, safe drinking water and basic sanitation. The lack of availability and use of long lasting insecticidal nets (LLINs) is another factor contributing to the malaria burden. Current interventions Integrated community case management In South Sudan, where health facility access and use is so low, ICCM is a complementary and appropriate strategy for the delivery of lifesaving curative interventions for common childhood illnesses. ICCM should not 'stand alone' as a community intervention outside of the formal health service delivery system but should, instead, support the skills of existing cadres of community health workers (CHWs) at the facility level. Community health worker terminology ICCM is carried out by community drug distributors in South Sudan, also known as community based distributors. CDDs receive six days' initial training and operate like volunteer community health workers in other parts of Africa. It is important to note that in South Sudan, community health workers are not volunteers, but rather fits within the Ministry of Health and are mostly based at health facilities after having received nine months' training Community management of acute malnutrition Since the early 2000s there has been a growing accumulation of global evidence from a variety of contexts (emergency, transitional, development) showing that community management of severe acute malnutrition (CMAM) is an effective and safe public health approach. This marks a shift from the resource intensive inpatient care that was previously practiced. A child suffering from severe acute malnutrition receives a nutritional supplement at an outpatient therapeutic feeding site in Aweil West
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SECTION 1 Combined approach While ICCM and CMAM were previously being implemented in South Sudan as separate interventions, Malaria Consortium was the first organisation to combine these approaches. There are five overall aims of both programmes and, owing to the interdependent nature of infectious diseases and SAM on mortality, they need to be addressed simultaneously for this to be achieved. . Maximum coverage and access Both CMAM and ICCM programmes are designed to achieve the greatest possible coverage by making services accessible to the highest possible proportion of a population in need. Both approaches aim to reach the entire target population (children with malaria, pneumonia, diarrhoea and SAM), especially including those in hard-to-reach areas Timeliness Both approaches rely on treating conditions rapidly before they progress and complications develop. ICCM aims to treat cases early in the onset of the symptoms of diseases while CMAM aims to begin case finding and treatment before the malnutrition escalates and additional medical complications occur. Appropriate care CMAM and ICCM both provide simple, effective outpatient care for those who can be treated at home and referral to clinical care for those who have complications. Task shifting The majority of cases are identified and treated in the community using simple protocols. This allows a lower cadre of health workers, including community volunteers, to deliver care for the majority of cases. This is particularly needed in a context where there are low numbers of formally trained health staff within the health system. The four components of CMAM 1. Community mobilisation stimulating the understanding, engagement and participation of the target population 2. Supplementary feeding programmes (SFP) providing dry take-home food rations and routine basic treatment for children with moderate acute malnutrition without complications 3. Outpatient therapeutic programmes (OTP) providing ready to use therapeutic foods and routine treatment using simple medical protocols for children with severe acute malnutrition without complications 4. Stabilisation centres providing inpatient care for acutely malnourished children with medical complications Shared key health promotion and messaging As there is a shared causality between malnutrition and these infectious diseases, the same population is targeted with relevant health interventions. These include optimal infant and young child feeding, hand washing with soap, safe preparation of water, sleeping under a LLIN, etc. Policy environment As both management of childhood disease and severe acute malnutrition are cross-cutting between health facility and community based interventions, aspects of the programme are included within several different policies at various stages of evolution in South Sudan. At the time of writing there was no explicit policy to support the model of delivery Malaria Consortium is implementing, however Malaria Consortium's approach complemented the following aspects of existing policies and guidelines including The Basic Package of Health and Nutrition Services (BPHNS) – updated in 2011, the Government of South Sudan MoH Integrated Management of Severe Acute Malnutrition (IMSAM) Guideline – 2009 and the Child Survival Strategy – 2009. South Sudan is currently in the process of developing the Home Health Promoters (HHP) – 2012 (draft) and ICCM Policy and Implementation guidelines. In June 2012 the Ministry of Health renewed its support for ICCM programming in South Sudan and formed an ICCM taskforce. Community base Both approaches rely on strong community involvement and ownership. They are dependent on community confidence in the CMAM and ICCM providers for effective mobilisation, referral and followup, and need to work through the same community networks for the programme to succeed. Community nutrition worker Simon Deng Garrang assesses a malnourished child at his OTP site in Aweil West 6 Learning Paper
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SECTION 2 The volunteers CDDs are volunteer community members, predominantly women, trained to provide basic health education messages to communities as well as ICCM. Each CDD is responsible for approximately 40 households. CDDs are supervised by CDD supervisors, who are also community volunteers, preferably with additional training in community health and are literate. Each CDD supervisor is responsible for overseeing the work of 15 CDDs. CDD supervisors are, in turn, supervised by Malaria Consortium staff. The NBeG programme had 1,683 CDDs across two counties (Aweil West and Centre) and 112 CDD supervisors. Supervisors supply commodities and collect data for central analysis and follow up of perceived problems. The intention is for the nutrition aspects of the programme to be integrated into the existing community child survival or ICCM programme, rather than creating an additional, separate vertical programme. AIM AIM To maximise the community coverage of the nutrition programme for early detection and referral of SAM cases and provision of prevention messaging To have sufficient nutrition technical capacity to supervise and support the CNW volunteers to deliver quality SAM treatment at the OTPs The ICCM programme is designed to maximise the coverage and access to treatment for malaria, pneumonia and diarrhoea and to cover the counties of operation. Based on the extremely low literacy rates of the majority of CDDs, it was not deemed feasible that the CDDs could also provide treatment for SAM as the protocol requires numeracy and detailed record-keeping. However, community screening using mid upper arm circumference (MUAC) and oedema screening is feasible for volunteers without literacy or numeracy, as the coloured bands on the MUAC tape can be used to decide whether or not to refer a child to an Outpatient Therapeutic Site where trained Community Nutrition Workers (CNWs) following defined algorithms can manage the care of children with uncomplicated SAM . The CDDs, therefore, added an initial screening and referral of SAM cases to the role of mobilising the community and their ICCM case work. RECOMMENDATION Use the ICCM CDD volunteer network to provide screening, referral, follow up and counselling for infant and young child feeding practices in the community When the programme was initially implemented, CDD supervisors took a dual role: supervising CDDs as part of the ICCM programme and to run the outpatient therapeutic programme (OTP) site as a community nutrition worker two days a week. CDD supervisors generally ran their OTP sites from their homes, carrying out clinical management of the identified cases according to the OTP treatment guidelines and coordinating follow-up of cases. The CDDs added an initial screening and referral of SAM cases in addition to their ICCM case work and mobilising the community However CDD supervisors who had this dual role reported having insufficient time to complete both duties. CDD supervision required them to be mobile to supervise the CDDs in their network whereas SAM treatment at the OTP sites required them to stay at home. In addition, some OTPs saw more than 100 beneficiaries per week. This resulted in CDD supervisors/CNWs feeling overstretched and beneficiaries having to wait a long time to receive treatment. In response to these challenges, additional volunteers were selected to act as CNWs. The involvement of the community and MoH in selection of the volunteers improved mechanisms for accountability. This allowed the CDD supervisors to return to their original roles, moving around providing support to their network of CDDs, while the CNWs remained at their OTP sites to provide treatment. The number of children receiving treatment at OTP sites was reviewed and thresholds for the maximum number of beneficiaries that can be managed by one individual were established. In the busiest sites, additional volunteers were trained to ensure that manageable beneficiary-to-CNW ratios were maintained. RECOMMENDATION Have nutrition specific, trained and experienced staff to supervise the nutrition treatment programme. 8 Learning Paper CDD Supervisor, John Uguak Deng, Aroyo, Aweil Centre
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SECTION 2 Programme HR structure - Phase 1 Programme manager 22 CDD supervisors / Community nutrition workers (CNWs) for each Field officer Field officer * CDD Sup CDD CDD CDD ** CDD Sup CDD Sup / CNW CDD CDD CDD CDD CDD CDD CDD CDD CDD CDD CDD CDD CDD Sup / CNW CDD CDD CDD CDD CDD CDD CDD * 15 CDDs for each CDD supervisor ** Each CDD is responsible for 40 households Programme HR structure - Phase 2 Programme manager Each Project / Field officer is responsible for approx 17 CDD supervisors, 118 CDDs ICCM programme officer ICCM programme officer Nutrition programme officer ICCM field officer CDD Sup Each CDD supervisor is responsible for 15 CDDs CDD Sup Each CDD is responsible for 40 households CNW CDD Sup CNW CDD Sup CDD CDD CDD CDD CDD 10 Learning Paper Each OTP officer is responsible for 10-11 CNWs OTP officer Some CNWs will receive referrals from more than one group of CDD Sup CDD CDD CDD CDD CDD CDD CDD CDD
AIM AIM To have sufficient qualified volunteers resources to deliver SAM treatment effectively To ensure coverage of OTP services at health facilities is complemented by additional community level treatment in remote areas In the initial phase of implementation, field officers (Malaria Consortium staff with clinical training) also had a dual role, providing supportive supervision to CDD supervisors, collecting reports and providing supplies for both the ICCM and nutrition programmes. Again, the work practices for effective supervision and technical knowledge in the ICCM programme and the nutrition treatment programme were different. Ideally the field officers should be observing and supporting the CDD supervisors in their supervision duties to CDDs, as well as giving direct supportive supervision to the CDDs. Although field officers had received formal medical training, they had varying levels of training in nutrition. It was challenging for field officers to provide effective supervision to OTP sites without having much experience in running them. In addition, it was recognised that the field officer to CDD supervisor ratio was too high to ensure quality supervision. This was made worse by the fact that the CDD supervisors were often spread over large areas. In order to provide specialised OTP supervision to the CNWs, Malaria Consortium recruited extra staff to act as OTP officers. This allowed the ICCM field officers (and newly recruited project officers) to focus fully on supervision of ICCM activities. RECOMMENDATION Have additional numerate and literate CDDs and community nutrition workers to deliver treatment of SAM at the outpatient therapeutic programme sites, with close linkages to CDD supervisors and the CDD network health and nutrition services in line with BPHS and Government of South Sudan strategy and improves access to services in remote areas. It was initially envisaged that all CDD supervisors would be trained in recognition and management of severe acute malnutrition (SAM). However, it was recognised that not all CDD supervisors had the capacity to perform the treatment protocol effectively. As a result, only the most skilled CDD supervisors were selected to act as both CNWs and provide SAM treatment. The majority of OTP sites (27 of 33) were concentrated in Aweil West a smaller geographical area than Aweil Centre, but with a much larger population. Concern Worldwide was also operating in Aweil West with health facility-based OTP sites; Malaria Consortium therefore targeted those areas not covered by Concern Worldwide. Malaria Consortium received additional funding which allowed for the expansion of the programme in Aweil Centre, where the majority of the health facilities were run by the MoH without any additional NGO support for OTP services. Twelve new OTP sites were opened, nine health facility-based and three communitybased. The addition of these new sites ensured that all functional health facilities in Aweil Centre had an OTP site delivering treatment for uncomplicated SAM cases. These sites opened in September 2012. The expansion resulted in a dramatic increase in admissions into the OTP programme, indicating that many more children were being reached by services. RECOMMENDATION Place a CNW in health facilities that were not providing OTP services. This allows integrated health and nutrition services in line with BPHS and Government of South Sudan strategy and improves access to services in remote areas Learning Paper 11
SECTION 2 Incentives and motivation AIM AIM To ensure that volunteers perform to expected standards in the OTP sites and are incentivised to do so To enable CDDs to have a healthy household and to provide examples to community members CDD supervisors/CNWs are not salaried staff. In Phase 1 of implementation, CDD supervisors were provided with cash incentives of approximately US$40 per month for operating the OTP sites for treatment two days per week. This was in addition to the US$40 per month for supervising the ICCM programme. CDD supervisors were also provided with bicycles and bags to carry reports, allowing them to cover the area that their CDDs serve. However, despite these cash and in-kind incentives, the volunteers showed varying degrees of motivation to perform their expected duties. Some CDD supervisors/ CNWs were absent from the OTPs on treatment days or would not conduct supervision activities within the programme reporting timetables. Some CDD supervisors/CNWs would complete reports, but to an extremely low standard. This suggested that they were more focused on completing the reports than ensuring that they were of an acceptable quality. In order to address these issues, in Phase 2 a performance-based element was introduced into CNWs' incentives with the aim of improving the quality and consistency of their service provision. CNW cash incentives became dependent on the provision of completed reports within the expected timeframe to the expected standard. In an attempt to encourage and support excellence, additional 'bonuses' are now being offered for CNWs who achieve beyond expectations. In addition to the incentives provided by Malaria Consortium, the community also gives feedback, which adds to volunteers' motivation. Volunteers are recognised as having skills and as providing services within their community and in some cases have been given formal recognition for this, for example being allowed to jump the queue at a water point. Conversely, where volunteers have not been performing their duties, the community reports to Malaria Consortium about poor performance and in extreme cases will request that volunteers are replaced. 12 Learning Paper In both phases of implementation, CDDs received non-cash incentives to motivate them. In Phase 1 the items were largely focused on supporting them in their role as CDDs (T-shirt, cap, torches, drug boxes). In Phase 2, there was an attempt to provide them with additional items that would assist them in creating a healthy environment in their homes: soap for hand washing, jerry cans for safe water storage, and LLINs. It is anticipated that these items will help CDDs demonstrate healthy behaviour and practices in their communities which will back up the health messages they are providing. RECOMMENDATION Provide CDD volunteers with in-kind incentives that enable them to have a healthy environment at home and demonstrate it to community members CDD supervisors/ CNWs are not salaried staff. In Phase 1 of implementation, CDD supervisors were provided with cash incentives of approximately $40 for operating the OTP sites for treatment two days per week. This was on top of the $40 per month for supervising the ICCM programme
Case study #1 Name Pual Malong Personal info Community nutrition worker, trained by Malaria Consortium Address Gueng Village in Mariem East Payam, Aweil West County Pual Malong is a community nutrition worker in Gueng Village in Mariem East Payam, Aweil West County. He has been a community nutrition worker since 2011 when he was first trained by Malaria Consortium. Previously he had been a supervisor for 133 community drug distributors. "When the nutrition programme was introduced to treat severe malnutrition cases, the community again selected me to be the community nutrition worker. I was then trained again by Malaria Consortium, after I had received the initial ICCM programme training. So far I have received two ICCM and three nutrition trainings and I have got all the skills for carrying out ICCM and as a community nutrition worker." Malong's training has meant he is able to not only help his community with ICCM care, but he is also able to help tackle malnutrition, which is a common problem for children in the area, increasing the risk of disease and mortality. Malong screens children brought to his outpatient therapeutic feeding (OTP) site, where he provides general health education. He screens the children for severe acute malnutrition and provides nutritional supplements (Plumpy'nut) to those who need it and refers more complex cases to the nearest health facility or Aweil Hospital. He has enrolled 32 children in the malnutrition and ICCM programme at his OTP site. Malong's work has been wellreceived by his community, especially by community leaders and caregivers, who are now able to access malaria and malnutrition treatment, recognise common disease symptoms and seek appropriate healthcare for their children. "The caregivers like the programme and they use the service, especially now they are able to recognise some danger signs in their children and immediately go to health facility or to the OTPs. The treatment they receive at the OTP site and the daily Plumpy'nut supply for malnourished children helps so much." Malong was concerned, however about delays in the supply of Plumpy'nut and some of the drugs used for ICCM. He also commented that the lack of storage facilities for the supplies needed to be improved as they are currently stores at his house. A simple shelter for OTP days in the rainy season would also be good, he added hopefully. His usual location is under a tree. But despite these concerns, he is generally very pleased with how his work is going. "The nutrition and ICCM programmes work well based on my experience as an ICCM supervisor and community nutrition worker. We refer most of the cases that might be beyond the capacity of the ICCM and nutrition programmes, based on the danger signs." "The programme is liked by all in the community and the leaders appreciate it and encourage the programme's continuity in the community to serve their children." Community nutrition workers fill out detailed patient records to ensure clear reporting Learning Paper 13
SECTION 2 Training AIM AIM The pilot had four stages To ensure that CNWs are supported and trained to perform OTP protocols adequately To ensure that health facilities understand services delivered in the OTPs, are able to provide referral services and have strengthened capacity to deliver OTP services 1. Needs assessment: Before the initial implementation of the programme, Malaria Consortium used regional technical experts to design and implement a training package. This would enable selected CDD supervisors and other volunteers selected by their communities to become CNWs based on the integrated CMAM training package, but adapted for the protocol agreed with the MoH. CDDs/CNWs were given a rapid training in MUAC screening and referral early in 2011. CDD supervisors were given a refreshertraining course in OTP protocols soon after the initial training to ensure that the concepts and skills from the initial training were understood and applied correctly. Recognising that refresher training is essential to ensure that community health workers retain the skills that they have gained in initial training, Malaria Consortium expanded staff capacity to ensure this would take place. A senior national nutrition programme officerand four OTP officers have been recruited to provide technical support and supervision to the CNWs. With an expanded nutrition team, it will be possible to deliver refresher training quarterly, based on identified particular training needs. RECOMMENDATION Ensure there is sufficient capacity within the programme management team to conduct refresher trainings at least once every three months Health facility staff were, in many cases, overstretched with their existing responsibilities and did not have the additional capacity to directly implement treatment for SAM, but it was important for them to understand the treatment delivered in the OTPs. In many cases, health facility staff had not had experience or received training in OTP services. RECOMMENDATION Provide short course, on-the-job training for health facility staff on OTP protocols AIM To have an effective system of referral of complicated SAM cases from the community/ out-patient services to in-patient/stabilisation centre care As part of the medical assessment and screening at OTP sites, CNWs are expected to identify the small number of cases of SAM which have medical complications and require specialised in patient care delivered through a stabilisation centre. In the first phase of implementation there was little information on the referrals that had been made; programme staff and volunteers were too overstretched to perform adequate follow-up. The children who have been identified as having complicated SAM are the most vulnerable and at increased risk of mortality and, therefore, in particular need of follow-up. In order to understand better the outcome of referrals and the barriers to achieving referral, Malaria Consortium designed a referral pilot to address this gap. 14 Learning Paper to collect quantitative and qualitative information on referral outcomes, barriers to referral and community identified solutions to support referral 2. Intervention design: based on the outcomes of the needs assessment Malaria Consortium worked closely with partners (community, Ministry of Health, agencies providing in-patient stabilisation centre care) to design an intervention to support community referrals from the OTP to the stabilisation centre 3. Intervention implementation: to be implemented for at least six months. 4. Intervention evaluation: to understand if the intervention has been successful in supporting community referrals of complicated SAM cases and if so, if it could be replicable and scaled-up
Service delivery Treatment, referrals and Ministry of Health County Health Department Civil Hospital Ministry of Health Stabilisation centre Complicated severe acute malnutrition (SAM) cases Danger signs Primary Health Care Centre/Unit Ministry of Health Outpatient therapeutic feeding programme Outpatient therapeutic feeding programme SAM cases CDD Sup CDD Sup CDD Sup Any other condition CDD CDD CDD CDD CDD CDD CDD CDD CDD CDD CDD CDD CDD Treatment for malaria, pneumonia, diarrhoea and screening for SAM Learning Paper 15
SECTION 2 Treatment protocol AIM AIM To have a feasible and technically appropriate treatment protocol for the treatment of SAM based on national guidelines To integrate management of MAM into the implementation model The programme adopted the government's IMSAM approach in line with the South Sudan nutrition strategies and standards. However, as the programme was being implemented in a specific context, some specific modifications to the treatment protocol were discussed and agreed with the Directorate of Nutrition in the MoH. These were as follows: 1. Admission to OTP on MUAC and oedema criteria only. 2. Treatment of children with uncomplicated malaria, pneumonia or diarrhoea and SAM without further complications at the OTP. 3. Discharge 'cured' criteria altered from 15 percent to 20 percent weight gain for two consecutive visits and/or green MUAC. 4. All asymptomatic children with SAM will be treated for malaria routinely using a full treatment course of anti-malaria drugs. Cure: a beneficiary who reaches the programmedefined discharge criteria l efaulter: a beneficiary who D is lost to the programme before reaching discharge criteria, and whose actual status (dead, recovered, other) is not known. If the beneficiary has not attended the OTP for three consecutive visits they will be considered a defaulter l eath: a beneficiary lost-toD follow-up who is reported dead by the family or by home visitors l on-response: a beneficiary N who did not meet the discharge criteria after four months in treatment. During the treatment, these children would have shown signs of non-response to treatment and should be referred to inpatient care or for medical investigation l Throughout both phases of implementation, treatment has focused on treatment of SAM, community mobilisation and referral of complicated SAM cases to stabilisation centres. It excludes the management of moderate acute malnutrition (MAM). The adequate management of MAM is vital to prevent and lessen the incidence of SAM, and increased risk of morbidity and mortality. Historically, partners in South Sudan have found it difficult to achieve good programme outcomes with traditional food based approaches for MAM management without the presence of a general food distribution. However, the Ministry of Health South Sudan together with the Nutrition Cluster has formed a working group, which is producing guidelines for MAM management. This has shown some promising results. Malaria Consortium plans to implement a Targeted Supplementary Feeding Programme pilot in two sites. One site in the community is at the returnee camp site of Apada. This site has extreme food insecurity and extremely high rates of malnutrition. The other site will be based in a health facility (primary health care centre) with a high patient load. The approach will be evaluated for its effectiveness and will compare the experience of community and facility-based sites. Based on the outcomes of the pilot the programme may be scaled up. RECOMMENDATION RECOMMENDATION Implement a modified version of the Government of South Sudan's IMSAM that takes into account the limitations of the community delivery model Pilot some initiatives for management of MAM using the MoH recommended approach and consider linkages with other programmes (food security,livelihoods, WASH, etc) for other innovative approaches 16 Learning Paper CMAM discharge outcomes explained
ICCM implementation roll out - Northern Bahr el Ghazal Sept 2009 2010 2011 2012 2013 Malaria (ACTs) Global Fund to Fight AIDS, Tuberculosis and Malaria funding 112 CDDs supervisors and 1,610 community drug distributors (CDDs) Canadian International Development Agency Common Humanitarian Funds USAID/ ADRA SSHINE funding Pneumonia (amoxicillin) Diarrhoea (ORS and zinc) 33 CDD Sup acting also as community nutrition workers (CNWs) 45 independent CNWs Malnutrition (Plumpy'nut) Phase 1 Phase 2 Common Humanitarian Fund funding Children will only be discharged from the OTP if they show a 20 percent weight gain over two consecutive visits or have a green MUAC measurement Learning Paper 17
SECTION 2 Coverage More than 90 percent of the target population is within less than one day's return walk (including time for treatment) of the programme site. Coverage is greater than 50 percent in rural areas, and 70 percent in urban areas and more than 90 percent in camp situations. Admissions The OTP sites in NBeG were established in late 2010 to early 2011. The programme began to gain momentum after the referendum period in January 2011. In South Sudan there are also seasonal trends in malnutrition patterns. There is a 'lean period' before the harvest, which generally runs from March to June in which malnutrition rates reach their peak. The 'post harvest' period is from October to December where malnutrition rates are generally expected to drop. Established OTP programmes usually see this trend in admissions. In the first year of implementation, 1,204 children were admitted to the programme. The majority of admissions were new admissions, with only two percent of admissions overall being readmissions. High numbers of readmissions would not be expected, though, as it was a new programme. In the second year of implementation, 3,564 children were admitted, more than double those admitted in the first year, with two months of data yet to be collected. Six percent of cases were readmissions, suggesting that there are children who have been discharged from the programme relapsing into SAM. Admissions peaked dramatically in September 2012 as 12 new OTP sites were opened in Aweil Centre. This indicated that the previous eight OTP sites alone were not adequate. Quality of Treatment Delivered in the Programme In Phase 1, the programme performance quality was extremely high, with an overall cure rate for the year of 94 percent, death one percent and defaulter rate of two percent, well within the SPHERE standards. In Phase 2, the overall performance was in line with the first year, with an overall cure rate of 89 percent, death rate of one percent and default rate of six percent Programme admissions and reporting rates, Phase 1 and 2, NBeG 2011 Total admissions 1,204% Reporting rate 42% 2012 Total admissions 3,564 Reporting rate 90% Note: 2012 figures are missing November and December data Discharge outcomes programme performance indicators. Phases 1 and 2, NBeG 2011 94% Cured 1% Died 2% Defaulter 2% Non Respondent 2012 89% Cured 1% Died 6% Defaulter 3% Non Respondent Note: 2012 figures are missing November and December data 18 Learning Paper
Monitoring and evaluation AIM To support the development of policy relating to community health, child survival and nutrition, based on the evidence gained through implementing the ICCM and nutrition programme In the initial start-up phase of the programme, Malaria Consortium conducted the majority of the programme supervision and management with little involvement of the SMOH (State Ministry of Health) or CHD (Community Health Department). However, in order to build ownership, oversight and capacity within the MoH, a greater involvement in monitoring and management of the programme was required. Malaria Consortium has developed a supervision framework for the ICCM teams that details key guidance including the frequency, content and approach for supervision visits. Learning from this, the programme is also developing a supervision framework for the nutrition team involving the CHD and SMoH in periodic supervision visits. This should also provide a bridge for greater integration between the health services delivered by MoH staff and nutrition treatment delivered by the CNW volunteers. RECOMMENDATION Advocate to the Ministry of Health, donors and ICCM partners that SAM management is an effective and feasible aspect of ICCM delivery and should be included in policy frameworks where appropriate In the lean period before the harvest in Northern Bahr elGhazal state (March to June), malnutrition rates are at their highest Learning Paper 19
SECTION 2 Routine reporting AIM To integrate nutrition programme data through the same platform as the ICCM programme In the first phase of implementation, the Malaria Consortium M&E team developed a database to collect key performance indicators for the programme: cure, death, defaulter and non responder rate, length of stay and weight gain. This allowed Malaria Consortium to report at a County level the performance of the programme to the MoH, UNICEF and the Nutrition Cluster using the standardised reporting tool developed by the Cluster. After a period of implementation, the programme staff found that it would be useful to have additional information recorded and reported such as proportions of returnee or host population admissions. Also, a District Health Information System (DHIS) database had been developed by the consortium of ICCM partners, which allowed community level treatments to be reported to the MoH and donors using the same platform as the facility-based Health Management Information System (HMIS). Following the success of the ICCM DHIS database, Malaria Consortium set about developing a DHIS database for the nutrition programme. This supported a higher level of analysis of programme data than previously possible with the original database. It could also potentially be used by other partners who are hoping to report at the facility/OTP level. RECOMMENDATION Develop a DHIS database for nutrition programme monitoring AWEIL Aweil - state capital Outpatient therapeutic Feeding Centres 20 Learning Paper
Case study #2 Name Ayak Mangok Personal info Care giver whose child received treatment Address Malithbuol Village, Gumjur East Payam, Aweil West County Ayak Mangok, the mother of two-year old Akol Bol from Malithbuol village in Aweil West County, describes the care her child received at the Malaria Consortium outpatient therapeutic feeding site. Can you describe what led you to seek treatment for Akol Bol at the OTP site? The first symptoms he had were a cough and convulsions. I took the child to Aweil Hospital for treatment, but he fell sick again. I returned with him to Aweil Hospital and was referred by Medecin Sans Frontiers staff to the Malaria Consortium OTP site. Can you describe the changes in your child since he started receiving treatment? There has been a very big improvement in my son since he started receiving the treatment. The changes include improved appetite, playing again and generally looking healthy. There are many patients seeking care during OTP days and this delays treatment for patients with more serious cases at home. The lack of examination facilities at the OTP site to review some sicknesses and sometimes there not enough supplies for the patients. How long does it take you to travel from your home to the OTP site? It is a 30 minute walk. What impact do you think malnutrition has on your community? Malnutrition is a problem. It is why our children are getting sick and the time we spend caring for them interrupts our business and work activities. Have you experienced any challenges in accessing treatment? How was your child before they started to receive treatment? Before receiving treatment my son was sick, very weak and thin, and couldn't play. But now after getting the treatment he is very healthy and playing actively, he looks strong and eats well. How long has your child been in the treatment programme? My child has been enrolled in the treatment programme for three months. Community based OTP sites are usually under a convenient tree Learning Paper 21
SECTION 2 Surveys At the time of writing, the South Sudan Nutrition Cluster and UNICEF encourage partners implementing nutrition programmes to conduct bi-annual SMART survey assessments using a standardised tool with two primary and three secondary objectives: Survey results – post harvest 2011 As Concern Worldwide was conducting a survey in Aweil West during this period, Malaria Consortium focused on Aweil Centre. The results showed extremely concerning malnutrition and mortality rates: the global acute malnutrition (GAM) rate was 17.7 percent - well above the WHO emergency threshold of 15 percent - and the SAM rate was 5.3 percent. Similarly mortality rates were of great concern with the crude mortality rate extremely close to the emergency threshold for sub-Saharan Africa (0.78 per 10,000 per day compared to 0.8 per 10,000 per day). The under-five mortality rate was above the threshold for sub Saharan Africa (2.23 per 10,000 per day compared to 2.1 per 10,000 per day). These rates of malnutrition and mortality would not generally be expected to be so high during the post-harvest period, when it is normally expected that food security should be at its highest and malnutrition at its lowest rate. Aweil Centre had experienced a large influx of returnees from Sudan during the referendum and independence period. They were living in camp-like situations and so had particular difficulties with food insecurity and vulnerabilities to infectious diseases. Nineteen year old Akek Akol Maehol is a returnee from Sudan to Aweil West. Her two year old daughter is severely malnourished 22 Learning Paper
Survey results – pre harvest 2012 The primary objectives are to estimate: m alnutrition rates through anthropometric surveys l nfant and crude mortality i rates through retrospective mortality surveys l The secondary objectives are to assess key behaviours in the study group relating to: h ealth and infant and young child feeding practices (IYCF) l ood security and f livelihoods (FSL) l ater, sanitation and w hygiene (WASH) l The surveys are intended to cover the whole county with the aim of capturing the variation between preand post-harvest malnutrition rates. This evidence should then provide information to assess the need for any alterations in programme approach. After the initial Aweil Centre survey, it became apparent that the majority of the returnees were unlikely to move in the near future. Their underlying characteristics were fundamentally different from the host population. In the first survey they had been treated as one group but additional analysis showed that malnutrition rates and food security were different between the groups. Malaria Consortium conducted two different assessments. The results showed that both populations had malnutrition rates well in excess of the WHO emergency threshold of 15 percent for GAM (21.6 percent in Aweil Centre and 27.4 percent in Apada), providing clear justification that therapeutic programming is required to control excess mortality. Apada returnee camp in particular showed a worryingly high rate of SAM with almost one in 10 children having SAM (9.3 percent) and very poor food security indicators suggesting the need for a comprehensive emergency nutrition intervention including a general food distribution. The results of these surveys were validated by the Nutrition Cluster's Technical Working Group and were widely shared with partners, including the MoH, UNICEF, World Food Programme and other NGOs operating in the state. AIM To build organisational and Ministry of Health capacity to conduct surveys Recognising that specialised skills involving both experience and technical training are required to conduct SMART surveys, Malaria Consortium recruited an external national consultant for the first post-harvest survey in 2011. However, as periodic assessments and surveys are required to monitor programme performance, Malaria Consortium invested in strengthening the organisation's ability to conduct surveys. RECOMMENDATION Provide in-house training to conduct surveys and involve the county and state Ministry of Health in all aspects of the process AIM To evaluate the performance of the programme as a whole Malaria Consortium was conducting a new programme approach that other partners had not yet conducted in South Sudan, combining ICCM and nutrition. It was realised that it was necessary to have an evaluation of the effectiveness of the approach and to identify areas which needed improving. Malaria Consortium conducted a two-week incountry programme evaluation to review the design, implementation and results of the programme over its first 18 months. The aim was to determine its efficiency, effectiveness, impact, sustainability and the relevance of its objectives. A programme evaluation report with clear recommendations was discussed with the in-country team for follow-up action. External programme evaluations will also be considered in the future. RECOMMENDATION Conduct periodic programme evaluations at defined intervals to assess the overall effectiveness of the programme and identify areas that need to be improved Malaria Consortium has worked with the MoH at county and state level for the planning and coordination of the surveys. Representatives from the MoH have also been involved in sensitising the communities about the survey and sharing survey results. There was a recognition that, in future, there is a need for greater involvement of the MoH in the data collection, data entry and analysis of surveys. Learning Paper 23
SECTION 2 Prevention strategies AIM AIM To provide appropriate and targeted preventive health and nutrition messaging through the community volunteers To improve Vitamin A and deworming coverage in children under five in the areas of operation The initial focus of both the ICCM and nutrition programmes was to ensure that treatment was delivered successfully. There was less focus on the preventive aspects of the programme, although simple health and nutrition messaging was delivered to caregivers while their children were receiving treatment in the programme. When Malaria Consortium revised the training materials for ICCM6 in early to mid-2012, significant focus was put on strengthening the prevention messages that CDDs delivered to caregivers during consultation. Moving forward, there will be qualitative assessments providing a better understanding of the barriers to healthy behaviour among individuals, communities and community structures. In addition to the messages at the point of treatment, there will be outreach services and messaging to reach the community before disease and malnutrition develop. As the diseases targeted through ICCM and malnutrition have similar and shared causes, there is value in addressing prevention in an integrated way. South Sudan's Lot Quality Assurance Sampling survey showed low micronutrient supplementation (Vitamin A) and deworming coverage in Malaria Consortium's areas of operation despite the routine immunisation services delivered through the formal health system. Vitamin A supplementation for under-fives is one of the 'scale up nutrition' supported interventions and is included in the South Sudan Nutrition Cluster's strategy. Malaria Consortium's ICCM programme design is to have full coverage in the counties of operation. It therefore presents greater potential for delivering biannual Vitamin A supplementation and deworming than other approaches. As the target group is children under five, it is also an ideal opportunity to conduct MUAC screening, and to refer children with SAM for treatment and to identify children with MAM for preventive interventions. Community volunteers with low levels of literacy are able to conduct the supplementation and basic reporting using pictorial based tally sheets. RECOMMENDATION RECOMMENDATION Conduct qualitative assessments to understand the barriers to healthy behaviours and develop the most effective mechanism to deliver integrated preventive health messaging using the ICCM community volunteer network Use the community volunteer network supported through the ICCM programme to deliver Vitamin A, deworming and MUAC screening to under-fives 6. Malaria Consortium Learning Paper: Developing and implementing training materials for integrated community case management in South Sudan 2012 http://www.malariaconsortium.org/resources/publications/182/developing-and-implementing-training-materials-for-integrated-community-case-management-in-south-sudan 24 Learning Paper
Stock and supply management AIM To avoid stock-outs of ready to use therapeutic foods (RUTF) in the programme In both Phase 1 and 2, the programme experienced stock-outs of RUTF. Stock-outs have serious implications for the programme, interrupting the treatment of children enrolled in the programme and jeopardising community trust and acceptance. Malaria Consortium introduced a series of measures based to lessen the risk of stock-outs. l Establishing minimum stock levels at the OTP sites. In the first phase of implementation there was limited storage space (for one month) at the community OTP sites. In many cases, these were the homes of the CNWs. This meant the CNWs would only be provided with one month's stock which provided no buffer against limited access to the sites due to environmental factors such as floods or a sudden increase in beneficiaries. In the second phase, Malaria Consortium invested in developing improved storage facilities at the sites to allow for additional buffer stock to be stored. l Improved mechanisms for reporting stock levels using the DHIS system. CNWs experienced great challenges in reporting on stock levels. In the first phase of implementation there was limited supportive supervision and training to support the development of these skills. This resulted in poor information being provided to the programme management team about the stock levels at the OTP sites. Following the introduction of the DHIS database and improved reporting tools, programme staff were better able to monitor stock usage and levels. l Prepositioning supplies ahead of the rainy season. In South Sudan there are many challenges in reaching remote rural areas. The counties where Malaria Consortium operates experience extreme seasonal flooding for four to six months a year. Malaria Consortium used staff who had good local knowledge and local authorities to work in areas that were likely to be cut off by flooding. RUTF and other supplies were brought in to these areas ahead of the rainy season. l Procurement of RUTF using alternative funds. In South Sudan RUTF is procured centrally through UNICEF and is provided to implementing partners. In late 2011, due to the influx of returnees and multiple humanitarian disasters in South Sudan, the RUTF supply in country was insufficient. This was resolved in 2012. To mitigate against the risk of national stock-outs, Malaria Consortium has now procured additional RUTF as a buffer stock. RECOMMENDATION Ensure adequate storage at community level to accommodate minimum stock levels, together with swift and accurate reporting systems that allow spikes in admissions to be detected. Malaria Consortium introduced a series of measures based to lessen the risk of stock-outs. AIM To minimise leakage and misuse of RUTF Following the scaling-up of community treatment of SAM in South Sudan there have been reports of RUTF being sold in the local markets and not used for treatment as intended. The leakage of RUTF in to the markets is extremely damaging to the CMAM programming. In both phases of implementation, Malaria Consortium received some reports of RUTF being sold and misused by CNWs. In these cases Malaria Consortium worked closely with the local communities to replace the CNW concerned and reported these occurrences to the county health department and state MoH. Malaria Consortium worked with the state MoH to make a statement about the gravity and consequences of selling RUTF. The improved stock management reporting introduced through the DHIS database means there are now additional methods for monitoring stock usage. RECOMMENDATION Work with local communities and the MoH to monitor, report on and take action if RUTF is being sold or misused Learning Paper 25
SECTION 3 Key lessons learned 1. OVERALL PROGRAMME STRATEGY AND IMPLEMENTATION IS RECOGNISED AND SUPPORTED BY PARTNERS IN COUNTRY Since the inception of the programme, the MoH at all levels has been supportive of the addition of SAM management into the ICCM model. Other partners implementing ICCM will be adding on the component of SAM management as part of the existing package for treatment of diarrhoea, pneumonia and malaria. 2. THE MODEL DELIVERS HIGH QUALITY INDICATORS FOR TREATMENT In both years of implementation, the quality of treatment provided has been consistently high and within the acceptable SPHERE minimum standards. Although coverage has not yet been evaluated it is expected that this will also be high because of the decentralised approach and high levels of community involvement. 3. THE INCREASED HEALTH FACILITYBASED OTP SITES HAVE LED TO THE PROGRAMME REACHING MANY MORE CHILDREN In a context where the MoH is unable to implement SAM treatment directly through their supported facilities, adding this component into the current health system using support from international NGOs has been effective. 4. SUFFICIENTLY WELL TRAINED, EXPERIENCED NUTRITION STAFF AT ALL LEVELS OF PROGRAMMING IMPROVES PROGRAMME PERFORMANCE While the community and treatment aspects of the nutrition programme are relatively simple, and capacity to deliver these services can be quickly built, it is vital to have in-country experience and expertise in nutrition for the management aspects of the programme. The introduction of a senior national nutritionist to the programme and OTP officers trained and experienced in SAM treatment has resulted in improved supervision, treatment compliance and reporting. 26 Learning Paper 5. REGULAR (QUARTERLY) REFRESHER TRAINING RESULTING IN BETTER COMPLIANCE WITH THE TREATMENT PROTOCOL AND REPORTING Increased regularity of refresher training has resulted in improved compliance with treatment protocols and a massive increase in programme reporting rates, also linked to the increased supportive supervision. In a post conflict/low education context, it is extremely important to continue to provide a combination of 'on the job' and classroom refresher training. 6. The Ministry of Health at all levels has been very supportive of the inclusion of SAM management into the existing community package for treatment of diarrhoea, pneumonia and malaria (ICCM) REGULAR MONITORING AND ASSESSMENT OF THE NUTRITION SITUATION IS FEASIBLE IN THIS CONTEXT AND VALUABLE FOR DIRECTING PROGRAMME APPROACHES Based on the new bi-annual SMART survey data, there is growing evidence about the ranges of malnutrition rates experienced in programme implementation sites. This is valuable as the area of operation involves a chronic emergency overlaid with spasmodic acute emergencies. It is necessary to have this background of evidence in order to decide if additional emergency intervention is required. 7. DEVELOPMENT OF THE HMIS SYSTEM HAS RESULTED IN EASY-TO-USE TOOLS FOR MONITORING PROGRAMME QUALITY AND HAS THE POTENTIAL TO BE INTEGRATED IN TO THE MOH SYSTEM As the ICCM programme already reports using the HMIS system it would be beneficial to have nutrition data processed through the same platform. As nutrition is not yet included in the MoH's routine HMIS reporting system, the reporting system developed by Malaria Consortium could be integrated into this. 8. INDEPENDENT PROCUREMENT OF RUTF BUFFER STOCK PROVIDES THE PROGRAMME WITH PROTECTION AGAINST BREAKAGES IN THE NATIONAL SUPPLY CHAIN Owing to the numerous logistical and access challenges in South Sudan, it is beneficial to have emergency stock prepositioned in programme implementation sites. Cooperation with the MoH and local communities is essential to ensure appropriate security and correct use of these supplies. ICCM trained community drug distributor, Nyidumo Uthur Uguak, is based in Aroyo, Aweil Centre. She shows her timer and beads for assessing child patients for pneumonia, but she also knows how to assess and refer children with SAM to the OTP
Learning Paper 27
SECTION 3 BACKG ROUN D Conclusion This Learning Paper has highlighted the synergy and complementary nature of ICCM and nutrition programme approaches. While ICCM and the IMSAM have been implemented separately in South Sudan, Malaria Consortium's experience of combining the two approaches has proved an effective means of reaching more malnourished children in the community. The addition of SAM assessment using the MUAC tape and oedema of the feet has been shown to be an acceptable additional activity for CDDs who are already carrying out ICCM activities. This has meant that these simple and quick techniques can benefit from the strong community base already in place, allowing large numbers of children to be screened, admitted to the programme and treated, with extremely promising outcomes. The community base for ICCM and nutrition also provides a strong foundation for establishing preventive measures towards ensuring child survival. To date, this base has not yet been fully developed. More work is needed on how to build those linkages with BCC and other health interventions (e.g. vaccination and micronutrient supplementation vitamin A). Pre-hunger season or six-monthly regular house to house screening by CDDs could also be done. Malaria Consortium's approach to integrate ICCM and nutrition at the community level has been succes
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Akshay Tritiya is the second most auspicious day after Dhanteras for buying gold, gems and jewellery. The word 'Akshaya' in Sanskrit means 'never diminishing' and that is why it is considered to be auspicious for buying gold, property and making other investments. Gold sales are expected to see as much as 40 per cent increase in year-on-year sales this year compounded by the wedding season as well as the summer vacations.
We take a look at 7 good reasons to buy gold this Akshay Tritiya:
1. With GST on the anvil, gold rates are expected to increase considerably. Taxation will add up to the total cost of the jewellery, which cannot be negotiable. Customers will have to shell out additional monies to purchase the same piece of jewellery.
2. Gold prices are on a steady increase due to social political factors across the globe. It is a favorable time to invest in gold when the rates are still within grasp.
3. India is largely a cash economy. Biggest consumers of gold are from rural India. A large chunk of their savings are invested in purchasing gold. It has been almost six months since demonetization; consumers are gradually adapting themselves to digitized payments. Digital payments for gold and diamond purchases have increased in urban areas considerably.
4. Investors seek stability before investing. Trust as well as stability are important factors while deciding investments, which affect buying as well as investment behaviour. The present government is winning hearts with its recent victories across multiple elections. Thereby showcasing a strong leadership at the top indicating stability of the government and trust of its subjects. Buying in gold is bound to increase!
5. A lot of brands are giving attractive offers to entice more customers this Akshay Tritiya. This is the right time to exchange or replace ornaments. Discounts have become an extremely crucial aspect of Gold buying.
6. Consumers this year are looking for new and attractive designs at attractive prices. Even millenials have shown a key interest in tying themselves to the tradition of buying jewellery on Akshay tritiya.
7. Southern India, this year has an added advantage of celebrating Akshay Tritiya for two whole days. Thus more sales are expected this year.
The author is chairman and managing director at PNG Jewellers. He is also a director at Indian Bullion Jewellers Association (IBJA)

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As people who already have them fitted can tell you, awnings are a simple solution if you are looking to both protect your home and increase its visual appeal and its value.
Gone are the days when awnings were made of just vinyl rollouts or simple wooden structures!
- Right now, it is possible to decorate any kind of home withvisually appealing materials, styles, colours and designs that precisely suit your individual needsand desires.
And below you can find out just why wonderful looking awnings can do wonders for all homes!
Modernawnings can be used to beautify your house and at the same timeoffer superb protection from the sun on those lovely afternoons spent chilling out on the porch.
- All patios with great looking awnings are the perfectplace to be for when there's any kind of gatherings for family or friends and even an intimate dinner.
- Whether retractable, wrought iron, or folding arm awnings, you can now find one's that will perfectly match your home's current style and décor.
Wrap-Around and Multi-Level Types
Multi-level awnings grant extra space to a home and give a cool look and feel of grandeur. They allow for enjoyable movement from one floor to the next even when outside,whether it's sunny, rainy,and windy or even if a storm is going on.
Wrap-around awnings, gives you the opportunity to havevarious outside spaces to enjoy (all under one roof), acosy BBQ space, a great dining area, or even a Jacuzzi! All are possible!
Surroundingthepatio or porch with a sturdy,cool looking awning, will add some extra footage which can be used atanybody's home, and provide enough space to develop a brand new and exciting area to enjoy using.
- You will be able to transformyour porch area into that of a home office, a guest area, or a chilled out space with plenty of plants.
Extra Shade System
If you mix an awning with a hanging shade system, it will convert any type of porch, patio, or balcony into a dual two-in-one system. When the weather is good, the shades can then be liftedfor full exposure to the exterior.
Whereas if it's overcastor rainy, the shades can be somewhat closedor fully so for protection from the elements, minus any loss of the ability to use your outdoor space.
Direct sunlight entering a roomvia windows can be harmful, to your skin, your flooring, and your lovelyfurnishings.
- After fittingelegant looking awnings on your windows, it will prevent the rays from shining directly inside, and give youfullcontrol over what light enters your home. (And certainly so with the addition of a cool looking set of curtains or drapes!)
As you will find out, awnings are the ideal home beauty enhancer wherever your home. With the selection of so many styles, colours, sizes, and designs available, you will find the perfect ones for your home.


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A snake's appetite varies as much as the species itself does. It is a species of animal that is slow, yet methodical in the way it travels. This carries over to their diet in the way in which they hunt or consume their snake food. They can be picky at times in what they eat, for example being careful about consuming an animal that is too large or difficult to swallow is one fell swoop. Some snakes in captivity prefer frozen rodents to live rodents for feeding time.
A snakes diet changes as it grows, consuming smaller prey when they are younger and larger when they are older and able to kill larger creatures. Since these animals are cold-blooded they do not need to eat as much as warm-blooded animals, only needing to be fed every 7-10 days. How often they are fed also depends on the size of the snake, younger snakes should be fed more often since they are in important growing stages and need proper nutrition. Remember also that snakes are ectotherms; this means that their body temperature and metabolism change depending on the temperature of their surroundings, this will affect their appetite. So if your snake is not eating, it may be too cold, or it may need its food put inside a hiding box to give the snake a sense of seclusions. You can tell when a snake wants to be fed by observing if they are prowling their cage more often or increasing the number of tongue flicks.
The most common snake food are mammals since a snake's main source of killing an animal, constriction and venom attacks, are easily carried out on these types of animals. In the wild, this can include small foxes, rabbits, rats, and mice. In captivity, many snakes eat frozen feeder rats, rabbits, and mice. Some snakes, like the King Cobra and the King snake, eat other snakes. Brown snakes tend to prefer snails, while the White-bellied Mangrove Snakes prefer crabs and blind snakes, which mostly live underground and don't have use of their eyes, primarily consume ants and termites.
When feeding your pet snake food, it is almost always recommended that you feed it pre-killed prey, like thawed frozen mice or frozen rats, instead of live prey. Very few snakes will insist on live snake food. It is recommended also that gloves are worn when feeding your snake in case the snake lunges at the prey. It is important to remember that each species has a reference book on its diet, and that the snake's natural food should be offered to it before you deviate to another food source.
If you have more than one snake it is highly recommended that you feed them snake food separately so as to not encourage a fight among them. For more information on feeding reptiles, check out our articles What Do Geckos Eat and What Do Lizards Eat.
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Hi Guys! This weeks post is by the lovely Isabella Piper. It is all about body confidence and societal expectations of women, specifically their dress code. Isabella tell's her own personal journey and struggle into the woman she is today and would like to share that with you! I hope you guys enjoy the story … Continue reading A Woman's Dress Code
Women's Wednesday
Hodan's Poem
Hi Guys! This week's post is by the lovely Hodan, It's a little different to what I normally share. It's a poem by Hodan and I'm sure we can relate to it to some extent. Hodan's social media will be linked below, show her some love! Hodan's Poem My biggest mistake was thinking this body, … Continue reading Hodan's Poem
Learning About Him
Hi Guy's This weeks Women's Wednesday is about life in general and how faith can help us face the problems life gifts to us. No matter what you believe in, I think we can all agree that faith provides hope in a certain way and can help overcome life's troubles. This lovely post was shared … Continue reading Learning About Him
Hi Guys! This Week's Women's Wednesday Post is by a rising social media star Sumayyah Akhter, thanks for getting in touch with us Sumayyah! Her Piece is about women in general and the accomplishments of women. She talks about how the role of women has changed in society over the years and how it will … Continue reading Women
My Skincare Dream
Hey guys! Really excited for this weeks Women's Wednesday post. It is literally such an inspiring story of such an inspiring woman! Who was brave enough to pursue her dreams and goals! This story is about Chimmy, who has launched her own skincare line! Something definitely to be proud of. She has been kind enough … Continue reading My Skincare Dream
Hi Guys! This Weeks Women's Wednesday post is by Aliesha Nura, many of you may know her from instagram! Her story focuses on the expectations of women to be married and the expectations of a happily ever after. How love isn't the only goal and how we should also focus on our relationship with God. If … Continue reading Intention
Sacrifices After Marriage
This is the first post of this project! If you want to get involved just send me a message! This weeks story is about a reader who talks about her life from a young age to after marriage and all that she has learnt on this journey. It is focused on cultural issues and expectations! … Continue reading Sacrifices After Marriage


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The theme for the Wetterberg Professional Web Site was to have an outdoor theme. That is why you see pictures all around the Hahn's Peak area. Below are description of pictures located on the Wetterberg Professional Web Site.
Wetterberg Shed
Steamboat Lake area
including looking at Sand Mountain and from Routt County Road 129
Pearl Lake
For font I decided to use Arial for the title and Arial Narrow for body text because every computer in the world can recognize Arial fonts (I don't know about Arial Narrow). For text color I went with white or some form of gray because of being readable to the text with the Hahn's Peak graphics as watermarks or backgrounds.
Copyright 1999-2000 Victor P. Wetterberg. All Rights Reserved.


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Two of Australia's most respected journalists, Hugh Riminton and Jamelle Wells, have penned their memoirs after decades of reporting on the lives of others. In conversation with fellow journalist, ABC's Eleanor Hall, they discuss their distinguished careers and how they've dealt with covering some of the most well-known crimes and tragedies of our time. Hugh's Minefields catalogues his four decades working in some 50 countries, while Jamelle's The Court Reporter details her time covering some of the nation's most notorious and high-profile court cases.
Hugh Riminton (Australian)
Hugh Riminton has been a journalist and foreign correspondent for nearly 40 years, working chiefly for CNN and Australian television. He has received major journalism honours in Australia, the United States and Asia - including the Dupont-Columbia Award (US), two Asian TV Awards, two Walkley Awards, a Logie and honours from the Australian Human Rights Commission and the UN Association Peace Award. He has reported wars and conflicts on four continents and witnessed some of the largest humanitarian disasters in recorded history. His memoir, Minefields: A Life In The News Game, was published in October 2017.
Jamelle Wells (Australian)
Jamelle Wells is a senior ABC Newsreader and Court Reporter. Her memoir, The Court Reporter, spans a decade of covering some of Australia's most notorious and high profile cases. Before Jamelle joined the ABC, she was a news presenter for commercial stations including 2GB and 2CH, a business reporter, magazine editor and columnist. Jamelle provides commentary on court cases for ABC television, radio and online.
Eleanor Hall (Australian)
Eleanor Hall is host of The World Today, and occasionally fills in as host on ABC TV's The Drum. She has two decades of reporting experience with ABC TV News, including working on 7.30, Lateline, and Foreign Correspondent. She was the ABC's Washington correspondent in the late 1990s and she worked for five years in the Canberra parliamentary press gallery. Prior to joining the ABC, Eleanor freelanced for US National Public Radio from Central America and worked at WGBH in Boston as the youngest ever recipient of the Harkness Fellowship. She earned her Masters in Journalism from Columbia University in New York, has been a fellow at Oxford University's Reuters Institute where she submitted a paper on the Obama e-campaign. In 2012 she won the European Union's Journalism Award.


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Join us in Columbus September 14-17, 2017 to experience nationally-known speakers, the largest exhibit hall in the region, fun social events and more!As we embark on the next milestone, our profession has never offered more promise or more challenges. From new technologies to new concepts in the practice of dentistry, Annual Session offers you the opportunity to stay engaged and informed. This year's meeting offers amazing workshops, compelling lectures, one-of-a-kind social events, and an impressive Exhibit Hall boasting more than 200 dental companies and organizations.
More Information
nforming, representing and serving the public and the dental profession in Ohio, the Ohio Dental Association represents more than 5,o00 dentists statewide.Dedicated to oral health, the ODA represents the interests of Ohio dentists and their patients on legislative, regulatory, and third-party payer issues. A not-for-profit association, the ODA is a leader in providing professional information and education to dentists and the dental team.
For those looking for fun things to do while in Columbus visit their visitors center website.


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What is PAP/CPAP Therapy?
Positive airway pressure (PAP) therapy is a general term used for all sleep apnea treatments that keep the airway open while sleeping by providing a constant stream of air through a mask. This eliminates snoring or breathing pauses during sleep and allows you to sleep through the night without waking up from a lack of oxygen. PAP treatments include:
- CPAP (continuous positive airway pressure)
- BiPAP (bilevel positive airway pressure)
- AutoPAP/APAP (automatic positive airway pressure)
Your sleep provider will recommend a certain type of PAP treatment based on your medical history and sleep study. CPAP is the most common treatment for obstructive sleep apnea (OSA).
You'll first need a sleep study to determine if you have OSA. If your study is positive for OSA, your provider will determine if you need require CPAP, BiPAP, or AutoPAP. If you need CPAP or BiPAP, you will need a titration study, which is a daytime or overnight sleep study done at our sleep center that helps us determine the level of pressure needed for your CPAP or BiPAP.
If you require an AutoPAP, there is no need for a daytime/overnight sleep study, since your machine will be set at a variable pressure–the machine adjusts the pressure automatically based on your breathing needs.
What Is Involved with PAP Therapy?
PAP therapy is a lifestyle change and it can take weeks or even months to get used to wearing it nightly, which is why it is best to work closely with your respiratory therapist to help identify the mask that best suits you. Finding the right mask is an important step in successful PAP therapy. There are several different types and styles of mask from which to choose:
- Nasal pillow mask: Small "pillows" that fit in your nostrils to create a seal
- Nasal mask: Covers your nose only
- Full Face mask: Covers your nose and mouth. This mask is the best choice if you have difficulty breathing through your nose for any reason.
The mask should be comfortable and create a seal so that air does not leak from it. If you are having issues with your mask, it's important to communicate with your respiratory therapist or CPAP equipment supplier right away so that they can address it with you.
PAP machines are smaller and quieter than ever—they are about the size of an AM/FM bedside radio. Masks and machines with stylish looks are now available, taking beauty sleep to a new level.
Women's 4Her masks and headgear are also available; however, manufacturers sizes are limited with this line.
You should use your PAP/CPAP every time you sleep, even while napping. Consistent PAP/CPAP use increases your quality of sleep at night, which will eliminate daytime sleepiness. It can increase memory function, daytime alertness and energy levels. It also decreases the risk of congestive heart failure, coronary artery disease, high blood pressure, stroke and diabetes.
PAP/CPAP Equipment and Supplies
PAP/CPAP are considered durable medical equipment (DME), which is prescribed by your sleep provider.
Sleep Insights conveniently offers PAP/CPAP supplies (DME) at our Rochester, Geneseo and Batavia locations and participates with the following insurances:
- Excellus BCBS (except Blue Choice Option)
- Pomco
- Univera
Cleaning, Replacing, and Ordering PAP/CPAP Supplies
PAP/CPAP supplies should be replaced every three to six months. You can easily order all your supplies from Sleep Insights by calling us at 385.6070 #3 or contact us.
PAP/CPAP Replacement Supplies
Filters and cushions
PAP/CPAP items to make your life easier or cleaner—sometimes both!
So Clean CPAP cleaning machine and accessories
So Clean CPAP wipes
RemZzzs CPAP mask liners
CPAPMax pillow 2.0
CPAP travel machines


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Thursday, June 3, 2010
Brand New Theme from Hedone Design: Biston
Welcome back from the long weekend everyone! Get your short week off to a good start with 25% a brand new theme from Hedone Design. Biston is a fast theme with an animated menu in a circle like you've never seen before. There are 9 user customizable icons on home screen, big and readable battery and signal meters, and TodayPreview for your future calendar events and new messages, etc. Fonts in lists are user customizable and can be changed to what ever size you prefer. You can not change Menu font!
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at 8:27 AM
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I have been amazed at the interest generated by some of the talks I have recently given on Palestine.
The 9 minute talk in Austin, Texas has been translated into French, Spanish, Italian, Japanese, and Farsi! And all by individual efforts (thanks to Ageel Shatry and Francesco Puglia and Ichiro KASAI) It has gotten more than 47,000 hits so far.
The 30 minute talk in Raleigh, North Carolina (previously discussed here) has just been translated into Portuguese (see here) and Spanish (see here). Again, these translations were done by individuals (thanks to Tali Feld Gleiser) This speech has gotten more than 12,000 hits.
What does this mean? Quite simply: there is an inspiring energy level – one that is further empowered by both social media and the strategy of BDS!


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When I tell people I'm a writer, they ask me what my novel is about and if I have a publisher. When I tell people I'm doing a PhD in creative writing, I'm usually asked how a creative discipline functions within a traditionally academic environment. Actually, people usually ask if I think creative writing can be taught. For my answer, read this recent article in the Guardian Review by Rachel Cusk and pretend I'm there, reading it out loud and passing it off as my own words.
As a writer, there's a clear – albeit financially unrealistic – career path: write a book then publish it. Repeat ad infinitum. As a creative practise-based academic, the boundaries over what I'm writing and why I'm writing it are much less clear, as are my thoughts about where I want to go next, and how I want to get there.
My PhD has prepared me for a career in academia but, having gone straight from my undergraduate MA Hons in English Literature at St Andrews University to an MLitt in SELLL here at Newcastle University, and then staying on for a Creative Writing PhD, I feel like I'm due a break from foot-notes.
So, for the first time since I started my PhD, I'm looking around the recession-scarred landscape to see what jobs both interested in and qualified for and trying to work out what I want to do once I've submitted my thesis
Over the next twelve months I'll be finishing the writing-up process, going through my viva, and looking for paid employment. I'll be blogging here regularly about the ups and downs of career hunting as a writer and a researcher, and what I'm doing in terms of professional development.
Viccy Adams is a final year Creative Writing PhD student at Newcastle University, funded by the AHRC. Her research examines the intersections between single-author short story collections and novels, with a particular focus on the contemporary British publishing industry.