Building health service capacity to manage severe acute malnutrition in Mali
By Dr Malam Kanta Issa
Dr Malam Kanta Issa has worked as the Head of Mission for ALIMA Mali since 2015. After obtaining his doctorate in medicine he worked for MSF in Niger for several years before joining ALIMA in 2013, obtaining an MSc in Public Health the same year.
|Click here to listen to Dr Kanta Malam Issa in conversation with Ambarka Youssoufane on ENN's Media Hub|
What we know: Well-trained health professionals are needed to ensure quality inpatient treatment of children with severe acute malnutrition (SAM).
What this article adds: In Mali state capacity to provide quality inpatient treatment for SAM with complications is limited by damage to health infrastructures, staff shortages and high staff turnover, and lack of sustained, high-quality pre-service and in-service training for health professionals. A Units of Recovery and Intensive Nutrition Education (URENI) teaching hospital was established in 2015 by AMCP/ALIMA with UNICEF and Ministry of Health support to deliver a three-week, intensive, hands-on training on complicated SAM treatment for selected staff. Regional nutrition focal points (NFPs) from five districts (who monitor the integrated management of acute malnutrition) received refresher training. From 2015 to 2017, 262 Malian health professionals were trained from 41 health facilities through 22 training courses. All trainees passed the training (50% or above in final evaluation) and returned to their URENI with agreed action plans to implement changes. Plans are to train health professionals from conflict-affected northern regions not yet covered, pending funding.
Mali has 65 Units of Recovery and Intensive Nutrition Education (URENI), where inpatient care for SAM children with complications is provided. URENI are usually integrated into the paediatric service within the reference health centre (CSREF), a secondary healthcare facility at the district level1. However, the ongoing crisis in northern Mali has severely hampered the state’s capacity to provide quality care for children with SAM due to damage of health infrastructure and equipment, looting of medical supplies and the massive outflow of qualified medical staff. Public use of health facilities is constrained by cost, access and perceptions of the quality of care provided. Major shortages in human resources in health facilities are a critical concern (Human Resources Statistical Yearbook of Health, Social Development and the Advancement of Women, 2016). In 2016, the ratio of health professionals (doctors, midwives and nurses) in the country was 5.2 per 10,000 inhabitants. This figure, which includes state professionals and private, part state-owned and religious organisations, is well below the WHO standard (23 per 10,000). This problem is particularly marked in rural areas: the ratio falls to 3.9 health professionals per 10,000 inhabitants when the capital, Bamako District, is excluded. Poor availability of qualified health staff in remote areas is further complicated by the security situation in central and northern regions of the country.
ALIMA in Mali
Gaps in health staff competencies
Short-term capacity development
Building competencies: URENI teaching hospital
The training is based on the ‘learning-by-doing’ method, which allows both reflective observation and active engagement of trainees, who learn through practice. Skills and knowledge are acquired by trainees who accompany the nurses and doctors of Dioila CSREF in the nutritional and medical care of SAM children with complications. Trainee doctors conduct joint visits to the URENI and paediatric ward with the responsible physician. Trainee nurses work in pairs with URENI nurses; the ALIMA deputy supervisor nurse guides the trainees in acute and transition phases while the ALIMA senior nurse accompanies them in intensive care, to provide close educational support.
Trainees’ knowledge and skills/competencies are evaluated at three stages: the beginning of training (to measure initial knowledge and skills), mid-term (to measure knowledge and skills gaps to adapt the training to meet identified needs) and at the end (to measure acquired knowledge and skills).
Regional nutrition focal points (NFPs) oversee monitoring the integrated management of acute malnutrition (PECIMA) at the regional level and have an important role in the supervision and evaluation of the URENIs and their staff. They are employed by the DN, which is part of the National Office for Health, under the responsibility of the MoH. One NFP per sanitary district has been deployed in accordance with the PECIMA. Monitoring and evaluation tools used by NFPs include a performance evaluation grid, designed by the MoH to monitor and evaluate the URENIs. Data provided by NFPs are reviewed by each Regional Health Director and then sent to the national-level DN. The NFPs in Koulikoro, Bamako, Mopti, Ségou and Kayes have benefited from a refresher course at the URENI school, helping to improve their techniques for monitoring and evaluating all URENIs. NFP training focused on frequency of supervision, use of existing monitoring tools, editing supervision reports and data collection. The follow-up plans produced by trainee doctors and nurses in their region were shared with the relevant NFP.
Outcomes of the URENI teaching hospital training
Figure 1: Map of URENI teaching hospital trainees regions of origin
Staff at Dioila CSREF had no objections to integrating the training into their regular work and did not receive extra payment; the added value was clear for all involved. While difficult to quantify the extra time required by regular employees, extra staff were recruited by ALIMA at the outset to strengthen CSREF capacity. This was a necessary part of the improvement in inpatient care at the URENI and to ensure trainees were properly managed. In total, 11 ALIMA/AMCP staff were recruited and funding was provided to support 42 workers at the URENI, including six doctors and 20 nurses.
While releasing staff for training was not an issue for doctors and nurses, it was challenging for NFPs who struggled to attend for three whole weeks, the initial length of their supervision training. Training was reduced to two weeks as a result. Interestingly, trainees fed back that even three weeks was too short. There are no practical training programmes for health workers at a lower level; however they can benefit from theoretical trainings provided by the MoH.
There are some significant barriers to full implementation of good practices and standards acquired during the training. The most common ones are the lack of suitable premises and medical equipment (specific tools such as otoscopes, glucometers and saturometers) and insufficient human resources. Addressing these requires financial and material support from the state; this in turn requires strong advocacy and the involvement of every stakeholder, from NFPs and district head doctors to laboratory and pharmacy managers.
Discussion and conclusions
The URENI training hospital brings together emergency medicine and development, since it both supports children with a high risk of mortality and develops the skills of Malian health workers, thus developing resilience in the health system. The main outcomes of the programme have been to provide a response to structural training needs in the face of the endemic nature of SAM in Mali; to prepare for future nutrition and health crises; and to strengthen capacity to respond to crises in the most challenging regions, particularly in northern Mali, where there are urgent needs. ALIMA has received very positive feedback on the training initiative and no significant changes to the approach are planned.
In the future, the URENI training hospital plans to train health professionals from conflict-affected northern regions (Gao, Timbuktu, Taoudenit, Menaka and Kidal) and central regions (Segou and Mopti) in CSREFs that do not currently receive support from an NGO in the management of malnutrition. The hospital plans to train eight health professionals per CSREF in these areas who have not yet benefited from the internship. Several grant applications have been submitted to donors to secure finance for the URENI training hospital.
With regard to the long-term goal of improving the treatment of children affected by SAM, we believe it is necessary to implement some complementary programmes, such as training in management of less complicated cases of malnutrition and training on early case identification. There is a real need for improvement of SAM treatment, but we also need to consider ways to reduce the number of children with complicated cases who require hospitalisation.
For more information, contact: Dr Malam Kanta Issa firstname.lastname@example.org
1There are four health divisions in Mali: state, region, district and health
2016 Human Resources Statistical Yearbook of Health, Social Development and the Advancement of Women (February 2017)
INSTAT 2016. National Statistics Institute of Mali (INSTAT). Nutrition and retrospective mortality SMART survey, Mali, July 2016.
OCHA 2017. United Nations Office for the Coordination of Humanitarian Affairs (OCHA) Financial tracking service (FTS) 2017. https://fts.unocha.org/
UNDP 2016. United Nations Development Programme. Human Development Report – 2016 HDR Report. http://hdr.undp.org/en/countries/profiles/MLI
UNICEF 2016. UNICEF Data. Monitoring the Situation of Children and Women: Under-five Mortality. October 2016 (updated). https://data.unicef.org/topic/child-survival/under-five-mortality/
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Reference this page
Dr Malam Kanta Issa (2017). Building health service capacity to manage severe acute malnutrition in Mali. Field Exchange 55, July 2017. p11. www.ennonline.net/fex/healthservicecapacutemalnutritionmali