Table 1 CMAM implementation challenges and recommendations in South Kordofan, Sudan

1.

INGO dependency and limited SMOH financial resources.

The state mainly depends on INGOs to operate most the OTP and TSFP centres by providing financial & technical support and project coordination, which affects sustainability of the programme after INGOs’ hand over.

The SMOH may use advocacy to lobby for allocation of more resources for nutrition programs. SMOH should focus on programme-based budgeting which attempts to allocate expenditures by program. The focus should be directed to preventive services which is underfinanced.

2.

Shortage /low motivated Nutrition officers

Due to low salaries offered by the state and INGOs, nutritionists are demotivated to work in OTP and TSFP centres. For example, The SMOH nutritionists earn between 27 and 40 United States Dollars (USD) per month and volunteers earn between 16 and 24 USD per month which is not very different from what INGOs offer. The salaries are sometimes paid out late. The demotivated staff end up working less hours which affects service delivery. These conditions discourage qualified nutritionists from seeking the open positions, leaving volunteers to run the projects.

The National government should focus more on strengthening Human Resources for Health (HRH) to address the staffing challenges (limited resources, maldistribution of nutrition officers, poor retention of nutrition officers in the rural areas) experienced in the region.

3.

Insecurity

Some localities such as Abujubaiha, Talodi, Rashad and AbuKarshola experience periodic tribal conflicts which tend to impede movement to and within these localities. This disrupts delivery of nutrition and other health services.

It would be a noble idea to integrate conflict perspectives in design stage of programs and projects with aim to minimize negative and maximize positive contributions to conflict prevention and peace building.

4.

Floods

Heavy rainfall seasons render roads impassable, cutting off transportation of nutrition commodities. This leads to shortage and sometimes stock out of both medical and nutrition supplies at OTP, TSFP and stabilization centres. Program monitoring is also affected as reporting and support supervision by SMOH is not conducted. Community based activities such as mobilization and mass screening are negatively affected, registering a low turn out

for case identification.

Construction of large warehouse and/or expansion of storage spaces within the health facilities is crucial to ensure pre-positioning of supplies to avoid stock outs during the rainy season. For future considerations, the state would initiate in-country production of RUTF using locally available ingredients which is important for ensuring cost effective readily available supplies to manage severe acute malnutrition. This will ensure sustainable CMAM programming.

5.

Poor referral system and gaps in continuity of care

Limited availability of ambulances coupled by poor road networks are a major challenge leading to high transport costs and longer hours spent on the road. This has a negative impact on emergency cases that need referral to the stabilization centres with some cases reaching the referral centres when it is too late to be saved. Some children referred to TSFP upon discharged from OTP do not join due to lack of transport to the nearest TSFP centre. This affects continuity of care.

The state should endeavor to avail stabilization centers in each locality and support all health facilities to provide OTP, TSFP services. The state should also strengthen the referral system for efficient and effective delivery of health services.

6.

Lack of operational and implementation research data

The different INGOs work with the oversight of the SMOH but in isolation with no clear way of sharing data and lessons learnt with each other. The lack of readily available operational research data limits evidence-based implementation.

In South Kordofan and similar contexts, timely and accurate data collection is affected by poor internet access, limited phone network coverage, poor roads and limited availability of trained staff [6]. Delayed and less accurate reporting affect evidence-based decision making and planning.

To ensure effective and well-coordinated CMAM implementation, the different stakeholders need to have the right to information via health information systems and data platforms. Investing in infrastructure development such as roads and telecommunication will improve timely reporting and increased incentives for trained staff working in hard-to-reach areas. Periodic refresher trainings on data management will ensure accurate and timely reporting for efficient planning. There is need for INGOs and the SMOH to initiate an operational research initiative for continuous project evaluation. It would also be valuable to allocate resources to study the implementation of CMAM (implementation research) seeking to understand further the real implementation conditions in South Kordofan.

Limited integration of nutrition services in other health services

Limited availability of enough and trained staff has negatively affected integration of nutrition services such as MUAC screening and nutrition counselling at the triage, outpatient department (OPD) consultation rooms and during vaccination days. This leads to less timely identification of cases leading to delayed diagnoses that are usually severe. Furthermore, lack of joint state cluster coordination meetings for nutrition, WASH and health makes it difficult to share lessons learnt and best practices across the different sectors for replication.

The on-job and classroom trainings for all health care workers (to include all cadres) should be revised to ensure that nutrition topics such as MUAC screening and infant and young child feeding (IYCF) practices are incorporated in order to improve knowledge, skills and be in a position to integrate and/or provide nutrition services alongside other health care services offered to children, pregnant and lactating women (PLW). There is need to introduce IYCF ‘corners’ in health facilities and increase IYCF awareness through increased facilitation of community nutrition volunteers.

SMOH should establish a joint learning and sharing fora where stakeholders and health departments meet, report, and share information, lesson learnt and best practices.