guidelines for the integrated management of severe acute malnutrition

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ACF-In Guidelines for the integrated management of SAM Community 20 schools (child-to-child or child-to-parent), football and other sporting and other networks should also be explored. A particularly important group to involve is the religious leaders of the community and passing information at places of worship can be particularly powerful. The information must be passed by the community figures themselves and not by strangers to the community. 4. Staff at community level Existing health staff Part of the organisation of programmes to identify and treat malnourished children in the community is to integrate these activities with the other community based health activities (EPI, community IMCI, midwifery, etc.). The staff who undertakes these activities should be taught how to screen using MUAC and oedema assessment and to refer the malnourished for treatment appropriately. Care must be taken not to overload these community workers; if this is the likely then the IMAM programme should employ staff, however, these additional staff should also undertake IMCI and EPI activities as well as IMAM: the terms and conditions of employment for all staff supported by the different programmes should be identical. Outreach Health workers Outreach health workers are employed full time to go into the communities. Where there are village volunteers they liaise with the village focal points, oversee their activities and support them; where there is no village focal point they perform the screening, follow-up and other outreach activities. The outreach workers should be literate, numerate and proficient in the local language of the district. The advantage of paying for outreach health workers is that screening is more organised, the work more regular and they are more likely to remain with the programme. The salary is often the main income for the household. The number of outreach workers that can be employed, and hence the number villages and frequency of visits, is determined by the funding of the programme. There should be secured funding for a minimum of two years 16 for each employee. Volunteers Volunteer is a person living within the community itself who is willing to spend time providing services to their neighbours without payment. In most resource poor communities there are insufficient employed staff to implement an effective community based programme where individual households are regularly visited and communal events organised. In such circumstances the community aspects of the programme can be run by volunteers, provided they are adequately supported. Where there are existing health volunteers, as with the outreach workers, they should be trained in active case-finding and follow-up of the IMAM programme. The pre-existing volunteers have been trained in other aspects of health promotion and usually have standing in the community with villagers willing and accustomed to seek their assistance. However, health volunteers should never be overloaded; the amount of time they can devote to volunteering is always limited. It is often necessary to recruit additional volunteers so that the workload can be shared and they can work together as a small team. Existing village volunteers are best placed to identify new volunteers that they can happily work alongside. CMWs can also be used for recruiting, training and following volunteers. 16 The sustainability of the programme is critical. It takes a lot of work to organise, implement and integrate a programme, and the expectations of the community are raised to a level where precipitate withdrawal of support leads to great disaffection. When it is implemented there should normally be a commitment to maintain the programme for at least 5 years; where the funds have not been fully secured, there must be a minimum period of “notice” before withdrawal, and orderly hand-over, training and support for local civil society to maintain the programme itself. It is often the case that funding is secured for therapeutic services only; active case finding in the community is an integral part of the programme and should always accompany therapeutic services.
ACF-In Guidelines for the integrated management of SAM Community 21 There is no limit to the numbers of volunteers that can be within a village, but they have to be organised 17 and cooperative. The major difficulties with a volunteer-based programme are: 1. choosing volunteers who are representative of their communities, 2. providing adequate support and 3. maintaining their motivation. A strength of both the community IMCI and IMAM programmes is the enthusiasm shown by mothers, volunteers, health care workers and the village leaders. With IMAM they actually see severely malnourished children change physically, become active and develop within a few weeks. This is a powerful experience that shows the community that the treatment works and creates demand for the programme. This in turn motivates volunteers and raises their standing within the community as they are seen as the conduit into the programme. Parents, mothers-in-law and traditional practitioners bring children for treatment. Successful treatment of individuals 18 empowers local health workers, enhances their esteem and gives them credibility with the community. Active case-finding by volunteers has several advantages. Volunteers being from the community itself are familiar with the area, many of the individuals and the society. Selection of volunteers Volunteers are usually self-selected. However, it is critical that the community itself selects and approves of the volunteers. The most common problem is for communities to select the community leaders’ relatives and males. The persons selected must be: 1- Honest and trusted by the community 2- Both males and females should be selected (with a bias towards females) 3- With a true desire to benefit the community altruistically 4- Being able to read and write is a distinct advantage, but not absolutely essential. Where the burden of work is very high and the community is very poor suitable volunteers may not be available. Once the programme is working, mothers who have successfully treated their own malnourished child and who otherwise fulfil the criteria for selection should be invited to volunteer. These mothers who have been through the programme, and are of the same socio-economic class as the new cases, are particularly credible, are able to relate to and guide new caretakers and will obtain information (for example on reasons for defaulting) that others may not solicit. 17 In Bihar, India, there is a focal point within each village who recruits volunteers. The village is mapped and each volunteer is responsible for visiting up to 10 neighbouring households. Each week all the volunteers from the village gather with the focal point for a meeting to discuss together the health and nutrition problems of the whole village. Pregnant women are identified early and followed, breastfeeding is supported, immunisation is ensured, the malnourished identified and referred and then followed up by the volunteer, minor health problems are identified and the district nurse consulted during her next visit. The volunteers assist the village focal point who does not feel isolated as she is part of a village team. Such a grouping within the village leads to solidarity, camaraderie, mutual support and ensures that there is a limited workload for each person. If one person “drops out” the programme does not collapse. 18 At the start of a programme it is common for an obviously very ill child to be brought by the villagers to “test” the programme and the promises that have been made. It is important that this “test case” is successfully treated. This child who the villagers all see is very ill, usually needs initial in-patient care. It is important that initial cases recover successfully so that what can be achieved is actually experienced by the community; this, more than anything else, establishes the credibility of the programme with the villagers and treatment for less severe cases will be sought. The in-patient facility is very important not only to treat some of the malnourished children, but also to demonstrate that the programme will cater for all the malnourished children and not only those who are relatively healthy and uncomplicated, to provide credibility and to allow the community to know that there is real “back-up” behind what is happening at the village and OTP level. Such successes and failures live long in the memory of communities.
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Cover photography: © ACF, Anne-Dom
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guidelines for the integrated management of severe acute malnutrition

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