Implementation of community-based management of severe acute malnutrition in conflict affected regions: a case of South Kordofan, Sudan

Abstract

Malnutrition is the major cause of mortality and morbidity globally with undernutrition contributing about 45% of all deaths of under five children. Besides the direct effects of protracted conflicts, the macroeconomic crisis that has greatly increased the national inflation rate hence devastating the purchasing power, the COVID-19 outbreak, flooding, and the Desert Locusts have contributed to a food security emergency. Besides being among the most under resourced states, South Kordofan has experienced years of conflict resulting in displacement of people and extensive infrastructure destruction with high rates of malnutrition. The state currently has 230 health facilities and out of these, only 140 are providing outpatient therapeutic programme centres with 28.6% (40) of these being operated by the state ministry of health and the rest by the international non-governmental organizations. Limited resources leading to donor dependence, limited accessibility due to insecurity and floods, poor referral system and gaps in continuity of care, lack of operational and implementation research data and limited integration of management of malnutrition in other health services have negatively affected effective implementation. Ensuring effective and efficient community based management of acute malnutrition, implementation needs action beyond the health sector with a multi-sectoral and integration approach. Federal and state development frameworks should ensure a comprehensive multi-sectoral nutrition policy with strong political commitment and allocation of adequate resources to ensure integrated and quality implementation.

Background

Malnutrition is the major cause of mortality and morbidity globally with undernutrition contributing about 45% of all deaths of under five children [1,2,3]. These deaths are mainly experienced in low- and middle-income countries [1, 3] which are also experiencing increase in cases of overweight and obesity [4, 5]. Globally, about 47 million (6.9%) under five children are wasted, 144 million (21.3%) are stunted, and 38.3 million (5.6%) are overweight or obese [1].

Sudan is located in Northeast Africa with a long history of protracted social conflicts that have had a negative impact on the country’s general health and nutritional status [1, 6]. Besides the direct effects of protracted conflicts, the macroeconomic crisis has greatly increased the national inflation rate hence devastating the purchasing power. The COVID-19 outbreak, flooding, and the Desert Locusts have contributed to a food security emergency leaving 16% (7.1 million) of the population in a crisis phase and above ( phase 3 and 4) [1]. While Sustainable Development Goal 2.2 aims to end all forms of malnutrition by 2030 and achieve internationally agreed targets related to malnutrition in children [7], data on malnutrition trends in Sudan is alarming [1]. According to the 2020 global nutrition report, Sudan has made no progress towards achieving the target for stunting and wasting, with 38.2% and 16.3% of children under 5 years of age affected with stunting and wasting respectively. These rates are all higher than the average for the Africa region [8]. In about 8.6 million people lacking adequate healthcare, 3.3 million are acutely malnourished, with over half a million children suffering from severe acute malnutrition (SAM) and 2.2 million children requiring treatment for moderate acute malnutrition (MAM) [1].

In recent years, due to limited inpatient capacity, high cost of inpatient management, few trained staff resulting in low coverage, low recovery rate, high mortality, and high default rate at the inpatient therapeutic programs, the management of acute malnutrition has shifted from the traditional facility-based approach to a combination of facility and community- based management approach to improve its coverage and impact [2, 9]. This approach, known as community-based management of acute malnutrition (CMAM) consists of four key elements that include: community mobilization, outpatient supplementary feeding programme (SFP) for patients with MAM but with no medical complication, outpatient therapeutic programme (OTP) care for uncomplicated cases of SAM, and stabilization center / inpatient care to SAM patients with medical complications [9]. CMAM enabling factors include; use of a simple screening tool (MUAC tape ) to detect both moderate and severe acute malnutrition by measuring the mid-upper arm circumference, home treatment using ready-to-use therapeutic foods (RUTF) and routine medical checkups, and use of a simple classification system that distinguishes SAM patient with medical complications from those with no medical complications [7]. Existing CMAM programmes have documented success with improved recovery and mortality rates [2, 7].

South Kordofan population is estimated to be 2.5 million people and is located in the South Central region of Sudan bordering South Sudan to the South [6]. The state has experienced years of conflict resulting in displacement of over 200 000 people and extensive destruction of infrastructure. [6]. It’s among the most under resourced states, which greatly limits essential service delivery [6]. The global prevalence of underweight and wasting among children under five years in this regions is 26.1% and 7.8% respectively[1].

Current status of CMAM implementation in South Kordofan state

Health and nutrition services are under the mandate of the South Kordofan state ministry of health (SMOH) which is oversighted by the Khartoum federal ministry of health (FMOH). South Kordofan has 14 localities in which the health and nutrition services are directly implemented by the locality health departments (LHDs) with the support of various international non-government organizations [6, 10, 11]. The state currently has 230 health facilities and out of these, only 140 are providing outpatient therapeutic programme (OTP) for SAM cases without medical complications. Out of these 140 health facilities, 28.6% (40) are operated by SMOH and the rest by international non-governmental organizations (INGOs). In addition, out of the 140 OTP centres, 73.6% (103) are currently providing targeted supplementary feeding programme (TSFP) for the management of MAM. Out of the 103 TSFP centers, 41.7% (43) are operated by SMOH while the rest by the INGOs. Out of the 14 localities in the state, only 11 have stabilization centres for the management of SAM cases with medical complications and only 63.6% (7) of these are operated by SMOH with the rest being operated by the INGOs. Community mobilization activities and screenings are done mainly through the support of the various INGOs.

Challenges and recommendations

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

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

Conclusion

To ensue effective and efficient CMAM implementation, multi-sectoral integration is paramount. Federal and state development frameworks should ensure a comprehensive multi-sectoral nutrition policy with strong political commitment and allocation of adequate resources to ensure integrated and quality CMAM implementation. Community based mechanisms ensuring growth monitoring activities and routine nutritional screening activities should be strengthened to increase access and utilization. Planning, advocating and lobbying for sustainable SMOH funding of the CMAM activities should be prioritized in order to minimize overdependence on donors and INGOs.