1. 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.

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

3. 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)

4. 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

5. 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.

6. 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).

7. 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

8. 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.

9. 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.