WHO, UNICEF, FANTA African Regional Training on Integrated Management of Severe Malnutrition, Dar es Salaam, 20th to 30th September 2006
We estimate that 20 million children under-five in the world are suffering from severe malnutrition. Severe malnutrition1 may act as a direct cause of death or an indirect cause by increasing dramatically the case fatality in children suffering from common childhood illnesses such as diarrhea and pneumonia. Current estimates suggest that severely malnourished children have a 10 to 20 times higher risk of dying than well nourished children. Given that approximately 1-2% of the under 5 population in the developing world are affected by severe malnutrition, this may correspond to around 1,000,000 child deaths every year (WHO 2006)2.
Despite the above, the burden of child mortality due to severe malnutrition remains largely absent from the international health agenda and few countries, even in high prevalence areas, have specific national policies aimed at addressing it comprehensively (1).
Recent evidence from field programmes has shown that management of severe malnutrition at home (known as ‘community-based management’) can be very effective and achieve high levels of coverage in target populations. This approach is based on early detection and assessment of severely malnourished children in the community and home-based management of those without complications; those with complications – notably marked by loss of appetite – will still need facility-based treatment. These procedures are considered to be effective for application both in emergencies, and in non-emergencies where there is significant severe malnutrition. They may also have important potential for inclusion in broader health and nutrition programmes – which include preventive measures – as a back-up for when severe life-threatening malnutrition nonetheless occurs (2).
With cases of severe malnutrition without complications being treated as outpatients, inpatient treatment can be reserved for the cases presenting with complications and for cases less than 6 months of age(usually <20% of the caseload). Restricting inpatient admission to these cases only decongests wards and decrease demands for skilled staff and resources.
Though the community-based approach was developed in the emergency context, its decentralized nature has been shown to lend itself to integration into existing services at the primary health care level in the longer term (3). However, severe cases of malnutrition with complications or less than 6 months should be referred to a health facility with skilled health care providers. It is therefore clear that community-based management of severe malnutrition should be properly combined with a facility-based approach and implemented on a large scale in order to prevent hundreds of thousands of child deaths.
Justification for the integrated training
Given the above innovations over the last 3 years there is a pressing need to bring the complementary approaches of inpatient and community-based management of severe malnutrition together and to support countries to roll out integrated programmes in order to achieve access to appropriate treatment for severe acute malnutrition to all those in need. WHO developed a comprehensive training course package for the inpatient management of severe acute malnutrition in 2002. This training includes a 4-days training of trainers, 6-days training for participants and uses different pedagogic methods (clinical sessions, video, role plays, exercises) and has been used to train practitioners and trainers, mainly from Sub-Saharan Africa and Asia. Since 2002, WHO has supported 7 regional trainings involving 39 countries, and national trainings in 9 countries. The WHO inpatient training modules are now incorporating the necessary community based approach and will be tested during the regional training in Tanzania.
Valid International has worked directly with UNICEF, NGOs and governments over the last 5 years to set-up and monitor programmes using the community-based approach and link them to inpatient services. The approach is new and therefore material and global training strategies are in a more formative stage than for the inpatient approach. WHO/UNICEF/SCN are currently developing guidelines on how to implement the approach; the development of standardized training modules are being planned.
This training brings together the experience of UNICEF, WHO, Valid International and the IUNS Malnutrition Task Force3 for the first time to carry out training on the two approaches and thus begin the process of harmonizing the implementation of the two approaches on a global level. It is the first step towards a truly integrated strategy of training and support for the management of severe malnutrition both in the emergency and development contexts. By bringing together UNICEF and WHO representatives from global and regional levels, it will also allow a future fully integrated training strategy to be planned jointly for maximum effectiveness.
The training will bring together 48 participants: government representatives, health practitioners from 8 countries in the East Africa sub-region (Kenya, Tanzania, Uganda, Botswana, Lesotho, Namibia, Ethiopia and Eritrea) accompanied by WHO and UNICEF Regional and Country Officers. The sessions will cover issues of how the two components fit together into an integrated approach as well as comprise in-depth training in facility-based care for practitioners and a detailed orientation on the community-based management of severe malnutrition for policy makers and managers.
- Pediatric care providers, governmental policy makers and planners, UNICEF and WHO representatives in the East and Southern African Region trained in inpatient facility-based and community-based approaches in management of severe malnutrition. This will include training of trainers in facility-based management and the orientation of key policy level people and managers for the future development of the newer community-based approach.
- Country level plans developed for future integrated training and support for the management of severe malnutrition including both facility-based and community-based approaches and a strong monitoring component included.
- (1) Gross R, Webb P. Wasting time for wasted children: severe child undernutrition must be resolved in non-emergency settings. Lancet 2006; 367: 1209-11
- (2) WHO, UNICEF and SCN. Informal Consultation on Community-Based Management of Severe Malnutrition in Children. Geneva, 21-23 November 2005
- (3) Mates, E. Institutional integration of CTC with existing clinical health systems. In: Khara T, Collins S. Community-based Therapeutic Care (CTC). Valid International, 2004. Oxford, Emergency Nutrition Network. Special Supplement Series
1 defined in children 6-59 months of age as below -3 z scores of the median WHO growth standards, an arm circumference less than 110 mm or by presence of nutritional oedema
2 WHO is currently estimating the global number of severely malnourished children and the global number of deaths associated with severe malnutrition.
3 The IUNS Malnutrition Task Force is an advocacy and capacity-building initiative that will re-instate young child malnutrition as a key focus for child survival.