1. + SAM Strategy in Ethiopia Case study by Team 3 Maria, Yang, Nan, Helen, Cui

2. + Contents Background 15342 Proposal outline Technical measures Practical considerations Logistical support 2

3. + Definition  A pathological condition of varying degrees of severity, and diverse clinical manifestations, resulting from the deficient assimilation of the components of the nutrient complex. (GOMEZ, 1955) 3

4. + 353,690 km² 28,067,000 pop. Oromiya 4

5. +  17 zones, 245 Weredas, and 36 town administrations with 6500 kebele subdivisions.  4 million residents of urban areas, urbanization rate of 13.8%.  The potential health service coverage is 70.5% and the health service utilization is 27%.  Only 17% of the female residents of rural Oromiya were literate with all of its implication for their way of life, health, child bearing and rearing, maternal and child nutrition, as well as disease prevention.  Oromiya also has its share of the regular disasters, mostly natural, but also man-made, such as food shortages, disease outbreaks, flooding, and droughts. ＊ ＊ WHO Emergency Humanitarian Action (EHA), Ethiopia Programme. Report on Field Trip to Provide Technical Support in Emergency Preparedness and Response to Oromiya Regional State. 2007 5

6. + Prevalence of Wasting, Stunting, and Underweight among Under-Five Children.1996–2004. ＊ Source: Successive Welfare Monitoring Surveys (CSA 2004) 6

7. + Stunting and underweight rates in under-five children in Ethiopia, by age, 2005 ＊ Source: CSA and ORC Macro 2006 7

8. + Social determinations Malnutrition Health care Education Economic Agricultural Sociocultural Dietary practices 8

9. + Stunting prevalence in Ethiopia, at Zonal level, 2004 ＊ Source: Estimates generated from data from the 2004 Welfare Monitoring Survey (CSA 2004) 9

10. + Select 3 districts of Oromiya  W. Harerghe (highest stunning rate)  Arsi  Bale 10

11. + Strategy in Oromiya Prevention activities throughout the process 11

12. + Proposal main points Integrated approach with a focus on the diagnosis, treatment and prevention of uncomplicated severe malnutrition in the Oromiya region. Activities will be carried out in the community and in health centers. Following WHO recommendations, cases of uncomplicated severe malnutrition will be treated in the community with Ready to use therapeutic food (RUTF). 12

13. + Community health workers Selection Lay workers Among the communit y where they are going to work Training Nutritional education Malnutrition diagnosis Treatment Psychosocial support Assign Specific geographic area Cater to the households 13

14. + Identifying cases in the community Community health workers will : Œ visit households  monitor the nutritional status of the children. 14

15. + Identification In the community  mid-upper arm circumference <115 mm / any degree of bilateral oedema In primary health-care facilities and hospitals  mid-upper arm circumference <115 mm / a weight-for- height/length <–3 Z-score  have bilateral oedema 15

16. + Case management Community [uncomplicated] Hospital [complicated] ＊ A link will be created in the hospital and the community for the follow up of discharged patients. 16

17. + Why are we going to use RUTF ? Soft or crushable foods Similar nutrient composition to F100 Simple production technology Not water-based Consume at home with minimal supervision Easily transferred 3USD/kg when locally produced 17

18. + Practical considerations The child will receive the RUTF for the first time in the child department in the health center. The community health worker will visit the household after 1 week and provide for a refill of RUTF. Subsequent frequency of visit depending on the state of the patient. Dosages of RUTF will be defined by a protocol. Both health care workers and community health workers will have records where they register the patients status. 18

19. + HIV  All children presenting with severe acute malnutrition will be tested for HIV with the permission of their mothers who will also be tested. TB  All children with severe acute malnutrition will be screened for TB. Children that test positive will be linked with other departments to provide integrated care. Integrated care 19

20. + Prevention activities Community Health facilities Antenatal care Child health 20

21. + Community health workers activities regarding prevention Individual and group counseling  Promote early and exclusive breastfeeding for 6 months and continued breastfeeding for up to 24 months.  Education about appropriate complementary feeding in food secure populations.  Water and sanitation education for the population. OBS: All cited activities have evidence to support their benefit.See : Bhutta ZA, Das JK, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? The Lancet. 2013;382(9890):452-77. 21

22. + Health facilities workers activities regarding prevention Antenatal care prevention activities:  Individual and group counseling  Provide HIV testing to all pregnant women Child health prevention activities: 37% of children present low retinol levels* less diarrhea episodes diminished mortality *Demissie T, Ali A, Mekonen Y, Haider J, Umeta. Magnitude and distribution of vitamin A deficiency in Ethiopia. Food Nutr. Bull. 2010 Jun;31(2):234-41. 22

23. + Logistical support for all activities Our organization will provide the RUTF, in a first step it will be imported from Malawi, will consider local production after the first year of the project. Our organization will be responsible for the supply chain management of RUTF until local capacity is created. Our organization will have administrators on the fields and implementers working alongside the Ministry of health workers. Estimated cost about 55 USD per child with imported pulpy nut. With an estimated 10000 children in need in our region. Total cost of 330000 USD. * 23

24. + Last but not least…… All interventions will be free of charge for the patients !!! All activities will be monitored, and quarterly and annual reports of the project will be presented. 24

25. + Thank you! 25