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HMG7420 Nutrition in Emergencies
Assessment 2: Case Study
Weighing: 40%
Word Limit: 2500 words
Read the following case history and answer each question.
- If the question is a calculation including your own calculations in coming to your
answer
- Where relevant justify your answer from the literature or international
standards or guidelines
X is a country of more than 12 million people of whom more than 2.4 million are children
under five years of age. It is among the poorest countries in the world with great scarcity of
resources and infrastructure. Eighty percent of its inhabitants live in rural areas and 63
percent are classified as living below the poverty line. Levels of child mortality and
malnutrition are high, even in normal (i.e., non-emergency) years. According to recent
surveys, life expectancy is 42 years (female) and 41 years (male), infant mortality 100 per
1000 live births, under-five mortality 198 per 1000, and fertility rates 7.1 children born per
woman. The rate of HIV infection amongst 15 to 49 year olds is 0.7 per cent. It is estimated
that only half of the population in the country have access to health care and no more than 60
per cent to safe drinking water. Fourteen percent of children below 6 months are exclusively
breastfed and vaccination coverage of DPT3 in children between one and two years is only
29 per cent.
In 2000, the rate of Global Acute Malnutrition (GAM) was estimated to be 14.1 per cent and
the rate of severe acute malnutrition (SAM) 3.2 per cent. Stunting was estimated to be 39.8
per cent but there was consensus that this had increased since the 2000 survey.
The health system in X follows a pyramidal primary health care structure with rural health
centres in every district, some of which are supported by health posts, and hospitals at
district, regional and national level. The system is undermined by lack of funding, effective
human resources and mismanagement in most districts.
X is subject to recurrent droughts, frequent food insecurity, high incidence of communicable
diseases, and high population pressure, particularly in the south. The country has suffered
major food crises in the past (on average once every decade). The consequences included
excess malnutrition and death, destitution and large-scale migration to neighbouring
countries.
Current situation
A humanitarian emergency was declared in 2005. The causes for the emergency was multifactorial
and included food production failure and market disruption in rural areas overlaying
endemic inadequate care and feeding practices, high prevalence of communicable diseases,
and poor health access. Nutrition surveys from several provinces started showing alarming
results including an earlier than expected seasonal increase in malnutrition cases detected at
health facilities. By August, some NGOs published statistics showing GAM rates of 22.3 per
cent and SAM rates of 4.1 per cent in the province of Alpha, inhabited by approximately 230
000 people.
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Food distributions to the general population started in Alpha in August 2005, and
international NGOs established programs addressing acute malnutrition and food insecurity.
There were no reported outbreaks of infectious diseases.
Food preferences
White maize grain is a staple cereal in Alpha. If the population have to receive maize grain,
then they overwhelmingly prefer the local (white) maize grain to the imported (yellow) whole
maize grain. Maize meal is also available for distribution, some of this is yellow imported
maize meal, and the rest is locally milled white maize. The yellow maize meal, which is
imported from the United States, has a much finer texture than the more coarsely ground
white maize. If given a choice between the yellow and white maize meal, the population
overwhelmingly prefer the white maize meal to the yellow meal.
Food preparation and milling
During normal times most households take their cereal grains to small commercial mills but
during the emergency many households could not afford to do this, even if maize grain is
provide in the general ration. If available maize meal is used to make ubugali, a stiff
porridge. Water is brought to the boil, then flour is added, and it is stirred continuously for
about 10 minutes, depending on the amount. In Alpha, whole white cereal grain is used to
make ndete. This is pounded maize, boiled and mixed with beans or lentils. This takes three
hours or more to cook. If beans are old they can take several hours and must be partially
cooked before adding to the pounded maize.
Food Assistance questions.
1. Why was a general food ration established? Justify your answer.
2. How might the composition of the general ration affect fuel requirements? How
can these be minimized?
3. Given the populations food preferences, how would you plan a nutritionally
balanced general ration that to goes some way to meeting these preferences?
4. What arrangements would you recommend for milling the cereals and why?
Need for Emergency feeding program questions
5. Using the information provided estimate the number of moderately and severely
malnourished children in the province.
6. Do you think that a supplementary feeding program for moderate acute
malnutrition would be necessary in this setting.
7. If yes, what type of supplementary feeding program would you recommend and
what would be the objectives of any supplementary feeding program?
8. Do you think a therapeutic care programme for the treatment of severe acute
malnutrition would be necessary in this setting?
9. If yes, list other information that you would need to design a therapeutic care
programme.
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Programme planning: Location of centres
With the information from above you are asked by your agency to submit an intervention
plan to provide therapeutic care in the region. You collect further information on the
demography of the province and its characteristics. The province is divided in 6 districts, as
follows:
Hospitals Health centres &
Health posts
Population Distance from Head
of district to capital
Province capital 1 (Provincial) 4 (Urban) 32 000 0
District A 1 (District) 3 (Rural) 28 700 50 km S
District B 1 (District) 4 (Rural) 34 600 10 km SW
District C 1 (District) 3 (Rural) 26 700 75 km SE
District D 1 (District) 4 (Rural) 34 200 125 km NW
District E 1 (District) 4 (Rural) 33 500 145 km NE
District F 1 (District) 5 (Rural) 40 300 115 km N
You know from the data that population size varies considerably between districts. The
districts in the south (Districts A to C including the capital which is in District A) are much
smaller in size and therefore have a much higher population density. In contrast, Districts D
to F which are further north are larger and have a very dispersed population.
Following the primary health structure of the health system in country X your initial plan is
to establish outpatient services close to each health centre or health post (22 in total) and one
inpatient facility (stabilisation centre) at each of the 7 hospitals. However, after checking with
your manager you realise that this may be not be feasible in the short-term. You are told that
with the available resources you may only plan for 1 or 2 inpatient facilities and a maximum
of 15 outpatient facilities. Furthermore, these will have to be opened progressively (a first
wave immediately and a second wave in the following 2 or 3 weeks).
Questions:
10. Discuss what criteria you could use to decide where to set up the facilities.
11. Are there any potential implications of the decision taken and what can be done to
limit any adverse consequences or limitations of this approach.
Programme planning: forecasting needs for staff and food
After discussion with your donors and agency it has been decided that your agency will
concentrate programming in districts A, B and C. One inpatient facility will be set up in the
capital to take advantage of the extra services provided by the provincial hospital. The need
for a second inpatient facility will be re-evaluated later. A first wave of 6 outpatient facilities
will be opened immediately and the others will follow in two weeks.
Questions
12. What is the number of children in need in the selected 3 districts (plus the
provincial capital)?
13. Assuming coverage of 80 per cent, what is the number of children expected in the
centres during the next three months? How many would you expect to see in each
type of facility?
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14. What are the staffing needs for the stabilisation centre and the 6 outpatient
facilities?
15. Calculate the required amount of food items for a period of three months (F75,
F100, and RUTF).
16. What other activities need to be planned at this stage?
17. How would you link this therapeutic feeding program to the supplementary feeding
program and why is this linkage important? Consider both admission and exits into
the therapeutic feeding program in your answer.
Community mobilisation
In conjunction with establishing the mobile teams for outpatient care you send out teams for
screening patients in the communities around each site (case-finding). This team works
intensively during the first two weeks. You also appoint 2 volunteers for each outpatient site.
The main components of your programme therefore comprise:
• 1 inpatient care facility at provincial hospital
• 6 mobile outpatient care facilities served by one team (1 in the capital, 2 districts with 2
sites and 1 district with 1 site)
• One screening team
• One or two volunteers per outpatient care site.
Questions
18. Do you think that these programme components are sufficient to meet your
objectives? Comment.
19. Describe the main features of community mobilisation.
Two months later
You have just received information from the second monthly report. Among other things you
observe that;
• The total number of children admitted to the programme so far is 984.
• 45 per cent of these children were admitted to inpatient care.
Questions
20. Comment on these two statistics. Estimate programme coverage.
With this information at hand you decide to check the centre register and discover that:
1. 20 per cent of the children come from neighbouring districts, and
2. There are no children from the villages further away from the centres.
Question
21. Comment on these findings and whether they would lead you to take any actions
Conclusion
List the main conclusions you draw from this case study.