Kenya

 

 

 

 

CONCEPT PAPER

 

 

 

MOYALE

COMMUNITY-BASED THERAPEUTIC CARE (CTC)

 

MAY – OCTOBER 2006

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Successive rain failures in Kenya resulted in extreme food insecurity and escalating levels of malnutrition in the Arid and Semi Arid (ASAL) districts. A  two stage (30x30) cluster nutrition survey conducted by UNICEF in   three ASAL districts ( Moyale, Marsabit and Samburu),  depicted a current serious food shortage  and high levels of malnutrition that require immediate intervention. In Moyale district, the prevalence of Global Acute Malnutrition (GAM) was 18.2% with Severe Acute Malnutrition (SAM) of 3.1%.  In order to address this situation, Concern Worldwide plans to provide nutritional care using the Community based Therapeutic Care approach (CTC). Concern Worldwide will implement this in partnerships with the Ministry of Health (MoH), CCM and CIFA.

 

The Community – based Therapeutic Care (CTC) will provide treatment and nutritional therapy at the community level. Its underlying aims are to maximise coverage and access. Community mobilisation techniques will be used to engage the population and maximise coverage. This program will build on local capacities and existing structures and systems, with the aim of equipping communities to deal with future periods of vulnerability.

 

A nutrition survey to evaluate the effectiveness of the CTC program is planned for September 2006.

 

The CTC intervention is targeted to reach approximately 6,865 beneficiaries including malnourished children under five ears, pregnant and lactating women and 300 needy elderly persons. The project implementation period is May to October, 2006.

 

2.      BACKGROUND AND RATIONALE

 

Moyale district is located in Eastern province in the Northern region of Kenya. It shares boundaries with the republic of Ethiopia on the North; Mandera district in the East; Wajir district on the S. East and Marsabit district on the S.Western side.  The district is divided in to 4 divisions; Uran, Central, Obbu and Golbu. Moyale district is part of the northern pastoralist zone and is classified as ‘arid’ lands. The population in Moyale is estimated at 61,476 people, 85% of these being pastoralists

 

In January 2006, a  joint  food security assessment by the Government of Kenya (GOK), UN and other agencies classified Moyale district as one of the ten most affected and food insecure districts. In March 2006, a two stage (30x30) cluster nutrition survey conducted by UNICEF found high rates of malnutrition indicating an emergency situation. The prevalence of Global Acute Malnutrition was 18.1% with Severe Acute Malnutrition of 3.1%.The WFP/UNHCR guidelines for Supplementary Feeding Programs in Emergencies classify as ‘serious’ a situation in which more than 15% of children are wasted, which is currently the case in Moyale and other parts of northern Kenya. 

 

The district livestock officer reported a loss of up to 80% of the livestock, the highest experienced in the last two decades. Many more cattle are reported to be dying with the start of the rain season either because of diseases or are too weak. At the time of the assessment done by Concern Worldwide that coincided with the UNICEF survey, one pastoralist reported to have lost 54 additional heads of cattle at the start of the rains. While the 2006 long-rains season has now begun, pastoral food insecurity remains extremely severe.  Pastoral households have lost a significant proportion of their livestock and livestock mortalities continue.  As a result, it is expected the recovery period will be difficult, even if the long-rains season establishes.  Livestock births and milk production is reported to be minimal as most of the pregnant animal succumbed to death during the drought. It will be at least another 10 months before milk availability can be realised. Relief food remains the main source of food for most families in the district for the time being.

 

For the lesser percentage of the population that practices agriculture, planting was limited due to lack of seeds and weak oxen.  There is also a reported infestation of cereal crops by dingy caterpillar which is expected to significantly affect crop yields.

 

 

The high levels of acute malnutrition in Moyale coupled with the dire food insecurity situation presents an urgent need to respond and treat acute malnutrition and prevent further deterioration of nutritional status.

 

 

 

The project aims to address acute malnutrition through community-based therapeutic care (CTC) approach for treating severe malnutrition. The CTC approach aims at treating a majority of the malnourished population at home rather than in the traditional TFC institution set ups, using existing health structures through collaboration, training and ongoing support, rather than establishing a parallel service delivery system. The three components of the CTC intervention are:

 

  • Supplementary Feeding Programme (SFP)
  • Outpatient Therapeutic Programme (OTP)
  • Stabilisation Centres (SCs)

 

4.      Goals and objectives

 

The goal of this program is to improve the health and nutritional status of 7729 drought affected population, including children, pregnant and lactating women and elderly persons, in Moyale district of Kenya.

 

Specific objectives include:

 

  1. To treat and rehabilitate 376 severely acutely malnourished children through provision of outpatient therapeutic care (OTP) and admission to stabilisation centres for children with medical complications.

 

  1. To treat and reduce  prevalence of moderate malnutrition in the primary target group of 1,833 under fives through provision of a high energy, micronutrient fortified supplementary food ( CSB)

 

  1. To treat and prevent malnutrition in 445 pregnant and lactating  women through provision of CSB

 

  1. To address malnutrition in 300 elderly persons

 

  1. Establish a referral system between communities and health facilities using local community networks

 

  1. Build capacity of MoH and local structures to respond to malnutrition in future emergencies

 

 

In order to achieve the stated goal and objectives, activities will be carried out as follows

 

5.1              Supplementary Feeding Program (SFP)

The supplementary feeding component of the CTC program will support moderate acutely malnourished children without medical complications   as well as those with special nutrient requirements by providing a dry take - home ration of CSB at 9 kg per person per month. Children with severe medical complications, characterised by anorexia and life-threatening clinical illnesses, will be referred to an inpatient facility for stabilisation.  Health and nutrition education will be provided during the SFP distributions. The SFP program will be implemented through partnership with CIFA, a local based NGO in Moyale district.

 

Given the high GAM rates , >15% , and to prevent further deterioration in nutritional status, Concern Worldwide proposes to do a blanket distribution of CSB for the initial three months (May- July) at a ration of 9 kg per person for month.  This ration provides 1518 k calories per day and will be given to all children less than 5 years old, pregnant and lactating mothers up to 6 months postpartum. However, for Central division that is not currently covered for General Food Ration, only malnourished individuals will be provided with CSB at the same ration of 9kg per person per month.

 

In the second phase, the SFP program will be narrowed to Targeted Supplementary Feeding Program (TSFP) to specifically focus on malnourished individuals and allow for closer monitoring.  The target group will be moderately malnourished children, pregnant women in the third trimester and lactating women up to 6 months post partum. Beneficiaries of this targeted supplementary feeding program will receive, bi-weekly, a monthly ration of 9kg CSB.

 

Beneficiaries enlisted in the targeted SFP program (malnourished children and lactating women) will receive systematic treatment of Vitamin A, Iron- folic acid and mebendazole as required.

 

Registration for the SFP beneficiaries is ongoing and actual distribution are planned to start on the 30th May.

 

5.2            Outpatient Therapeutic Program (OTP)

The OTP will provide home based treatment and rehabilitation of severely acutely malnourished children who have appetite and are free of medical complications. Around 85-90% of the severely acutely malnourished children are expected to be treated in the OTP. Children admitted in the OTP will be treated with routine medication and given Ready to Use Therapeutic Food (RUFT) to eat at home. They will attend the OTP weekly for medical check up, to receive additional medical treatments if required and to collect their one- week supply of RUTF. All OTP children will receive soap (250 grams/ person/ month) for hygiene promotion and Insecticide Treated Nets (ITNs) to prevent malaria.

 

The Outpatient Therapeutic Care will be provided on a mobile service in 23 sites by two teams, east and west of the district. Eleven of these sites are MoH dispensaries. This program will be implemented in partnership with the Ministry of Health (MoH) Moyale and CCM Italy. The MoH will run the mobile service in 13 sites (OTP East) on the eastern part of the district while CCM- Italy will cover 10 sites on the western part of the district (OTP West). Concern Worldwide will provide technical support and training necessary for the implementation of this program.

 

The initial phase of the program will involve sensitising the community and partners to promote understanding of the program objectives and methods. Training and on-job capacity building will be provided for the OTP mobile teams on treatment severe malnutrition using the CTC approach.

 

This program s planned to commence on the 22nd May, 2006.

 

5.3            Stabilization Centres (SCs)

In order to provide intensive inpatient care for severely acutely malnourished children with complications two stabilization centres (SC) will be set up in partnerships with the Ministry of health and CCM- Italy. One of the centres will be set up at the Moyale District Hospital on the eastern part of the district. The other SC will be set at the Sololo Mission Hospital in the western part. The MoH will manage the SC based at the district hospital while CCM – Italy will manage the SC at Sololo Mission Hospital. 

 

 

6.      Number of Beneficiaries and Commodity Requirements for the CTC Intervention

 

Beneficiary calculations are based on a reference estimated population of 61,476 and the UNICEF nutrition survey results for Moyale (GAM 18.2% and SAM 3.1%)

 

An estimated 376 severely acutely malnourished children will be treated in the outpatient therapeutic program (OTP). About 10% of these children will be admitted in to the stabilisation centres (SCs). This will require 6.2 MT (452 cartons) Plumpy nut, 83 kg (10 cartons) F75 therapeutic milk, 3.6 Kg (11 cartons) F100 therapeutic milk.

 

For the initial phase of the Supplementary feeding Program (SFP) – May to July- Concern Worldwide proposes to do a blanket distribution for the three divisions (Uran, Obbu and Golbu) and targeted distribution for Central division. For the second phase, August to October, targeted distribution will be done for malnourished individuals only.

 

The total number of SFP beneficiaries to be served in the initial phase of three months is 7,729 (6,629 under fives, 800 mothers and 300 elderly persons). The calculations are based on blanket SFP for three divisions at an estimated coverage of 80% and percentage malnourished (18.2% for children and 29.3% for mothers) for central division.  This is   approximately a total of 5,447 under fives and 565 pregnant and lactating mothers for Uran, Obbu and Golbu division and 1,182 under fives,  235 mothers, for central division. This will require 208.7 MT of CSB.

 

 

The second phase of the SFP, the target SFP, has a total estimate of 2,278 beneficiaries (1,833 under fives and 445 pregnant and lactating women). This will require 61.5MT of CSB.

 

Thus the total tonnage requirement of CSB for the entire 6 months duration of the program is 270 MT. Due to urgent need for intervention, Concern Worldwide will front load 82MT of CSB for the first month of the program.

 

7.      Coordination and Partinerships

Concern Worldwide will work with and through local partners namely the Ministry of Health (MoH), CIFA, CCM and the Diocese. The MoH and the Catholic Diocese, through which CCM supports the Sololo hospital, are addressing primary health care needs in the four geographical divisions in the district. Concern Worldwide will work with them to identify areas of collaboration with regard to addressing emergency malnutrition and building the capacity staff at health centres. Concern Worldwide will take part in the district health coordination meeting in Moyale as well as the overall district steering group.

 

A district CTC Nutrition taskforce was set up during a health and nutrition planning meeting convened by Concern Worldwide in Moyale. The members of this taskforce are drawn from all stakeholders involved in health and nutrition activities in the district namely the MoH, Concern Worldwide Worldwide, CCM –Italy, Catholic Diocese of Moyale, CIFA, Arid Lands and World Vision. This taskforce will sit once a month with the MoH Moyale as the Chair.

 

At a national level, Concern Worldwide will coordinate with the other actors involved in nutrition such MSF F, MSF B, and World Vision. Concern Worldwide will participate in the Health and Nutrition Working group in Nairobi and maintain close contact with UNICEF and WFP through regular meetings. Concern Worldwide will ensure that WFP and UNCICEF are on board from the beginning with regard to the CTC approach. Concern Worldwide will source for commodity support, therapeutic and supplementary food in addition to other program supplies anthropometric equipment, from WFP and UNICEF.

 

Concern Worldwide will also exchange information with other NGOs involved in CTC in the country such as Merlin in order to share experience.

 

 

In order to monitor the programme and assess impact, indicators shown in the logical framework will be collected on a monthly basis. Indicators for monitoring the emergency nutrition program will be based on standard SPHERE indicators for nutrition feeding programmes and will include percent coverage, number of re-admissions; percent cured defaulters and death cases. 

 

Results of the nutrition surveys conducted in March will provide baseline data for comparison with a nutrition survey planned for in September 2006 to evaluate the effectiveness of the CTC program.

 

  • Security situation in Moyale will remain stable.
  • Road are passable for community access
  • There will no major disease epidemic that will negatively affect the targeted population.   
  • Basic/staple food and general ration will continue to be available and accessible to most the population.
  • There will be effective collaboration with other actors involved in health/nutrition in Moyale. 
  • Health authorities in Moyale and at the national level will accept CTC as an alternative method to treat malnutrition
  • The target population will accept CTC. 
  • Adequate supply adequate of RUTF (plumpy nut).
  • WFP and UNICEF will continue to supply food ration and milk respectively.
  • Most of the district will be accessible through out the program implementation period. 

 

 

Budget preparation is on going; it is anticipated to be complete end of the second week of May, 2006

11.    organisational & logistics summary

 

We are holding meetings with MOH, CCM in Nairobi this week and with MOH, CIFA and other partners in Moyale from April 28th-May 3rd. The proposed organizational and logs summary may be revised following these meetings. The essence of what we are trying to achieve is an effective and speedy response, utilizing current capacities in Moyale and building local health organizations understanding of and capacity to implement CTC now and in the future.

 

 

Roles and Responsibilities are shares as follow as follows:

 

Organization

Roles and Responsibilities

MOH Moyale

Operating SC from Moyale district Hospital

Dispensary staff be present for OTP consultations and follow up on OTPs

 Base and running of team (East)

CCM & Diocese

Operating SC from Sololo hospital

Providing some training and support to Moyale District Hospital for management of severe malnutrition

Running one of the OTP teams (west)

OTP team uses CCM established outreach clinics during OTP rounds

Assign transport

Some funding ??

CIFA

Recruit all non technical staff

Implement the blanket distribution program

Referral from blanket to OTP (CIFA recruiting a nurse)

Hosting Concern Worldwide nutritionist and program support person in CIFA offices

Assign one car to the program

Admin and logistical support to the program

Concern Worldwide

Overall design of the program

Nutrition and CTC training for implementing partners

Quality control and program monitoring

Deployment of two nutritionists (one permanently based in Moyale, one part-time)

Deployment of one program support person( admin/log/finance)

Provision of initial supplies of plumpy nut  and CSB and other program goods

Access DEC funds

Assign two cars

Participate on national Health and Nut technical group

Support the establishment of the District Health & Nutrition working group

MOH National

Deploy 1 nurse- Nutritionists  for the SCs in Sololo Mission hospital- verbal agreement

UNICEF AND WFP

Provision of CSB and PLUMPYNUT and nutrition equipment. Both UNICEF and WFP have current shortages and have asked that Concern Worldwide front load the operation and they will allocate supplies as they become available (June).

 

               

                                                                                               


Annex I.      LOGICAL FRAMEWORK

 

 

 

Intervention Logic

Objectively Verifiable

Indicators

 

Means of Verification

Risks and Assumptions

 

Goal

To improve the health and nutritional status of 7,729 people in Moyale district.

 

Number of people successfully treated in the CTC program

. 

Project progress and evaluation reports and key informant interviews

 

- Security situation in Moyale will remain stable. 

- There will no major disease epidemic that will negatively affect the targeted population.   

-Basic/staple food and general ration will continue to be available and accessible to the population.

 

 

Objectives

 

 

To treat and rehabilitate 376 severely acutely malnourished children through provision of outpatient therapeutic care (OTP) and admission to stabilisation centres for children with medical complications.

 

To reduce the rate of moderate acute malnutrition amongst the primary target group of 1833 under fives.

 

Treat and/or prevent malnutrition in 445 mothers over 6 months.

 

To address malnutrition in 300 elderly persons

 

Establish a referral system between communities and health facilities using local community network

 

Build capacity of MoH and local structures to respond to malnutrition in future emergencies

 

 

 

 

-        Prevalence of severe malnutrition rate  reduced from 3.1% to less than 2%

 

 

 

 

-        Prevalence  of global acute malnutrition rate reduced from 18.2% to less than 10

 

-        No of mothers treated  in the SFP program

 

-        No. of elderly people treated in the SFP program

 

-        A referral system for the treatment of malnutrition put in place using local community network.

 

-        No of trainings conducted for the MoH and local partners

 

-        MoH and partners successfully implement the different components of the CTC program

 

-        improved capacity of health centres to treat malnutrition and medical complications associated with malnutrition

 

Project progress report

 

 

 

 

 

 

 

 

- There will be effective collaboration with other actors involved in health/nutrition in Moyale. 

-Health authorities in Moyale and at the national level will accept CTC as an alternative method to treat malnutrition

-The target population will accept CTC. 

 

 

Outputs

 

 

By the end of October 2006 at least 10 MoH nurses and 28 community health workers in Moyale will have capacity to detect and treat severe acute malnutrition and complications associated with severe acute malnutrition using CTC approach will be developed and strengthened.

 

 

 

By the end of July 2006, 17910 vulnerable people will have received a blanket supplementary ration per month

 

 

1833 moderately malnourished children and malnourished pregnant and lactating women will receive a fortnight distribution of a premix ration.

- Number of MoH workers trained and participating in CTC activities. 

- Number of community health workers able to screen and refer the acutely malnourished for treatment

- Number of volunteer community agents able to provide nutrition information to members of their community.

-  Number of stabilising centres opened and efficiently run. 

 

 

- Number of people registered and receiving supplementary monthly rations

- Number of blanket distribution sites to target beneficiaries.

 

 

 

Filed monitoring and progress reports

Beneficiary cards

Training records

 

 

 

 

 

 

 

 

 

Registration books

 

 

 

 

Beneficiary registration books and cards

 

 

 

 

- Adequate supply adequate of RUTF (plumpy nut). 

- WFP and UNICEF will continue to supply food ration and milk respectively.

- Most of the district will be accessible through out the program implementation period.. 

 

 

Activities

OTP done on a weekly basis at 14 MoH facilities run by 2 mobile staffs MoH staff. 

OTP established at additional outreach centres that do not easily access MoH facilities

Continued training and support for MoH workers at CCM, and the MoH district Hospital for Stabilisation Centre care

Training of outreach workers, MoH workers and community volunteers (including relief workers) to mobilise communities and follow-up children at home.

Capacity building of the MoH on technical aspects of the CTC, monitoring, reporting

 

Monthly distributions of supplementary ration from May- July

Fortnight distributions and weight monitoring of supplementary ration to moderately malnourished children and mothers from August- October.

 

Administration of routine medication to all SFP beneficiaries.

 

Nutrition survey in September

 

 

 

 

 

 


Annex II.  Admission criteria’s

 

 

SFC Admission criteria

 

-          Children < 5 years old W/H <80%

-          Pregnant women in the last trimester with MUAC <21 cm

-          Malnourished Lactating women (MUAC <21) with children < 6 months old.

 

Discharge criteria:

-          Children W/H >85% 2 consecutive weightings

-          P/L women MUAC > 23 cm

 

 

 

CTC Admission criteria