Project Description

Concern is implementing the project titled “Integrated multi-sector support to nutrition at risk communities in Sindh, Pakistan”. The core objective of this project is to improve resilience of the drought affected population in Sindh province, with a special focus on addressing immediate humanitarian needs of drought affected communities. Community based Management of Acute Malnutrition (CMAM) has been one of the stalwart interventions under this project. While being executed with the support of an implementing partner i.e. NGOs Development Society (NDS), CMAM is being implemented across 12 union councils of Taluka Umerkot, at district Umerkot, Sindh.

CMAM Project Manager is responsible for the programme execution in the field. Project Manager is supported by CMAM programme staff. Staff comprises of 12 field teams. Each team consists of a Nutrition Assistant, a Supplementary Feeding Programme Assistant, an IYCF Counsellor (female) and a Community Mobilizer (male). Other support staff to the programme includes M & E Officer, NIS assistant, warehouse assistant and data entry operator.

As far the coverage structure of the CMAM programme is concerned, programme operates at least one static CMAM site in each Union Council of Taluka Umerkot. However, keeping in view the challenge associated with the travel time (more than half hour for a round trip), visits & availability of the transport, there are mobile sites in place as well, in order to ensure coverage to those prospective community members who can’t reach to the OTP sites.  For mobile sites, depending upon distance, a weekly or a fortnightly coverage frequency based schedule is followed.

In order to determine the access & coverage of CMAM programme, Semi- Qualitative Evaluation of Access and Coverage (SQUEAC) survey was conducted in Umerkot Taluka, district Umerkot, during June 2016. At the time of survey 12 field teams of Concern Worldwide were working in the targeted area and all the 12 OTP sites were functional. SQUEAC investigation was conducted based upon the standard SQUEAC methodology.

SQUEAC expertise from Coverage Monitoring Network (CMN), UK was taken on board in order to address the technical requirements related to SQUEAC investigation. Along with the CMN, an experienced SQUEAC Survey Manager was deployed in order to handle the on-ground investigation in the field. SQUEAC investigation was supported by a nutrition expert, a research design expert and a field coordinator.

Based upon the findings, key results of the SQUEAC investigation are summarized as under:

  • The coverage of CMAM program is estimated at 51.3% (CI-42.8% to 59.7%). The coverage is calculated based upon single coverage calculation approach.
  • Out of the total children admitted to the CMAM programme, 93.8% have been admitted between MUAC values of 114 mm to 110 mm, which depicts an early case detection.
  • Based upon programme exit data, 90.47% of enrolled children were cured, 5.59% defaulted, 0.3% deaths were recorded and 3.63% of the enrolled children didn’t respond to the treatment.
  • The average length of stay of children with in the program has been 7 weeks.
  • 3% of the cases had a travel time less than or equal to 15 minutes (by walk for a round trip), in order to reach the OTP site. Furthest village has been located at a travel time of 60 minutes (round trip by walk).

CMAM Programme Boosters

  1. Effective coverage of mobile teams
  2. Coordination among the programme field staff, Peoples Primary Health Care Initiative (primary health care service provider mandated by the Government at community level) and government staff
  3. Positive perception of CMAM programme with in the community related to treatment of the malnourished children & community’s awareness about the malnutrition phenomenon.
  4. Active volunteerism with in the community

CMAM Programme Barriers

Key barriers established during the SQUEAC investigation include the following:

  1. Incomplete and improper information of the community about the CMAM programme and lacking community knowledge about the nature of CMAM programme its work pattern, admission criteria etc.
  2. The understanding of community about RUTF has also been vague, as it was termed as “chocolate” or “Malai” by the community.
  3. OTP staff’s non-acceptance of the cases referred by the health workers in the health facilities of district has also appeared as a strong barrier. This non-acceptance has a correlation with the influence of the community feudal.
  4. Behavioral issues of the staff during rush hours & rude behavior of the staff with the programme beneficiaries, has also been established as a barrier. However, frequent changes in the OTP staff also contributes to barriers of the CMAM programme. The programme beneficiaries find it difficult to get associated with the new staff during the follow up visits
  5. Default due to seasonal migrations is one of the established barriers for the programme. Once triangulated with the admissions & default trends (on a month wise basis) and the seasonal calendar of crops, it’s quite clear that due to seasonal migrations, the corresponding admissions trend slows down and default rate picks up in the same period.

Based upon the overall quantitative and qualitative findings, the key recommendations include:

  • Identified barriers should be addressed and programme boosters should be promoted.
  • CMAM programme field staff’s capacity should be strengthened in the areas of social mobilization, client & community management, work load management & community service attitude. On the job mentoring is also recommended in order to address this human resource capacity development requirement. Job aids should be further improved.
  • Since staff behavioral issues have been identified as one of the key barriers, therefore it’s recommended that staff training should be conducted in the areas of effective communication skills and ethics.
  • Strengthening of referral mechanisms and strengthening of health promotion sessions by developing effective job aids is highly recommended as well. Certain groups including schools teachers, imam masjid, local leaders, peers, women support groups, men support groups etc should be capacitated and activated through effective social mobilization, so that they could be able to identify and refer the cases of malnutrition. Furthermore, they should also be sensitized to track the referred cases and make arrangements to re-refer any of the default cases as well. These groups should also be capacitated to provide awareness raising sessions about CMAM, admission criteria and proper usage of RUTF.
  • Community engagement & sensitization should be ensured by CMAM programme staff for recognizing the RUTF, its usage and its consumption practices.
  • A quarterly meeting based co-ordination mechanism is highly recommended to ensure an on-going work co-ordination among all the health related stakeholders working for the community health including Community Health Committees, Village Health Committees, Lady Health Workers, Basic Health Units and Community Volunteers etc. This co-ordination will address the acceptance of the malnourished cases by OTP staff. A reporting structure should also be adapted to keep track for all such co-ordination meetings.
  • Sessions with the community gate keepers, traditional healers, feudal(s) and spiritual leaders should be conducted for raising awareness on prevention and treatment of acute malnutrition. Eradication of understanding prevailing in the community regarding stigmatic nature of malnutrition should be addressed through such sessions as well.