In South Sudan, Malaria Consortium saves lives by preventing and treating malaria, pneumonia, diarrhoea and undernutrition
Since 2009, Malaria Consortium has been implementing a programme for the integrated community case management (iCCM) of malaria, pneumonia and diarrhoea in children. iCCM centres around the idea that these most common childhood killers can be readily and safely diagnosed and treated by people within the community, including those with limited educations and medical training.
Three-quarters of deaths in children under five are caused by malaria, pneumonia, diarrhoea and newborn conditions; more than a third of these deaths are linked to malnutrition. Research has shown that iCCM, in addition to a focus on identifying and referring sick newborns, has the potential to decrease childhood mortality from these conditions by 60 percent. As a result, Malaria Consortium decided to add a nutrition component to the iCCM approach.
Children suffering with severe acute malnutrition (SAM), a particular form of undernutrition, are some of the most vulnerable, and have a greater than nine-fold increased risk of dying than children who are well nourished. These children are more likely to enter into a vicious cycle of becoming malnourished through poor absorption of nutrients, while those already malnourished are more likely to die from malaria, pneumonia and diarrhoea due to a compromised immune system.
Without tackling undernutrition in addition to these key childhood diseases, efforts to reduce incidence of disease and illness will face challenges, especially in under-resourced settings.
Implementation in South Sudan
This was particularly true for our iCCM project in Aweil and Lol states, South Sudan, where there is persistent malnutrition in children under five, with multiple factors contributing to the high prevalence – fragile food security due to late rains and flooding, inefficient child feeding practices and a dramatic rise in inflation, making food prices soar.
With funding from UK aid from the UK government, Malaria Consortium implemented a project that integrated nutrition into iCCM services in communities in Aweil Centre and Aweil West counties in April 2013. The iCCM approach is not a standalone programme; rather it is designed to complement the existing health system while increasing access to health services for the early diagnosis of malaria, pneumonia and diarrhoea as well as treatment of these illnesses, early detection of SAM and referral to nutrition services.
Malaria Consortium, in partnership with UNICEF, has established a network of outpatient therapeutic programme (OTP) sites in Aweil Centre county in Aweil state and Aweil West county in Lol state, with the aim of improving the delivery and coverage of nutrition services within these two counties.
The integration of nutrition services into the ICCM programme in Aweil Centre county and Aweil West county – which include the assessment of children and provision of food supplements – is designed to help prevent or reduce cases of wasting among children six to 59 months. It incorporates an adapted form of community management of severe acute malnutrition (CMAM), which brings OTPs to the communities, rather than expecting caregivers to bring their children to a health facility for weeks at a time.
In both counties, a total of 9,123 SAM cases were admitted to OTPs. The outcome of the OTP sites exceeded Sphere standards – one of the most widely known and internationally recognised sets of common principles and universal minimum standards in life-saving areas of humanitarian response – with only 227 children (2.5 percent of the total) who didn’t complete the treatment from January to December 2015.
Of the remainder, 5,493 recovered (were cured and discharged), 158 were referred and 15 died (0.16 percent). This meets the Sphere standards’ guidelines, which outline that: fewer than 10 percent died, 75 percent recovered and 15 percent defaulted.
In 2014, due to ongoing conflict in the region and temporary suspension of services for some months, 1,265 children out of 3,106 didn’t complete their treatment.
A much higher number of children was admitted in 2015 compared to 2014; an average of 720 SAM cases was admitted to 50 OTP sites monthly in 2015. A spike in admissions was observed from May to June and from August to November. Harvesting time in Aweil Centre typically begins in July and ends in September, and food security is usually lowest immediately before and during the harvest.
Placing the OTPs within the communities so that the children and caregivers do not have to leave their own communities during the time a child with SAM is admitted has resulted in high recovery rates.
Community nutrition workers are very capable of treating SAM cases. Linking this with iCCM services and with social and behaviour change interventions have made community involvement in the process optimal and provided a more integrated approach to the management of childhood ill health.
Following our CMAM programme in Aweil and Lol states, we want to see this scaled up and adopted as a core strategy by the Government of South Sudan. If, over time, the people of South Sudan can take more ownership and allocate funds for this strategy, it will become more sustainable and will contribute to improved health outcomes for the country as a whole.
Malaria Consortium is using experience gained in South Sudan to develop ‘iCCM plus nutrition’ programmes in Myanmar and Nigeria, where high levels of malnutrition and lack of access to care for childhood diseases are prevalent. In Asia, this knowledge is being applied to large outbreaks of other vector borne diseases such as dengue.