Aahar sprovision of Supplemental Readyto-Use Foods, Vitamins, and Medications Processes and Electronic Data Collection as part of a Community-Based Management of Acute Malnutrition (CMAM) Program
T he Society for Nutrition Education and Health Action (SNEHA) is a Mumbai - based non profit invested in building viable urban communities by targeting maternal and child health care providers and care seekers. SNEHA works at the community level and collaborates with existing public health systems and health care providers to create sustainable improvements in urban health. SNEHA's Child Health and Nutrition (CHN) Program has been coordinating a Community-Based Management of Acute Malnutrition (CMAM) Program known as Aahar since 2012. Aahar The Aahar program, covering a population of 300,000, targets a child s life from conception to age three, and adopts a holistic approach through prevention and treatment to reduce malnutrition in Dharavi Slum. Aahar works in partnership with the central government Integrated Child Development Scheme (ICDS) and the Municipal Corporation of Mumbai (MCGM) Nutritional Rehabilitation and Research Centre (NRRC) at Lokmanya Tilak Municipal General (LTMG) Sion Hospital. Community Based Management of Acute Malnutrition The Aahar CMAM approach involves early identification of malnutrition through Screening and Growth Monitoring of all pregnant women and children under three, behavioral change on feeding and care practices of caregivers through home-based and group Counseling, timely Referrals to public health care systems for children in need of medical attention, and Treatment of malnourished children through community based medical screenings and provision of antibiotics and Medical Nutrition Therapy (MNT). Medical Nutrition Therapy MNT cups are ready-to-use-therapeutic-foods (RUTFs), which are given to children aged 6 to 36 months that are severely malnourished, do not suffer from medical complications, and have passed an appetite test. MNT is a nutrient dense dietary supplement, lipid-based paste designed to treat severely malnourished children. The advantage of RUTFs is that they are not water-based and do not require cooking. They can be used safely in the home without refrigeration and can be given directly to the child by a caregiver (WHO, 2013). The 2013 updated WHO guidance on
the management of SAM in infants and children recommends that children who pass the appetite test, and are clinically well, should be treated as outpatients (WHO, 2013). The MNT provided to children by Aahar is indigenously prepared and procured from the NRRC at the LTMG Hospital. The LTMG hospital, in partnership with IIT Mumbai, produces MNT using the WHO formula in the NRRC production unit located in an urban health center in Dharavi. The product consists of milk powder, sugar, vegetable oil, peanut butter, vitamins and minerals, creating a paste that requires no further treatment (Jadhav, 2014). Table 1. Medical Nutrition Therapy composition Nutrition Facts (Per 100g) Ingredients Protein Carbohydrates 16 44 Peanut, Skimmed milk powder, Powdered sugar, Soybean oil, micronutrient Lipids 34 mix and Emulsifier. Energy 540 Kcal The intensity of the nutrition therapy varies according to the nutritional status of the children and most children typically follow an eight week regime. Each SAM child is to be given the required amount of MNT prescribed by the doctor following the WHO reference chart for RUTFs. If children are unable to gain weight with MNT then further investigations are carried out to understand the weight stagnation of the child. During the community based health camps a doctor evaluates children referred to her by SNEHA's Community Organizers (COs). Eligible children are prescribed MNT, antibiotics, and vitamin and mineral supplements as needed. The medications provided by CIPLA and distributed by SNEHA include: Fevago, Dexorange and Novamox as well as Zinc supplements and Vitamins MNT Provision and Stock Flow LTMG NRRC SNEHA Aahar Office (1) Aahar Community Points (2) NRRC Community Organizers (79) Households of Malnourished Children The provision MNT at the community level allows for large numbers of children to be treated at one time. MNT cups directly flow from the production and storage location at the NRRC laboratory in the LTMG Hospital Urban Health Centre (UHC) to SNEHA's Aahar office. From here, the commodities are distributed to points in the community where COs can pick up the MNT cups for delivery. COs generally deliver the cups to a maximum of five households (points of consumption) per day. Each CO has fixed geographic coverage areas and the households covered by each CO for MNT distribution vary according to the number of children in their assigned area prescribed MNT. 2
Aahar maintains an inventory of approximately 300 MNT cups per day, however this number can increase or decrease according to the number of children enrolled in the MNT program. Generally, deliveries from the NRRC are made once or twice per week and it takes two to three working days for the NRRC to provide Aahar with a new supply of MNT cups once requested. Additional procurement of MNT cups can be made by COs if needed as the NRRC is located within Dharavi. Antibiotic and Supplement Provision and Stock Flow CIPLA SNEHA Centre Office SNEHA Aahar Office (1) Community Organizers (79) Households of Malnourished Children Health Camps The amount of antibiotics CIPLA provides SNEHA depends on past trends in prescriptions at the camps. The shipments are made to the SNEHA Centre office in Chembur, Mumbai and picked up by Aahar staff to be delivered at the Aahar office. COs pick up a stock of medication from the SNEHA Aahar office and bring it to the community health camps. In the case that the doctor prescribes antibiotics or vitamin supplements to a child, they are typically given to the caregiver directly at the health camp. If there is insufficient supply of medication at the health camp, the CO will deliver the medication to the household by the following day. Mobile Logistics Prescription, pick-up, delivery, and consumption of MNT and antibiotics are monitored by COs using CommCare, an android mobile data monitoring application designed for community health workers. The Aahar CommCare application facilitates data-driven management of malnourished children at a community level. The application has reduced the burden of processing paper records and also supports COs in their routine visits children. Each CO can view certain case properties of each child in their coverage area on their mobiles, such as the child's screening nutritional status, their current status, their date of birth, and contact information. MNT, antibiotics, or nutritional supplement prescriptions also are stored in the case properties, which COs can view on their phones when picking up stock or visiting the homes of each child 3
The MNT module in the Aahar CommCare application consists of four forms to be filled out by the COs at specific locations. 1. MNT Pick-up: filled out at an Aahar MNT distribution point which is a space available near the COs coverage area. This form is case/child specific. It includes information on the expiry date of the cups and which supervisor is handing out the MNT cups. The form also provides the CO saved information on the amount of cups the child is supposed to receive. 2. MNT consumption filled out at the household level in the Dharavi community This form is case/child specific and is filled out at the home of a child currently on the MNT regimen. This form tracks whether a child has consumed the prescribed amount of MNT cups from the previous day and also includes recording and referral for any illnesses the child may be experiencing. This allows the team to understand which children are consistent consumers and which require additional attention. 4
3. MNT return at the distribution point or at the Aahar office where the MNT and antibiotic stocks are kept. A short form that only records the number of returned cups and the person to whom they are handed over. This information, along with the MNT pick up data, allows the office admin to keep track of stock outs. 4. MNT discontinued this is a form that is filled out only when the child is no longer taking MNT for over 2 weeks. This can be due to migration from the community or simply the family refuses to feed the child the MNT cups. Monitoring and Reporting Supervising staff regularly review the data entered by COs to monitor: o MNT and antibiotic prescriptions given at the health camps o MNT consumption in the community and thus defaulters and drop outs as well as cases with need of additional follow-up intervention. o Height and Weight of children, to assess the weight gain and nutritional status of children on MNT o MNT stock outs and returns CommCare has been particularly useful in generating data that helps the team take immediate action among cases of non-compliance or ensure alternative treatment for a malnourished child. Over time the data will allow Aahar to generate evidence of impact of MNT by investigating the contribution of MNT on weight gain and recovery of severely malnourished children. One of the main advantages of CommCare is that it is simple and easy to use--community health workers with basic training on the technology and smartphones can make commodity tracking for nutrition possible. 5