A SECOND YEAR OF SCALING UP TREATMENT OF ACUTE

MALNUTRITION
SWAZILAND

Action Against Hunger (ACF) in Swaziland is working in close collaboration with the
MoH (Ministry of Health) and SNNC (Swaziland National Nutrition Council) providing
technical support on the treatment of acute malnutrition through the Integrated
Management of Acute Malnutrition (IMAM) approach.

To implement the IMAM approach at different levels, the capacity of MoH staff is built
on the detection, referral and treatment of malnutrition through trainings and on-the-
job coaching on the various aspects:
1) In-patient Therapeutic Programme (ITP) for children with acute malnutrition and
medical complications;
2) Out-patient Therapeutic Programme (OTP) for non-complicated cases of severe
and moderate malnutrition;
3) Community mobilization through sensitisations and trainings of community leaders
and volunteers and community caregivers who play an essential role in early
identification of cases and referrals to health facilities for treatment.

ACF is also involved at the national level in developing policies, strategies and
protocols to ensure proper management of malnutrition in the country as well as the
linkages with HIV and AIDS.

Achievements
In 2009, the IMAM programme was expanded into more MoH sites with more
relationships and collaboration with partners working on HIV, increasing the link
between manlnutrition and HIV services.

Sites 2008 Opened in 2009 Current Total

ITP 4 2 6
OTP 9 14 23
Total 13 17 29

We focused on MoH sites and surrounding communities where people needed more
support on nutritional issues and as a result an additional 130 staff were trained at
health facilities and 1895 at the community level, 17 new sites were opened. This
all contributed to increasing coverage of services, resulting in a total of 1345
malnourished children admitted over the year (857 ITP, 488 in OTP). Due to the close
relation between HIV and malnutrition in the country, there is consistently more
children are admitted with complicated cases that need ITP care.
Statistics
IMAM outcomes over the past couple of years are still below the Sphere International
Standards. Below a table with the outcomes (combining ITP and OTP) for the 2 year
implementation programme can be seen.

Sphere standards 2008 2009

Cured >75% 38% 52%
Death <10% 21% 24%
Defaulter <15% 17% 24%
Unknown - 24% -

Overall, the cured rate shows significant improvement, especially as in the first half of
2008 it was only 28%. The quality of reporting has also improved, in 2008 nearly a
quarter of the children had “Unknown” outcome, but these have been more
appropriately recorded in 2009. Considering the short life of the programme, it has
still been a challenge to improve the death and defaulter rates. With increasing
number of sites and awareness at community level, more children are referred and
admitted, some of them in difficult medical and social circumstances.

The children admitted in IMAM are also tested for HIV (below). It is important to
highlight is that only 21% of the children are confirmed HIV negative at ITP and 28% at
OTP, demonstrating again, the link between HIV and malnutrition. A higher rate is
expected in ITPs as the children often present with additional medical complications.
As well, the status is unknown for a significant proportion of the children on often due
to the fact that they die soon after admission to hospital.

2008 2009
ITP & OTP ITP OTP
HIV positive 26% 29% 21%
HIV negative 19% 21% 28%
Exposed 25% 27% 18%
Unknown 30% 23% 33%

PARTNERSHIPS
ACF continues to have successful collaboration both with partners and community staff
on implementing the IMAM programme. All our activities are planned and
implemented in partnership with SNNC with the direct collaboration with the
Ministry’s regional offices.

At community level, the programme is introduced to community leaders and via

mobilization of influential people and volunteers such as Rural Health Motivators
(RHM), the community is aware of the malnutrition and HIV services available in the
area. With training and follow up by ACF staff, they are able to detect and refer
malnutrition cases at early stages. For most effective results, there is close
collaboration with RHM trainers in the regional offices.
LESOTHO

There are a total of 18 ITPs and 60 OTPs that have been opened in Lesotho since
February 2008. ACF has been providing technical support to the Ministry of Health and
Social Welfare and following up on 13 ITPs and 20 OTPs in 7 districts.

The following numbers show the admissions in ITP and OTP for 2009:

Admission and discharge indicators

ITP OTP
Admission 766 188
Discharges 721 109
Transfer to/between OTP 64.6% 2.8%
% Cured 1.5% 67.9%
% Defaulter 1.5% 12.8%
% Death 30.4% 8.3%

Demonstrating the link between HIV and malnutrition, it is of importance to highlight

is that only 17.6% of the children in ITP and 33.9% in OTP are confirmed HIV
negative.

HIV status upon discharge

ITP OTP
HIV Positive 12.3% 11.9%
HIV Exposed 9.7% 6.4%
HIV Negative 17.6% 33.9%
Status unknown 60.3% 47.7%
Total 721 109

Additionally, mortality is lower in negative cases than in the positive or exposed.

The death rate in children who were HIV positive was twice that in children who are
HIV negative (ITP - 37.1% vs 18.9%; OTP - 30.8% vs 2.7%).

Mortality Rate within HIV status

ITP OTP
HIV + 37.1% 30.8%
HIV - 18.9% 2.7%
Unknown 31.5% 7.7%
Exposed baby 35.7% 0.00%

It is essential that technical support for monitoring and follow-up of the

implementation of IMAM site continues to ensure that achievements continue and
improve. Longer term support to MoHSW for integration of IMAM within routine
activities, linking with HIV services as well as the continuous improvement in the
quality of implementation and reporting needs to be the focus.
 HIV IN THE WORKPLACE
ACF has an HIV in the workplace policy that is being implemented in the mission and
was presented to all staff again after a large number of staff was recruited. Different
sessions are held as part of the programme including one on the basics of HIV led by
one of the HIV focal points, Nothando Dlamini (Log-Admin Assistant) to all staff. Some
of the interesting facts summarized by the staff from the session, included that
southern Africa has the highest rate of HIV and that women are more affected
(Guard/Gardener), and also that people are most infectious in the first 3 weeks post-
infection which is when people are most likely to not know they are positive (Driver).

On 18 September 2009, the US Embassy and International NGO’s held a Wellness Day
session for our local staff. NGO’s were invited to present health and wellness
information. This was a participatory event with people showing great interest and
freely moving between the tables to find out more information on various topics. ACF
provided information on nutrition, malnutrition, links with HIV and measured body
mass index (BMI) and had many interested participants.

PLANS for 2010

In Lesotho, implementation of the UNICEF funded project was completed in November
2009 with a handover to the MoHSW, and the office is now closed.

In Swaziland, ACF will continue to work in partnership with the government at the
national and regional levels while at the same time build capacity in communities on
nutrition and the linkages with HIV and AIDS. Additional IMAM facilities are expected
to be opened in the following months, so that people will have easier access to
treatment. Given the main challenge of transport, the hope is that the increase in
sites will result in more children being admitted into the programme before
encountering clinical complications and also decrease defaulter rates. This will also
be addressed through a new 2-year project on community involvement in Shiselweni
and Lubombo on nutrition and HIV issues that will be starting in 2010. ACF will
continue to provide technical support for monitoring and follow-up of the
implementation of IMAM and linkages with HIV services.

Contact Information
People interested in receiving additional information can contact the organisation at:

Gwynneth Wong, Head of Mission

Action Against Hunger
PO Box 4310, Lot # 33 Malunge Township
Mbabane, Swaziland
+268 409 0074 / +268 602 3753
hom-ls-sz@acf-e.org

Funded by: