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Post-earthquake recovery in urban Nepal: Using hospitals to detect and treat child and maternal malnutrition

Sophiya Uprety is a public health nutritionist and worked as a nutrition officer for UNICEF Nepal supporting the post-earthquake recovery.

Rajkumar Pokharel is Chief of the Nutrition Section in the Child Health Division, Ministry of Health in Nepal.

Mahendra Prasad Shrestha is Chief of Policy, Planning and International Cooperation Division, Ministry of Health.

Jhalak Sharma Paudel is the Director of the National Health Training Centre, Ministry of Health. He was Chief Public Health Administrator in the District Public Health Office Lalitpur during post-earthquake recovery.

Anirudra Sharma is a nutrition specialist with UNICEF Nepal and has worked as the emergency Nutrition Cluster Coordinator for the last eight years.

Stanley Chitekwe is the Chief of Nutrition for UNICEF Nepal.

Background

Nepal was rocked by a 7.4 magnitude earthquake in April 2015 and aftershocks in the following months. The Government of Nepal (GoN) declared 14 out of 75 districts in the country to be severely affected, three of which (Kathmandu, Lalitpur and Bhaktapur) are in the Kathmandu valley. A comprehensive nutrition in emergency (NIE) response and recovery programme was implemented in all severely affected areas. Integrated Management of Acute Malnutrition (IMAM) was a key component of this response and included the treatment of severe acute malnutrition (SAM) (between June to December 2017) and moderate acute malnutrition (MAM), as well as a focus on pregnant and lactating women (PLW) (from June 2016 to July 2017).

The target population in Kathmandu Valley was spread over urban areas, including slums, peri-urban and outlying rural areas. A common implementation strategy for the IMAM was initially planned across all 14 earthquake-affected districts and involved community-level screening based on mid upper arm circumference (MUAC), which was measured by Female Community Health Volunteers (FCHVs.) However, the implementation of the approach could not ensure that children with acute malnutrition or PLW were adequately detected for referral. The challenge called for innovative and complementary approaches for maximising programme coverage and reaching out to vulnerable target groups.

A new strategy for urban areas

The barriers faced in identifying acute malnutrition cases were raised in District Nutrition Cluster (DNC) meetings. These were sub-national clusters set up in affected districts following activation of the National Nutrition Cluster. DNC members included not only the regular nutrition community but also representatives from hospitals in the districts. Cluster members agreed that the approach of mobilising only FCHVs was clearly inadequate in the urban areas. A number of factors were affecting regular MUAC screening by the FCHVs at community level: the disproportionate ratio of FCHVs compared to the dense population in their given catchment area; time constraints on urban FCHVs, who are often engaged in other education or income-generating activities; the difficulties posed by a mobile and migrant population; and the unwelcome reception of FCHVs in some urban households where they are not given access due to lack of familiarity with the service compared to rural areas.

The DNC realised that hospitals offer a largely under-utilised platform for the urban context and the intended target population. While they provide opportunities to conduct screening for acute malnutrition among children brought for routine immunisations and other paediatric services, they did not proactively screen all at-risk children. In other words, nutrition interventions in urban areas had not hitherto been implemented through the hospitals in a systematic and comprehensive way for IMAM.

Concerned stakeholders, including the Child Health Division, District Public Health Offices (DPHO), UNICEF and partner NGO (the Social Development and Promotion Centre (SDPC)), decided to conduct a few rounds of MUAC screenings in Kanti Children’s Hospital, a tertiary-level paediatric referral hospital. This process identified a significant number of children with acute malnutrition; as a result, Outpatient Therapeutic Centers (OTCs) and Targeted Supplementary Feeding Centres (TFSCs) were established in six key public hospitals in Kathmandu valley.

Use of mid upper arm circumference (MUAC) screening at Patan Hospital, Lalitpur

Hospitals come on board

Training on NIE (including IMAM) was organised in Kathmandu, Lalitpur and Bhaktapur districts for hospital management, paediatricians, matrons, nurses and dieticians. Necessary supplies and technical support were provided by UNICEF, while the partner NGO supported the running of the OTCs. The NGO workers measured MUAC of children visiting the hospitals; those identified with acute malnutrition were immediately enrolled in the treatment programme as per international protocols. Nutrition corners were also set up to provide nutrition education and counselling on infant and young child feeding. Gradually, the hospital management allocated better location and space for the OTCs/TFSCs, and paediatricians also started to refer children for MUAC screening, ready-to-use therapeutic food/ready-to-use supplementary food (RUTF/RUSF) provision and nutrition counselling. For PLW, those with a MUAC <23 cm were referred for treatment with supplementary foods.

The new approach started to show results straightaway as the number of identified cases began to increase. Between June 2015 and December 2017, a total of 3,868 cases of children with SAM were identified and treated in the three districts of Kathmandu Valley; 66 per cent of these (2,569 cases) were reached through the hospitals. The data for Kathmandu (the most populous district) showed that 84 per cent of cases were identified from hospital settings. In addition, over 13,000 cases of MAM and over 12,000 PLW were treated.

Challenges and lessons learned

Initially, all IMAM data from the hospitals, including case identification and management, were being vertically reported by the NGO partner. After discussion among the DPHOs and hospital management, it was found that medical recorders in the hospitals would be able to enter data into the Ministry of Health (MoH) Health Management Information System; this has now been included as part of routine reporting in the hospital.

Another challenge involved the human resource capacity needed for regular follow-up of those treated to ensure that they did not default. The number of cases identified and admitted in the hospital-based OTCs was much higher compared to community-based settings, and included cases from other parts of the country, adding further challenges for follow-up.  

The MoH has allocated budget to local government to continue core activities such as logistics supply (including purchase of RUTF); periodic programme reviews at local level; and monitoring and supervision (the total amount budgeted is being finalised through the annual work plan). The MoH is committed to providing programme support in those districts for continuation of the services provided during the earthquake recovery. 

Complementing community level efforts

Hospitals have been identified as an important platform in urban areas through which to identify acute malnutrition cases, offer treatment and provide nutrition counselling. This approach complements the community-level efforts, especially as it was learned that reliance on the FCHVs alone is inadequate in an urban setting. There was a need to engage with the hospitals on a strategic level. The leadership of the DPHOs and MoH played a key role in initiating the intervention, as well as the progress made in the hospital settings. Overall, this approach significantly contributed towards achieving the results for IMAM outlined in the nutrition component of the GoN’s Post-Disaster Recovery Framework 2016-2020.

Urbanisation is an evolving area of importance for all nutrition interventions and Nepal is among the top ten fastest urbanising countries in the world. Hospitals can also offer a valuable platform for urban nutrition programming, including the management of acute malnutrition during and outside periods of crisis. They can also be utilised for broader activities to improve maternal infant and young child nutrition, as well as to address the rising burden of overweight/obesity and non-communicable diseases in these populations.

 

Acknowledgements: Partner NGO Social Development and Promotion Centre (SDPC) and concerned hospital managements.

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Reference this page

Sophiya Uprety, Rajkumar Pokharel, Mahendra Prasad Shrestha, Jhalak Sharma Paudel, Anirudra Sharma, Stanley Chitekwe (2018). Post-earthquake recovery in urban Nepal: Using hospitals to detect and treat child and maternal malnutrition. Nutrition Exchange 10, July 2018. p22. www.ennonline.net/nex/10/earthquakerecovarynepal