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Lessons from Namibia’s Nutrition Assessment Counselling and Support Programme for addressing child, adolescent and maternal undernutrition and HIV/AIDS

Children who have lost parents to HIV/AIDS with their carers, NamibiaHilde Liisa Nashandi and Marijke Rittmann

Hilde is the Senior Health Programme Officer in the Food and Nutrition Sub-Division of the Ministry of Health and Social Services in Namibia.

Marijke is a nutritionist who previously worked at the Ministry of Health and Social Services in Namibia. She is currently studying for her Masters at Rutgers University, New Jersey, USA.

Namibia has an estimated population of 2.1 million. Although Namibia is food secure, many rural households are not able to produce or purchase enough food for consumption. According to the Namibia Demographic Health Survey 2013, stunting (low height for age) is 24% and wasting (low weight for height) is 6%. National HIV prevalence in Namibia is estimated at 18.2 percent (2012) though this varies from 39 percent to 8 percent across the regions.

To address the problem of severe acute malnutrition (SAM) in children under five years of age, the Ministry of Health and Social Services (MoHSS) developed an Integrated Management of Acute Malnutrition (IMAM) programme in 2008, focused on assessment and treatment of SAM. The carers of children with moderate acute malnutrition (MAM) were provided with counseling and encouraged to prepare nutritious local foods for their child but were not admitted to specific treatment programmes. However, there were many MAM cases that developed SAM, some with complications. To address this issue, the MoHSS launched the Nutrition Assessment Counseling and Support (NACS) programme in 2010, offering wider services in nutrition, to replace the IMAM programme. The NACS has been funded by a number of donors though today, it is funded by the Global Fund, Centers for Disease Control (CDC) and the Government.

NACS provides routine universal nutrition assessment and treatment for all MAM and SAM children, pregnant women and post partum women 6 months after delivery and people living with HIV/AIDS (PLHIV). NACS is currently being implemented in all regions and most clinics in the country. Most health workers, including doctors and nurses, have been trained to effectively screen, treat, refer and provide follow-up services for SAM and MAM children, PLHIV, and pregnant and post-partum women for up to six months. 

Nutritional assessment

The NACS nutrition assessment is conducted on all those visiting health facilities or accessing outreach services. Nutritional status is assessed using mid-upper-arm circumference (MUAC) or body-mass-index (BMI) for adults, weight for height (WFH) and MUAC for children, and MUAC for pregnant and post-partum women. In addition, dietary assessment is conducted to inform nutritional counseling. Regular weighing is conducted to monitor the effectiveness of care, treatment, and nutrition interventions and to prescribe medicine doses. During home visits by the Community Health Care Providers, assessments are done with MUAC. Individuals found to have a low MUAC are referred directly to the nearest health facility for follow up.

Nutritional Treatment

Treatment for SAM consists of take-home rations of Ready-to-Use Therapeutic Food (RUTF) and Ready-to-Use Supplementary Food (RUSF) for MAM. These are prescribed to individuals for a limited time, based on clear admission and discharge criteria. These nutrition products are provided alongside nutritional counseling by the health workers at the health facility.

Programme review

A review of the NACS was conducted in November 2012 with the assistance of UNICEF, FANTA, CDC and the Global Fund. Key findings from the report include:

One of the key challenges, which likely contributed to some of the findings raised in the report, was poor management and supervision from district and regional levels. This is reportedly due to the fact that staff at these levels were not adequately trained in how to manage and supervise the programme. This gap has resulted in a lack of implementation support for facility-based staff, including how to correct mistakes and encourage increased caseload detection and coverage.

Measuring MUAC at St Benedict clinicLearning from others

In considering how to improve the NACS, national level MoHSS programme officers noted that the Extended Programme of Immunisation (EPI) was a well managed and supported programme at all levels. EPI indicators are integrated in the Health Information System (HIS) and data entered by the Information Officers in the Ministry. Key factors underpinning the success of the EPI programme include:

Based on the review and the EPI experience, in 2013-2014 the NACS programme undertook the following activities to improve its management and supervision.

Conclusion and Way Forward

The MoHSS is continuing to geographically expand the NACS programme so that it will be implemented in all the health facilities in the country. There is political commitment to improve and expand capacity for the implementation of NACS and specifically, on-the-job training and possibly digital video conferencing sessions will be held for all regions. The Ministry continues to advocate for building human resource capacity in nutrition at the pre-service training level. Additionally, there are plans to improve NACS data management by developing standard operating procedures for reporting and there is some consideration of moving towards electronic reporting. Finally, the MoHSS aims to establish a referral system for NACS clients who successfully recover from the treatment of acute malnutrition yet are in need of economic and livelihood support. These individuals will be referred by health workers to the government-supported drought relief programmes and donor funded income-generating projects.

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Hilde Liisa Nashandi and Marijke Rittmann (2016). Lessons from Namibia’s Nutrition Assessment Counselling and Support Programme for addressing child, adolescent and maternal undernutrition and HIV/AIDS. Nutrition Exchange 5, May 2015. p9. www.ennonline.net/nex/5/lessonsfromnamibianutassess

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