(5) Co-Creating a Nutritionally-well Society
Category: FIELD NOTES
Written by Selahuddin Yu Hashim (MDM 2013), Philippines
Eastern Samar. In February 2014, 23-month-old Jana was brought at the rural health center of Quinapondan. Jana is one of the more than 21,000 under five children in the 22 municipalities of the Province of Eastern Samar who were screened using the mid-upper arm circumference (MUAC) which determine the nutritional status of 6-59 mos children and pregnant and lactating women (PLW). She was identified with Severe Acute Malnutrition (SAM) including other eighty-two (82) children in the province.
Jana is the youngest of the three children of Lisa Rosaldo (21 yr old and pregnant for 8 mos). During the screening, the Barangay Nutrition Scholar who measured Jana was very concerned of her physical state. “She was crying the whole duration and you can feel her discomfort. She was very thin and small with a height of 73cm and a weight of 6.9kg. Her MUAC is 119 mm and a Z-score of below -3,” the BNS who attended her shared the sad fate of Jana. Five weeks after, Jana was brought by her mother at the RHU and this time she was smiling all over. The RHU staff noticed that Jana was even playful and lively. “When we took her measurements, her MUAC increased to 139mm, her weight also reached 8.8kg and height of 73.3 cm while her z-score is now -1.5. For two weeks, her MUAC and Z-score were consistently normal. Even after we discharged her, we still continue to monitor her status and provide counseling to her mother,” the BNS said.
Jana’s late referral at RHU is an indication that many parents do not really understand malnutrition, its causes, treatment and how to prevent it. Like many parents of SAM patients, they claim that the poor physical appearance of the children is due to lack of resources.
What is troubling more is that earlier on, many RHU staffs also have limited knowledge about the underlying and immediate cause of malnutrition. Most of them have only heard of the Community-based Management of Acute Malnutrition (CMAM) only after Yolanda devastated their province. Ms. Sallie Javinal, the Provincial Nutrition Action officer (PNAO) of Eastern Samar, related, “the province has a nutrition program but is very weak. The budget allocated to nutrition is very meager and is not able to cover the implementation of nutrition-promoting activities. It gained less support from the local government unit. When Typhoon Haiyan (Yolanda) devastated most of the areas of the province, several international organizations such as UNICEF, ACF and HOM arrived in our place and introduced the concept of CMAM. At first I was skeptic, but with thorough discussion and evidence-based presentations, it changed my heart and mind. I was really hoping that we could implement the program in our province immediately.”
Eastern Samar in the past ranks no. 1 in terms of the prevalence of malnutrition based on the 1998 National Nutrition Survey (NNS) conducted by Food and Nutrition Research Institute (FNRI) of the Department of Science and Technology (DOST). Currently, it is still the highest in Eastern Visayas in terms of the prevalence of stunting and wasting.
Finding the Lights in the Darkest Tunnel
After Supertyphoon Yolanda hit the Central regions of the Philippines, it resulted to a widespread structural damage and thousands of casualties with a total of 3,547,212 individuals remained displaced (3,547,212 outside of ECs and 101, 363 within the ECs) from the 8 majorly hit provinces. These include the provinces of Iloilo, Aklan and Capiz in Region 6, Cebu in Region 7 and Leyte, Southern Leyte, Eastern Samar and (Western) Samar in Region 8. The typhoon left 28,689 injured, 6,268 deaths and roughly 1,061 still missing (Health Cluster Bulletin #17 March 28, 2014).
To determine health and nutrition conditions in the affected communities 3 months after the typhoon, various agencies conducted SMART3 Survey. Initiatives in preventing undernutrition are sub-optimal in terms of coverage and practice in Regions 6, 7 and 8. Only 58% of children 0-23 months were initiated breastfeeding within 1 hour after birth, less than 50% were exclusively breastfed and 14% never been breastfed. In contrary, about 46% of the 0-23 months were bottle-fed, a substantial increase from the 39% average of the 3 regions recorded in 2011. Of particular note is the high rate (41%)3 of infants less than 6 months given infant formula. Large proportion of children (90 %) was initiated with complementary feeding at the age 6-8 months but only more than half (65.1%) have iron-rich food consumed.
Poor maternal health greatly contributes to poor child health and survival. Maternal and child undernutrition increase maternal and perinatal mortality. There will be Intra-uterine growth retardation (IUGR), preterm birth and low birth weight resulting to 45% death among the under-5 years of age. Long term effects of undernutrition results to impaired cognitive development and reduced work productivity.
While Typhoon Haiyan damaged most of the properties, it somehow shifted the paradigm of key stakeholders in responding to crises. The typhoon highlighted the huge gaps in the healthcare system and delivery especially programs that protect maternal and child’s health and nutrition. Somehow, it urged everyone to start doing something.
A Borderless Humanitarian Response
The Medicine Sans Frontier (MSF) first introduced the CMAM program in Maguindanao Province from 2008-2010 following the conflict that displaced thousands of people in Central Mindanao. Afterwards, Save the Children International (SCI) and UNICEF partnered to continue the program in 2010. During those times, former staff of MSF organized themselves and established the only local humanitarian health organization in Mindanao and named it Health Organization for Mindanao (HOM). As the team who pioneered the CMAM program, UNICEF and SCI tapped HOM as the Technical Service Providers (TSP) of the CMAM Program. A total of 84,586 under five children were screened, 779 were identified with Moderate Acute Malnutrition (MAM) and SAM and at the end of it, a remarkable success rate was achieved.
Learning from its years of implementation of the CMAM program, HOM responded to the crises in Yolanda affected areas and entered into partnership with ACF and UNICEF to address the concern on nutrition. Based on their experience, without comprehensive intervention provided, there is high probability for a child to die with severe acute malnutrition condition.
And on December 2013, HOM travelled almost 2 days from Cotabato City to Eastern Samar Province. Initially, the group faced several challenges and was anxious as well as nervous in serving a foreign place with a condition that is totally different from where they came from and the magnitude of the disaster was too huge to comprehend. Moreover, originally, all staffs are practicing Muslims. There was apprehension regarding the perspectives of the community about the Muslims. And yet, just like all humanitarian organization, the team immediately saw the huge gaps in terms of health and nutrition and saw it as an opportunity to serve the province dismissing the perceived difficulties and apprehensions. In two weeks time, HOM team was able to coordinate with the provincial health office and established strong partnership with key stakeholders: Line Agencies; Nutrition Cluster Partners; PHO’s PNAO; RHUs MHOs, MNAOs, NDCPs, Midwife, PHNs; Barangay Nutrition Scholars; Local Chief Executives; Media; Religious Sectors; Community Leaders; the PLWs; and, Youth.
Bridging the Gap of Healthcare System: The Community-based Management of Acute Malnutrition Approach
In its eight (8) months of operation in Eastern Samar, HOM saw the need to redesign its approaches and refocus on important component of the nutrition program. The most important initiative was capacitating the health sector on CMAM following its protocols and guidelines. All of the 10 municipalities covered were trained and coached from screening, assessment, monitoring, evaluation, treatment, care practices and other support activities. It has also design series of advocacy activities to direct policies toward strengthening and sustaining the program.
In the first five months of the program, both the provincial health office and HOM found an acceptable global acute malnutrition (GAM) prevalence of 4.1%3 among the 6-59 months. This is lower than the pre-typhoon rate average of 6.9%. Interestingly, acute malnutrition mostly affects children aging 6 months to 2 years and mostly those belonging to the marginalized section and receiving cash transfer program from the national government (4Ps). Meanwhile, 18% of women of reproductive age have acute malnutrition. This mainly affects women aging 15-19 years old with 4 times risk of developing acute malnutrition.
To strengthen its operation, the program involves active and passive screening and an out-patient program that is administered by municipal health workers of the rural health units (RHUs) and the Barangay Nutrition Scholars. Mothers bring their children each week, on a specific day to be weighed and measured and the children are given special peanut based RUTF (Ready-to-Use Therapeutic Food) to eat whilst in the clinic. As long as the child has appetite and is able to eat the food, the mother is given enough packs for a week, and strict instructions on how to administer it. Mothers are also counseled on breastfeeding, nutritious complementary foods as well as other best childcare practices.
Jana’s case tells a story of the need for a comprehensive and innovative approach in addressing malnutrition. During the CMAM verification and admission, the Public health Nurse of Quinapondan RHU related that “Jana’s parents are shy and they didn’t brought her during the screening. It was only during one of the counseling sessions on Infant and Young Child Feeding (IYCF) that Jana’s mother brought her. The BNS saw her condition and immediately referred Jana to the RHU after doing initial screening.”
After the RHU staff explained thoroughly to Jana’s mother the features and benefits of CMAM, her mother decided to enroll Jana in the OTP program and pledged to strictly follow the procedures and treatment requirements. Quinapondan’s Municipal Nutrition Action Officer (MNAO), Ms. Pacita, requested HOM IYCF Counselor and Mental Health Specialist to provide series of counseling to Jana’s parents because it seems that the parents are having other domestic concerns which may affect the quality of care practices and treatment. Ms. Pacita also noted the closer distance or age gaps of their children.
HOM staff responded with series of cognitive behavioral therapy and IYCF counseling. Series of home visits in the remote area where Jana lives were done to ensure faster recovery of Jana.
“After 2 weeks of follow-ups, the mother was really complying with the proper treatment of her child which made a very good result. Jana gained 1kg,” said by Jow Bangen, HOM Nutrition Supervisor. Jana’s mother, Lisa, also said “we are very happy with the results that we are seeing. According to our neighbours, Jana is really gaining weight and becoming round.” As she was talking about the improvement of her child, the smile on her face was visible, she was really happy. Ms. Pacita reinforced Lisa’s statement encouraging her to continue the things that she was doing well.
On the 4th week of follow-up at RHU, Jana was already in a normal range but she has to stay in the program for another week just to make sure that she maintains her progress. While UNICEF’s protocol is to discharge SAM patients using the MUAC alone, based on experience, HOM finds it helpful to extend the period of treatment for up to two weeks to ensure that both MUAC and Z-score indicators are back in normal range. This was proven to be effective in curbing any form of relapse.
In another instance, the HOM team has also observed that Lisa was experiencing hypotension (her hemoglobin count was low). She was then admitted at Quinapondan Community Hospital for further treatment (Blood Transfusion). With limited resources, Lisa requested that treatment be done at her house since she can’t afford to pay for transportation and other costs caused by her admission in the RHU. Despite resistance, the MNAO provided the needed medicines and requested HOM and the midwife’s assistance in monitoring and supervising Lisa’s medication.
On the 5th week of treatment (March 31), Jana was still on the normal range and constantly increasing weight. Lisa at the same time was also feeling better and she even verbalized that after giving birth, she and her husband will follow the family planning methods.
Even after the discharged, HOM’s MHPSS Specialist continue the counseling and reiterate to Lisa on how she can maintain her children/family’s physical, mental and social well-being. Lisa thanked the BNS, RHU staff and HOM. Up to now, Lisa still regularly attends the Care Practices Sessions and IYCF Counseling. She would even share her story and Jana’s success to encourage other parents to comply and change their behavior towards ensuring the health and nutrition of their family member. Many were inspired with their story. And more and more of the pregnant and lactating women of various ages would conform Lisa and Jana’s success story.
The CMAM program is now being adopted by most organizations in the Philippines focusing on health and nutrition. Moreover, various agencies and organizations are now working to develop a national policy that can make this treatment available to all children in the Philippines who need it.
HOM believes that with everyone working together, we can Co-Create a Society where no child will be left malnourished.
 SMART (Standardized Monitoring and Assessment of Relief and Transition) Survey 2014, Yolanda-affected Areas: acute malnutrition (acceptable= <5 %, of concern= 6-9%, serious 10-14%, critical ≥15%), chronic malnutrition (low <20%, medium 20-29%, high 30-39%, very high ≥40%)
 National Nutrition Survey 2011
 Lancet series 2013
 Region 6 (5.8%), Region 7 (7.2%), Region 8 (7.8%)
 4Ps Pantawid Pamilyang Pilipino Program
 Mid-upper arm circumference (MUAC) < 210 mm
About the writer
Selahuddin Yu Hashim is a member of the Master in Development Management (MDM) Class of 2013. He is now the Executive Director of Health Organization for Mindanao (HOM).
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