In 2005, an innovative strategy consisting of moving the treatment of severe acute malnutrition out of hospitals was expanded massively for the first time, and reached a record number of children.Ten years later, strategies to tackle other deadly diseases in Niger are combining with the fight against malnutrition in a public health approach.
Rahi Harouma is 40 and lives in Keleme, a small village in the Bouza department in southern Niger. It is November and the family has already collected all the harvest. “This year the size of the harvest was normal”, explains Rahi, sitting in the yard of her home, while her older daughters grind some grain to prepare lunch.
This is the most important harvest of the year and most families in Niger depend on it for survival. Nutritional crises are recurrent in the country, especially from June to October, when food stocks start to dry up in the period running up to the following harvest. The younger children are the first to suffer the consequences.
Rahi's husband is a farmer and they live with their six children; the youngest is Adbousidi, who is six months old. “With Adbousidi everything is easier. I take him to the health centre so that he can grow healthily”, says Rahi. The Keleme health post is one of six health facilities in the Tama area, where MSF has launched a project for the treatment and prevention of the main causes of infant mortality, malnutrition being one of them.
Rahi takes the baby to the health post for a check-up once a month. The health agent there checks that the child’s development is as it should be, administers any vaccinations that are needed, and also gives out some small sachets of prepared foods, one for each day, for babies aged from six months to two years. It is a small additional nutritional contribution designed to prevent children from suffering malnutrition.
“Right now there are about 3,200 children in the programme, that's virtually the entire population under 24 months in the area”, explains Emmanuel Goumou, head of the MSF programme. “Soon, the preventive and curative comprehensive care package programme (known by its French acronym as PPCSI) aims to provide comprehensive healthcare for all these children.”
The route taken
The PPCSI programme began last March, 10 years after the serious nutritional crisis suffered by Niger in 2005, and is yet another example of how the fight against malnutrition has evolved over the last decade.
Nines Lima, currently MSF’s malaria adviser, was a medical coordinator in the country back in 2005. “The scale of the emergency was huge and MSF was working in the worst affected areas. I was in Ouallam, in Tillabéri, where the number of malnourished children meant our work continued until December. We then went to Madaoua and Bouza in the Tahoua region, where there were many cases of malnutrition and no one able to cover the needs, and where we’re still working today,” she explains.
In 2005, ready-to-use therapeutic foods (RUTF), which enable home treatment of severe acute malnutrition without medical complications, were used on a massive scale for the first time. As a result, more than 69,000 children received treatment. “I was impressed by the intensive nutrition centres I visited in Zinder, where malnourished children with complications were admitted, because there were so many of them, more than 600 in two centres.It was like a town of malnourished children,” recalls Nines.
Since 2005, thanks to various medical and nutritional innovations, as well as Niger’s new health policies, the number of children with severe acute malnutrition who are treated in the country has not stopped growing – there were over 360,000 in 2014. These high numbers do not necessarily indicate that malnourished children are more numerous, but that the national coverage has improved. In 2013, there were over 800 facilities providing treatment for malnutrition in Niger. Moreover, the adoption of the new anthropometric measures to define malnutrition, which are more inclusive, automatically led to an increase in the number of children considered malnourished. Meanwhile, there has also been significant progress in tackling major childhood diseases such as malaria, which attacks malnourished children very aggressively.
Nines returned to Niger last year. “The great progress with malaria in recent years has been the implementation of seasonal malaria chemoprevention, which provides preventive treatment to children aged between three months and five years during the months of highest incidence of the disease”, Nines explains. “What’s more, we’ve worked to make it possible for simple malaria to be diagnosed and treated within the community by personnel with little training, thereby improving access and preventing the development of severe malaria”, he adds.
Children at the centre
The health authorities in Niger have also worked in the same direction, training health workers so that they can address the country’s main causes of death: malaria, pneumonia, diarrhoea and malnutrition. This strategy aims to alleviate one of the Nigerien health system’s main problems, which is the lack of doctors and nurses, especially in rural areas.
“Malnutrition remains a reality in Niger and should be treated from a public health viewpoint”, asserts Luis Encinas, head of MSF projects in Niger. “To combat it, we must work on a set of basic health measures aimed at the youngest children, as we are doing now in Tama with the PPCSI programme to help children to grow healthily.
Lessons learned in this decade
1) Severe acute malnutrition can be treated en masse.
Until 2005, children were systematically admitted for a one-month treatment. The introducion of ready-to-use therapeutic foods simplified the treatment and enabled it to be taken at home. In 2005, 300,000 treatments were sold worldwide; in 2013, were about three million.
2) More inclusive criteria to define malnutrition.
After analysing infant growth in eight countries on the five continents, the WHO published new anthropometric curves to address malnutrition. Thus, many children who before were considered as moderately malnourished - but at high risk of mortality - are now considered severely malnourished and receive treatment, making it easier to cure them.
3) Severe acute malnutrition particularly affects the youngest.
Among children under five, those aged between six and 23 months are the most affected by severe acute malnutrition; about 80 per cent of cases occur in this age bracket. With this data, programmes to reduce child morbidity and mortality increasingly focus on treating the youngest children.
4) Malaria and malnutrition, a lethal combination.
Malaria is one of the main causes of death in many countries affected by malnutrition. This occurs during the same time of year as malnutrition, leading to strategies that address both problems. For example, while a child receives seasonal malaria chemoprevention, their nutritional status is assessed and they are referred for treatment if needed.
5) Treat all the illnesses that a child has.
Malnourished children have very weakened immune systems and are less able to fight diseases such as malaria, diarrhoea and respiratory infections. At the same time, children with these diseases are also more likely to be malnourished. More and more programmes are trying to respond in a comprehensive manner to all the needs of children.
6) Decentralise and simplify treatment.
Simplifying the approach to the major childhood diseases allows health workers with minimal training to diagnose and treat them, at the health facility nearest to the child. Thus, only the most severe cases need to be referred.