WASH IN NUTRITION Session number 3 Caroline Abla International Medical Corps 9th October 2014 Any acknowledgments can be made here – add logos if needed, e.g. of funder.

Background Armed groups occupied the regions of Timbuktu, Kidal and Gao in Mali between March 2012 through January 2013. Control was regained in January 2013

Background contd Health system severely disrupted; displacement of health staff, looting of health facilities and high insecurity on the roads hindering both access to health facilities and quality of care During conflict health and nutrition indicators were poor (DHS 2013); Infant mortality 56/1000 Under five mortality: 96/1000 Rural areas: 113/1000 National GAM prevalence 12.7%, SAM prevalence 5.1% GAM prevalence in Timbuktu estimated at 16% (SMART 2011)

Programme details: IMC Mali Programme activities started in Timbuktu and Gourma Rharous in April 2013 as emergency response The objective was to reduce the prevalence of acute malnutrition via multi-sectoral interventions addressing the underlying causes of malnutrition Nutrition activities: CMAM and IYCF 14 health facilities; 2 Referral health centres 12 health clinics Direct beneficiaries: 15,281 children under 5 and 3,898 PLW Nutrition activities integrated with primary/secondary health care, reproductive health, WASH and GBV Since 2013, with support from ECHO, OFDA, UNHCR, UNICEF and WFP, IMC-UK has been able to help reinstate primary/secondary health care, nutrition, and GBV services in Timbuktu and Gourma Rharous currently targeting 14 health facilities including 2 Referral health centers and 12 health clinics and their catchment communities

Programme details contd IMC integrated WASH activities within its CMAM program as follows: distribution of WASH kits to caretaker of OTP beneficiaries (2 collapsible jerricans of 10 litres each, 1 bucket of 14 litres each, 7 soaps and 9 pads of 10 Aquatab tablets each. Soaps and Aquatab tablets was renewed every 4 weeks and at discharge, each child received supplies for 1 month)  hand washing and water purification demonstrations ensuring availability of potable water at supported health facilities Nutrition and WASH education In an attempt to curb the vicious cycle of diarrhoea and malnutrition, IMC Mali Nutrition program introduced WASH-in-Nut activities within its integrated CMAM program in the 7 months period between July 2013 and January 2014, as follows: distribution of WASH-Nut kits, hand washing demonstrations, ensuring availability of potable water at supported health facilities, and health education.   With UNICEF support, IMC distributed a WASH-Nut kit to each admitted child and discharged-as-cured child in CMAM programme to promote hygiene practices at household level. Each kit consisted of 2 collapsible jerrycan of 10 liters each, 1 bucket of 14 liters each, 7 soaps and 9 pads of 10 Aquatab tablets each. Soaps and Aquatab tablets were renewed every 4 weeks. At discharge, each child received 7 soaps and 9 pads of 10 Aquatab 33 mg tablets to cover for 1 month. Each IMC-supported health facility had 2 nutrition assistants trained to convey messages about hygiene and use of kits upon admission in the program, as well as network of Community Health Volunteers (CHVs monitored correct utilization of WASH kits, hand-washing, and proper sanitation at the health center level and household level. In addition, health facility staff organized hand-washing/ water-purification demonstrations and for care-givers and pregnant women during each follow up visits in health facilities. Education sessions conducted at health facility level focused on training the mothers of severely malnourished children on the use of aqua tab, and hand washing. All 7 health facilities were equipped with boreholes or trucked water to ensure availability of clean potable water. To ensure proper hygiene, hand washing points were installed in the health facilities, and health education messages strategically displayed to encourage proper hygiene. Meanwhile CHVs regularly monitored the correct use of aqua tabs in the households and other hygiene practices such as hand washing and promotion of clean latrines.

Key findings/experiences GAM prevalence in Timbuktu decreased to 13.3% (SMART August 2014) A decrease of 2.7% compared to GAM of 16% in 2011 At national level an increase of 0.6% from 12.7% to 13.3% (2013 – 2014) The prevalence of global acute malnutrition prior to the intervention was 16 % and the incidence of diarrheal cases was 5 % in Timbuktu. Program data (attached) shows zero defaulter rates in OTP and SC between July and December which coincides with the peak implementation (no pipeline breaks) of WASH kit distributions. Prior to this period, the abandon rate was 10.4 for OTP. However the coverage/ caseloads data is equivocal, probably because distributions coincided with onset of the rainy season, (access issues).

Key findings/experiences contd OTP defaulter rate 10.4% from April till July OTP defaulter rate 0.0% from July till December Coincides with the peak distribution of WASH kits

Conclusions & recommendations Integrated WASH activities in CMAM contributes to prevent acute malnutrition and improves defaulter rate Integrated implementation was not a major challenge despite emergency context WASH is thus a key area which could maximize nutritional impact.

Discussion points Morbidity data was not included in latest SMART survey but from observations number of diarrhoea cases has decreased Prior to intervention incidence of diarrhoea was 5% in Timbuktu (SMART 2011) Long term impact of integrated nutrition and WASH on stunting could not yet be determined Handover to questions from the floor.