Nutrition Intervention in District Tharparkar - HANDS · Nutrition Intervention in District...

Analysis of Nutritional Status in Tharparkar 2014

1

Nutrition Intervention in District Tharparkar

Analysis of Nutritional Status

In

Community-based Management of Acute Malnutrition (CMAM)

Project

March – August 2014

Collaboration:

Unicef, Sindh

World Food Program

District Government Tharparkar


2

Analysis of Nutritional Data

Community-based Management of Acute Malnutrition Project

March – August 2014


3

Acronyms

CMAM Community-based Management of Acute Malnutrition

HANDS Health And Nutrition Development Society

IYCF Infant and Young Child Feeding

MAM Moderate Acute Malnutrition

MCH Mother and Child Health

MUAC Middle Upper Arm Circumference

NGO Non-Government Organization

NNS National Nutrition Survey

OTP Outpatient Therapeutic Program

RUTF Ready to Use Therapeutic Food

SAM Severe Acute Malnutrition

SC Stabilization Center

TFP Therapeutic Feeding Program

Unicef United Nations Children’s Fund

WFP World Food Program


4

Acknowledgement

First of all let us thank Almighty ALLAH (Subhan-eh-Taala) who has blessed us with an

organization like HANDS that has provided us a wonderful platform to serve humanity and enable

us to contribute good deeds; to bring relief in the lives of drought affected people through

Community based Management of Acute Malnutrition interventions.

We would like to thank UNICEF, World Food Program for their financial assistance and technical

guideline throughout project period. We are grateful to Nutrition Wing Government of Sindh for

their technical guidance and valuable inputs. District Government Tharparkar played encouraging

role in implementing CMAM activities in selected union councils. We highly appreciated District

Health Department for being kind enough to provide premises and allow community based staff for

facilitating CMAM activities.

We are thankful and acknowledge the efforts of field teams and especially thankful to Dr. Satram

Roopani, District Executive Manager- HANDS Tharparkar, Mr. Ashfaque Baloch, District Project

Manager- CMAM who efficiently escorted the teams in carrying out all activities successfully.

We are fortunate to have technical input of Dr. Shaikh Tanveer Ahmed, Chief Executive- HANDS,

his timely guidance and supportive role throughout project period was key success. In addition, Mr.

Salman Arshad, Senior Manager Health program HANDS contributed gigantically in leading district

teams efficiently and kept all data secure for analysis and reporting.

Our special thanks to Ms. Rubina Jaffri – Senior General Manager, ME&R, Mr. Noor Muhammad

Baloch, Senior Manager- ME&R and team for developing efficient data recording and reporting

tools that helped us out in getting required data on daily, weekly and monthly basis.

Dr. Muhammad Sarwat Mirza Zulfiqar Ali Sario

Chief Research and Development Executive Senior Manager MER program

HANDS HANDS


5

Executive Summary

The Tharparkar has faced the drought due to low level monsoon rains, lack of measures to ensure the

food security, lack of fodder and disease among the livestock resulted in loss of large number of

animals. The situation analysis revealed the poor health and nutrition status of the women and

children.

HANDS with support of Unicef and World Food Program has initiated the community-based

management of acute malnutrition project. The project was implemented in 20 union councils of two

talukas Mithi and Diplo of district Tharparkar. During the project period from March to August

2014, total population reached by HANDS teams was 232517 in 560 villages. Total 50274 children

under 5 years of age were screened for malnutrition through MUAC (Mid-Upper Arm

Circumference) measurement. The malnourished children identified were 9570 (19%). This is

slightly higher than the overall Sindh data of malnourished children as revealed by the National

Nutritional Survey (NNS 2011). Among these malnourished children 52.5 percent were girls. The

severely acute malnourished children were 3018 (6% of the total children) and moderately acute

malnourished children were 6552 (13% of the total children).

The pregnant and lactating women were also screened for malnutrition through the MUAC

measurement. Total 26360 women were screened including 13627 pregnant women and 12733

lactating women. The malnourished women were 5037 (19.1%), that is also slightly higher than the

percentage of women (17.5%) revealed by the NNS 2011 for Sindh.

The children of severely acute malnutrition admitted to Out-patient Therapy Program (OTP) and

Stabilization center (SC) were 3018. Most of them 2008 (67%) were cured, 166 (6%) were defaulted

due to migration of the family from the area while 9 children were died at Stabilization center. The

cure rate is slightly lower than the standard cure rate of more than 75%. But 720 children (24%)

were still under nutritional treatment. The children who have been died were had many

complications as diarrhea, acute respiratory infections and dermatoses etc. Out of these children 64%

were girls and all were severely malnourished. The youngest child was of 4 months of age.

The food supplements were provided to all malnourished children, pregnant and lactating women.

Most of the distribution targets were achieved. The Infant and Young Children feeding program was

also implemented that included the nutritional guidance and counseling of the mothers and

promotion of breast feeding practices, promotion of intake of multiple micro-nutrients, iron-folate

supplements etc.

There is a need for continuation of the nutrition interventions in same geographical area and to cover

all population in district Tharparkar. In addition, there is a need for other nutrition sensitive

interventions to ensure the food availability and security at household and community level.

Thereby, long term programs may support to break the vicious cycle of malnutrition in this area.


6

Background

For many years Pakistan has had persistently high rates of acute malnutrition exceeding emergency

thresholds1. Rates of severe acute malnutrition (SAM) are particularly high with a national average

of 5.8%. Pakistan is second only to India in contributing to the global burden of SAM 2. The

majority of SAM cases are under 24 months with a notably high burden in infants1. Addressing the

persistently high burden of SAM through treatment and prevention programs is critical in meeting

the MDG 4 (reduction of mortality). It requires an integrated approach that is sustainable. The links

between food insecurity and acute malnutrition have been well documented2. In addition,

inadequate child care and feeding practices are a direct cause of acute malnutrition in Pakistan.

Tharparkar: District Tharparkar is facing serious drought situation over the last one year. The compromised

livelihood situation, due to a combination of factors including low level monsoon rains in 2013-14

and its impact on food stocks and the livestock situation, together with poor sanitary and hygiene

facilities, limited availability of clean drinking water, limited access to health care services and

likelihood of epidemics aggravated the nutritional situation further and there is rise in morbidity and

mortality being reported now in media.

Project Introduction: CMAM is a comprehensive approach for the management of acute malnutrition that includes the

management of severe acute malnutrition (SAM) in outpatient care (for children 6–59 months with

SAM without medical complications); SAM in inpatient care (for children 6–59 months with SAM

and medical complications, and children under 6 months of age with acute malnutrition); the

management of moderate acute malnutrition (MAM) (for children 6–59 months with moderate acute

malnutrition [MAM]); and community outreach for community involvement, early detection and

referral of cases for treatment, and follow-up of problem cases. The set of interventions included the

four CMAM components as

1) Community outreach

community mobilization,

screening of children, and pregnant and lactating women for acute malnutrition,

promotion of breast feeding

de-worming,

provision of multi-micro-nutrients for children, pregnant and lactating women,

provision of blanket distribution of supplementary feeding for children under 5 years of age,

pregnant and lactating women,

referral

1 National Nutrition Survey (NNS). Planning Commission/UNICEF/Aga Khan University, 2011

2 Based on a SAM rate of 5.8% and an under five population of approximately 21.4 million (180m pop),

Pakistan has an estimated 1.5million SAM cases


7

2) Outpatient treatment (OTPs)

For Severely Acute Malnutrition (SAM) children without complications;

community based treatment of severe and moderate acute malnutrition (Out Patient

Therapeutic Program-OTP

3) Inpatient treatment in stabilization centers (SCs)

Treatment of acutely malnourished children with medical complications to stabilization

centers (SC).

4) Management of moderate acute malnutrition (MAM) through IYCF counseling

promotion of infant and young child feeding practices,

Targeted supplementary feeding program (TSFP,

In early March 2014, rising numbers of clinical admissions and child mortality due to malnutrition

were reported in media got attention for humanitarian response by the world. HANDS have already

sensed the disastrous situation and planned to start CMAM activities in Tharparkar in early January

2014 with UNICEF and World Food Program and started nutrition interventions in Tharparkar in

March 2014

The district is administratively divided in to six Talukas as Mithi, Diplo, Islamkot, Chachro,

Nagarparkar and Dahili. Majority of the population located in all Talukas are affected by the

droughts and its effects. HANDS conducted the initial drought assessment of all 44 union councils

with support of UNOCHA during March 2014. Afterwards with support of Unicef, The Project

Objective is to improve access to Community -Based Management of Acute Malnutrition (CMAM)

and encourage adherence to IYCF among the under-five population of selected Union Councils in

district Tharparkar. HANDS started implementation in Targeted 20 Union councils of Talukas Mithi

and Diplo. The Total 46503 families were reached and screening of children and women was

conduct.

Table: Details of Intervention area

Variables Total Affected HANDS

Intervention

Total Population of

district Tharparkar

1346793 1346793 232517

Talukas 6 6 2

Union Councils 44 44 20

Villages 2188 2188 560

Households 269358 259946 46503

The project phase I started in March 2014, HANDS district teams started the community

mobilization in the targeted union councils. They initiated the screening of children under 5 years for

identifying the malnourished through Mid-Upper Arm Circumference (MUAC) measurement.


8

Progress Analysis:

Total number of the children under 5 years of age screened were 50274 in 560 villages. They are

well above (179%) the target proposed in the project. Out of those 53% were female children.

Graph: Status of targets achieved for screening of Children

Nutritional Status of Children:

The screening of the children was conducted by measurement of Mid-Upper Arm Circumference

(MUAC). According to the WHO standards the children more than 13.5 cm are of normal nutritional

status. The children with measurement between 13.5 – 12.5 cm are graded as mild nourishment or

have some risk of malnutrition. The children with measurement between 12.5 – 11.5 cm are graded

as Moderate Acute Malnutrition (MAM). These children require support Supplementary Feeding

Program. The children with measurement below 11.5 cm marked as suffering from Severely Acute

Malnutrition (SAM). Those children managed through Oral Therapeutic Program.

Table: Scale of MUAC for Malnutrition assessment

Scale Category of

Malnutrition Treatment

<11.5 cm Severely Acute

Malnutrition (SAM) OTP

11.5-12.5 cm Moderately Acute

Malnutrition (MAM) SFP

12.5-13.5 cm Mild Acute

Malnutrition (at Risk) IYCF

>13.5 Normal

The screening of total 50274 children revealed that 6 percent (3018) children were Severely Acute

Malnourished (SAM). It is slightly better situation than the 6.6% of children severely malnourished

0

10000

20000

30000

40000

50000

60000

Male Female Total

14349 13786

28135 23616 164%

26658 193%

50274 179%

Screened Children vs Targets

Targets Screened


9

in Sindh, as revealed by National Nutritional Survey 2011 report. There was no difference between

the female and male children. The Moderately Malnourished children were 13% (6552), slightly

higher in number than the overall Sindh data, that revealed 11% moderately malnourished children

(NNS 2011). But the overall malnourished children were 19 percent (9570), slightly higher than the

Sindh, that were 17.5%.

Graph: Malnutrition Status of Children

Malnutrition Management Activities:

Performance of OTP and Stabilization Center:

All Severely Acute Malnourished (SAM) children were referred to OTP (Out-patient Therapeutic

Program). They received the recommended doses of RUTF. All were followed weekly by the project

field teams. The children who got cured were 67%, while 6% were defaulted (migrated out of the

area with the family) and total 9 children died during the treatment.

Table: Trend for Cure, Defaulter & Death Rates

TFP Rate Tharparkar Mar-Aug

2014

Sphere Standard

Cured 67% > 75%

Defaulter 6% < 15%

Death 0.30% < 10%

The cure rate is slightly below the standard i.e. more than 75% children should be cured. Fortunately

the death rate is significantly lower than the expected, depicted the program effectiveness and

efficiency.

0

20

40

60

80

100

SAM children MAM Children Normal

6% 13%

81%

6.6% 10.9%

82.5%

Malnutrition Status of Children

Tharparkar NNS 2011 (Sindh)


10

At stabilization center, eleven children died during their treatment. Most of them were girls 7 (64%)

and 4 (36%) were boys. Nearly half of them were infants, and youngest was four months of age girl.

All children were severely acute malnourished with some complications including diarrhea, acute

respiratory infection and dermatoses.

Table: Age distribution of Children died

Age group of Children Number of

Children Percentage

chidren below 12 months 5 45.4%

13-24 3 27.3%

above 24 months 3 27.3%

Performance of SFP for Children:

In the Supplementary feeding program, the Moderately Acute Malnourished (MAM) children and

the Severely Acute Malnourished (SAM) children improved at OTP were enrolled. Then the

recommended feeding supplements provided to the children and regularly followed up by the field

teams.

During the project implementation period from March to August, total 6453 (98%) MAM children

were enrolled for SFP. Most of them 4521(70%) get cured while 1868 (29%) were under treatment

as the project concluded. Only 64 (1%) were defaulted as their parent moved out of the area for

different reasons.

Graph: Performance of SFP – status of children treated by SFP

4521 70%

64 1%

0 0

1868 29%

Status of Children treated by SFP

Children (m&f) cured

Children (m&f) defaulted

Children (m&f) Died

Children (m&f) Other

Children (m&f) Currentlyin Treatment


11

Performance of SFP for PLW:

The pregnant and lactating women were screened and out of them 5026 (98.5%) treated by

Supplementary Feeding Program. Total 3462 (68.2%) pregnant and lactating women were cured,

while 27 (0.5%) were defaulted (due to move out of the area) and 1573 (31%) were still getting

supplementary food for recovery.

Graph: Performance of SFP --- Status of PLW after treatment

Food Supplements Distribution:

The food supplement given to children were Ready to Use Therapeutic Food (RUFT) for children

with severely acute malnutrition, the Achamum was given to children with moderately acute

malnutrition. The Multiple Micro-nutrient sachet was given to all malnourished children. The total

number of food supplements supplied to children was higher than the estimated numbers. Total

535200 RUFT packets, 77436 kg of Achamum, and 33104 Multiple Micro-nutrient sachets were

provided to the children.

Graph: Status of Food Supplements distribution for Children

3426 68.2%

27 0.5%

1573 31.3%

Status of Women Treated by SFP

PLW cured

PLW defaulted

PLW Died

Children (m&f) Other

PLW Currently Registered

0

100000

200000

300000

400000

500000

600000

RUTF (# ofpackets)

MM Sachets(# packets)

Achamum forchildren (Kgs)

369266

29541 59083

535200 145%

33104 112%

77436 131%

Food Supplements Utilized by Children Target vs Achieved

Target

Achieved


12

The food supplements provided to the malnourished Pregnant and lactating women were Wheat

Soya Bean, edible Oil and Multiple Micro-nutrient tablets. Total 77810 kg wheat soya bean, 14108

kg oil and 444000 Multiple Micronutrient tablets were distributed among the malnourished pregnant

and lactating women.

Graph: Status of Food Supplements distribution to Pregnant & Lactating Women

Conclusion:

Tharparkar is a desert terrain, faced drought situation after every 3-4 years due to seasonal

variations. The current data revealed that the nutritional status of children and women is alarming,

and contributing in mortalities. There is a need to provide immediate relief through direct nutrition

specific interventions, especially focusing the most vulnerable women and children. These

intervention should be continued for a certain period until there would be food security and dietary

practices and nutritional status of children and mothers improved. To prevent the mortalities, the

health care services at community level and then at secondary care must be ensured.

The community mobilization through CSOs, technical and resource assistance from larger NGOs,

philanthropists and sustain measures by the Government must be continued for improving the

situation.

There is also need to plan short-term nutrition specific and sensitive interventions, to improve the

nutrition status of the children and women. But there is also need to ensure the food security at

community and house hold level, provision of improve water, accessible health services on long–

term basis.

0

100000

200000

300000

400000

500000

MM Tablets WSB for PLW(Kgs)

Oil for PLW(Kgs)

446000

97657

19531

444000 99.6%

77810 80% 14108

72%

Food Supplements Utilized by PLW Target vs Achieved

Targets

Achieved

Nutrition Intervention in District Tharparkar - HANDS · Nutrition Intervention in District...

Documents

Transcript of Nutrition Intervention in District Tharparkar - HANDS · Nutrition Intervention in District...