1. Treatment of severe acute malnutrition Experience from developmental context Jimma, Ethiopia Tsinuel Girma Asst professor of Pediatrics and Child Health Jimma University Mar 2008 (2000)

4. Child health indicators

5. Current U5MR trend Vs MDG trend

6. f Neonatal, 25% Malaria, 20% Pneumonia, 28% Diarrhea, 20% AIDS, 1% Measles, 4% Other, 2% 500,000 under-5 dying each year Ranking 6 th in the world 72 % preventable Malnutrition 57% HIV/AIDS 11%

7. Nutritional Status of Children Under Age Five

8. Key interventions selected for targeted condition NATIONAL STRATEGY FOR CHILD SURVIVAL IN ETHIOPIA,2005 Malnutrition Prevention/promotion Clinical care Breast feeding Complementary feeding Nutrition advice and supplementation Vitamin A supplementation PMTCT Measles vaccination Family Planning Management of severe acute malnutrition Vitamin A Zinc Nutrition advice

10. In-patient treatment- hospital based Opened as part of pediatric in-patient service (Feb 2004) Maximum capacity of 30 patients Staff : Feeders, nurses,interns,residents and consultants Implementation of national protocol Open 24 hrs

11. Achievements

12. Disciplined treatment, improved practicum set-up, new outlook about treating SAM and interest in nutrition related research

13. More than 1350 patients treated so far most with co-morbidities (TB/HIV) Death Rate < 6% ARWG ~ 15g/kg/d ALOS 4 weeks

15. Observed and expected deaths from Jimma TFU using Prudhon Index

16. Out- Patient Treatment Context In 5 Health centers using RUTF (Dec 2005) Community mobilization and screening MOH is primarily responsible UNICEF provides RUTF and antibiotics Concern – Ethiopia: training Jimma University- Department of Pediatrics and Child Health

17. Performance Post-training follow –up, after 2 months in nine HCs showed Implementation within 34days (20-58) Enthusiastic health workers Good acceptance by mothers and caregivers (also demonstrated in another study) But Poor adherence to protocol ( one in five) Poor medical recording No proper evaluation of appetite – (field tested )

18. Types of malnutrition on admission n=324,four health centers

19. Treatment outcome

20. Outcome RWG for recovered children was 6.0 g/ kg/d and no difference between types of malnutrition RWG for defaulters < 5g/kg/d Length of stay for all recovered children was 36.0 and 39.0 days, respectively.

21. different outcome between HCs but not on the type of malnutrition

22. Malnutrition and HIV/AIDS Variable according to implementing agency so NO harmonized and standard care Screening for SAM and treatment in adults is practically absent in most programs Planned RCT in Jimma on supplementary feeding for patients on HAART

23. Challenges Staff turnover Supply breaks Sharing/ selling of RUFT Poor recording Protocol breach High defaulter rate Payment for drugs

24. Conclusion Appropriate treatment of SAM and integration to routine health care delivery can save many lives There is favorable environment: Interest in health service managers at different level, motivation of health workers and mothers by the treatment outcome Quality of care has to be improved through constant supportive supervision, in-service training and strengthening pre-service training as long term solution

25. Conclusion … Develop local expertise by working closely with higher learning institutions which is crucial for sustainability of new initiatives, research and development There is an urgent need for more operational researches