Analysis of Nutritional Status in Tharparkar 2014
1
Nutrition Intervention in District Tharparkar
Analysis of Nutritional Status
In
Community-based Management of Acute Malnutrition (CMAM)
Project
March – August 2014
Collaboration:
Unicef, Sindh
World Food Program
District Government Tharparkar
Analysis of Nutritional Status in Tharparkar 2014
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Analysis of Nutritional Data
Community-based Management of Acute Malnutrition Project
March – August 2014
Analysis of Nutritional Status in Tharparkar 2014
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Acronyms
CMAM Community-based Management of Acute Malnutrition
HANDS Health And Nutrition Development Society
IYCF Infant and Young Child Feeding
MAM Moderate Acute Malnutrition
MCH Mother and Child Health
MUAC Middle Upper Arm Circumference
NGO Non-Government Organization
NNS National Nutrition Survey
OTP Outpatient Therapeutic Program
RUTF Ready to Use Therapeutic Food
SAM Severe Acute Malnutrition
SC Stabilization Center
TFP Therapeutic Feeding Program
Unicef United Nations Children’s Fund
WFP World Food Program
Analysis of Nutritional Status in Tharparkar 2014
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Acknowledgement
First of all let us thank Almighty ALLAH (Subhan-eh-Taala) who has blessed us with an
organization like HANDS that has provided us a wonderful platform to serve humanity and enable
us to contribute good deeds; to bring relief in the lives of drought affected people through
Community based Management of Acute Malnutrition interventions.
We would like to thank UNICEF, World Food Program for their financial assistance and technical
guideline throughout project period. We are grateful to Nutrition Wing Government of Sindh for
their technical guidance and valuable inputs. District Government Tharparkar played encouraging
role in implementing CMAM activities in selected union councils. We highly appreciated District
Health Department for being kind enough to provide premises and allow community based staff for
facilitating CMAM activities.
We are thankful and acknowledge the efforts of field teams and especially thankful to Dr. Satram
Roopani, District Executive Manager- HANDS Tharparkar, Mr. Ashfaque Baloch, District Project
Manager- CMAM who efficiently escorted the teams in carrying out all activities successfully.
We are fortunate to have technical input of Dr. Shaikh Tanveer Ahmed, Chief Executive- HANDS,
his timely guidance and supportive role throughout project period was key success. In addition, Mr.
Salman Arshad, Senior Manager Health program HANDS contributed gigantically in leading district
teams efficiently and kept all data secure for analysis and reporting.
Our special thanks to Ms. Rubina Jaffri – Senior General Manager, ME&R, Mr. Noor Muhammad
Baloch, Senior Manager- ME&R and team for developing efficient data recording and reporting
tools that helped us out in getting required data on daily, weekly and monthly basis.
Dr. Muhammad Sarwat Mirza Zulfiqar Ali Sario
Chief Research and Development Executive Senior Manager MER program
HANDS HANDS
Analysis of Nutritional Status in Tharparkar 2014
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Executive Summary
The Tharparkar has faced the drought due to low level monsoon rains, lack of measures to ensure the
food security, lack of fodder and disease among the livestock resulted in loss of large number of
animals. The situation analysis revealed the poor health and nutrition status of the women and
children.
HANDS with support of Unicef and World Food Program has initiated the community-based
management of acute malnutrition project. The project was implemented in 20 union councils of two
talukas Mithi and Diplo of district Tharparkar. During the project period from March to August
2014, total population reached by HANDS teams was 232517 in 560 villages. Total 50274 children
under 5 years of age were screened for malnutrition through MUAC (Mid-Upper Arm
Circumference) measurement. The malnourished children identified were 9570 (19%). This is
slightly higher than the overall Sindh data of malnourished children as revealed by the National
Nutritional Survey (NNS 2011). Among these malnourished children 52.5 percent were girls. The
severely acute malnourished children were 3018 (6% of the total children) and moderately acute
malnourished children were 6552 (13% of the total children).
The pregnant and lactating women were also screened for malnutrition through the MUAC
measurement. Total 26360 women were screened including 13627 pregnant women and 12733
lactating women. The malnourished women were 5037 (19.1%), that is also slightly higher than the
percentage of women (17.5%) revealed by the NNS 2011 for Sindh.
The children of severely acute malnutrition admitted to Out-patient Therapy Program (OTP) and
Stabilization center (SC) were 3018. Most of them 2008 (67%) were cured, 166 (6%) were defaulted
due to migration of the family from the area while 9 children were died at Stabilization center. The
cure rate is slightly lower than the standard cure rate of more than 75%. But 720 children (24%)
were still under nutritional treatment. The children who have been died were had many
complications as diarrhea, acute respiratory infections and dermatoses etc. Out of these children 64%
were girls and all were severely malnourished. The youngest child was of 4 months of age.
The food supplements were provided to all malnourished children, pregnant and lactating women.
Most of the distribution targets were achieved. The Infant and Young Children feeding program was
also implemented that included the nutritional guidance and counseling of the mothers and
promotion of breast feeding practices, promotion of intake of multiple micro-nutrients, iron-folate
supplements etc.
There is a need for continuation of the nutrition interventions in same geographical area and to cover
all population in district Tharparkar. In addition, there is a need for other nutrition sensitive
interventions to ensure the food availability and security at household and community level.
Thereby, long term programs may support to break the vicious cycle of malnutrition in this area.
Analysis of Nutritional Status in Tharparkar 2014
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Background
For many years Pakistan has had persistently high rates of acute malnutrition exceeding emergency
thresholds1. Rates of severe acute malnutrition (SAM) are particularly high with a national average
of 5.8%. Pakistan is second only to India in contributing to the global burden of SAM 2. The
majority of SAM cases are under 24 months with a notably high burden in infants1. Addressing the
persistently high burden of SAM through treatment and prevention programs is critical in meeting
the MDG 4 (reduction of mortality). It requires an integrated approach that is sustainable. The links
between food insecurity and acute malnutrition have been well documented2. In addition,
inadequate child care and feeding practices are a direct cause of acute malnutrition in Pakistan.
Tharparkar: District Tharparkar is facing serious drought situation over the last one year. The compromised
livelihood situation, due to a combination of factors including low level monsoon rains in 2013-14
and its impact on food stocks and the livestock situation, together with poor sanitary and hygiene
facilities, limited availability of clean drinking water, limited access to health care services and
likelihood of epidemics aggravated the nutritional situation further and there is rise in morbidity and
mortality being reported now in media.
Project Introduction: CMAM is a comprehensive approach for the management of acute malnutrition that includes the
management of severe acute malnutrition (SAM) in outpatient care (for children 6–59 months with
SAM without medical complications); SAM in inpatient care (for children 6–59 months with SAM
and medical complications, and children under 6 months of age with acute malnutrition); the
management of moderate acute malnutrition (MAM) (for children 6–59 months with moderate acute
malnutrition [MAM]); and community outreach for community involvement, early detection and
referral of cases for treatment, and follow-up of problem cases. The set of interventions included the
four CMAM components as
1) Community outreach
community mobilization,
screening of children, and pregnant and lactating women for acute malnutrition,
promotion of breast feeding
de-worming,
provision of multi-micro-nutrients for children, pregnant and lactating women,
provision of blanket distribution of supplementary feeding for children under 5 years of age,
pregnant and lactating women,
referral
1 National Nutrition Survey (NNS). Planning Commission/UNICEF/Aga Khan University, 2011
2 Based on a SAM rate of 5.8% and an under five population of approximately 21.4 million (180m pop),
Pakistan has an estimated 1.5million SAM cases
Analysis of Nutritional Status in Tharparkar 2014
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2) Outpatient treatment (OTPs)
For Severely Acute Malnutrition (SAM) children without complications;
community based treatment of severe and moderate acute malnutrition (Out Patient
Therapeutic Program-OTP
3) Inpatient treatment in stabilization centers (SCs)
Treatment of acutely malnourished children with medical complications to stabilization
centers (SC).
4) Management of moderate acute malnutrition (MAM) through IYCF counseling
promotion of infant and young child feeding practices,
Targeted supplementary feeding program (TSFP,
In early March 2014, rising numbers of clinical admissions and child mortality due to malnutrition
were reported in media got attention for humanitarian response by the world. HANDS have already
sensed the disastrous situation and planned to start CMAM activities in Tharparkar in early January
2014 with UNICEF and World Food Program and started nutrition interventions in Tharparkar in
March 2014
The district is administratively divided in to six Talukas as Mithi, Diplo, Islamkot, Chachro,
Nagarparkar and Dahili. Majority of the population located in all Talukas are affected by the
droughts and its effects. HANDS conducted the initial drought assessment of all 44 union councils
with support of UNOCHA during March 2014. Afterwards with support of Unicef, The Project
Objective is to improve access to Community -Based Management of Acute Malnutrition (CMAM)
and encourage adherence to IYCF among the under-five population of selected Union Councils in
district Tharparkar. HANDS started implementation in Targeted 20 Union councils of Talukas Mithi
and Diplo. The Total 46503 families were reached and screening of children and women was
conduct.
Table: Details of Intervention area
Variables Total Affected HANDS
Intervention
Total Population of
district Tharparkar
1346793 1346793 232517
Talukas 6 6 2
Union Councils 44 44 20
Villages 2188 2188 560
Households 269358 259946 46503
The project phase I started in March 2014, HANDS district teams started the community
mobilization in the targeted union councils. They initiated the screening of children under 5 years for
identifying the malnourished through Mid-Upper Arm Circumference (MUAC) measurement.
Analysis of Nutritional Status in Tharparkar 2014
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Progress Analysis:
Total number of the children under 5 years of age screened were 50274 in 560 villages. They are
well above (179%) the target proposed in the project. Out of those 53% were female children.
Graph: Status of targets achieved for screening of Children
Nutritional Status of Children:
The screening of the children was conducted by measurement of Mid-Upper Arm Circumference
(MUAC). According to the WHO standards the children more than 13.5 cm are of normal nutritional
status. The children with measurement between 13.5 – 12.5 cm are graded as mild nourishment or
have some risk of malnutrition. The children with measurement between 12.5 – 11.5 cm are graded
as Moderate Acute Malnutrition (MAM). These children require support Supplementary Feeding
Program. The children with measurement below 11.5 cm marked as suffering from Severely Acute
Malnutrition (SAM). Those children managed through Oral Therapeutic Program.
Table: Scale of MUAC for Malnutrition assessment
Scale Category of
Malnutrition Treatment
<11.5 cm Severely Acute
Malnutrition (SAM) OTP
11.5-12.5 cm Moderately Acute
Malnutrition (MAM) SFP
12.5-13.5 cm Mild Acute
Malnutrition (at Risk) IYCF
>13.5 Normal
The screening of total 50274 children revealed that 6 percent (3018) children were Severely Acute
Malnourished (SAM). It is slightly better situation than the 6.6% of children severely malnourished
0
10000
20000
30000
40000
50000
60000
Male Female Total
14349 13786
28135 23616 164%
26658 193%
50274 179%
Screened Children vs Targets
Targets Screened
Analysis of Nutritional Status in Tharparkar 2014
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in Sindh, as revealed by National Nutritional Survey 2011 report. There was no difference between
the female and male children. The Moderately Malnourished children were 13% (6552), slightly
higher in number than the overall Sindh data, that revealed 11% moderately malnourished children
(NNS 2011). But the overall malnourished children were 19 percent (9570), slightly higher than the
Sindh, that were 17.5%.
Graph: Malnutrition Status of Children
Malnutrition Management Activities:
Performance of OTP and Stabilization Center:
All Severely Acute Malnourished (SAM) children were referred to OTP (Out-patient Therapeutic
Program). They received the recommended doses of RUTF. All were followed weekly by the project
field teams. The children who got cured were 67%, while 6% were defaulted (migrated out of the
area with the family) and total 9 children died during the treatment.
Table: Trend for Cure, Defaulter & Death Rates
TFP Rate Tharparkar Mar-Aug
2014
Sphere Standard
Cured 67% > 75%
Defaulter 6% < 15%
Death 0.30% < 10%
The cure rate is slightly below the standard i.e. more than 75% children should be cured. Fortunately
the death rate is significantly lower than the expected, depicted the program effectiveness and
efficiency.
0
20
40
60
80
100
SAM children MAM Children Normal
6% 13%
81%
6.6% 10.9%
82.5%
Malnutrition Status of Children
Tharparkar NNS 2011 (Sindh)
Analysis of Nutritional Status in Tharparkar 2014
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At stabilization center, eleven children died during their treatment. Most of them were girls 7 (64%)
and 4 (36%) were boys. Nearly half of them were infants, and youngest was four months of age girl.
All children were severely acute malnourished with some complications including diarrhea, acute
respiratory infection and dermatoses.
Table: Age distribution of Children died
Age group of Children Number of
Children Percentage
chidren below 12 months 5 45.4%
13-24 3 27.3%
above 24 months 3 27.3%
Performance of SFP for Children:
In the Supplementary feeding program, the Moderately Acute Malnourished (MAM) children and
the Severely Acute Malnourished (SAM) children improved at OTP were enrolled. Then the
recommended feeding supplements provided to the children and regularly followed up by the field
teams.
During the project implementation period from March to August, total 6453 (98%) MAM children
were enrolled for SFP. Most of them 4521(70%) get cured while 1868 (29%) were under treatment
as the project concluded. Only 64 (1%) were defaulted as their parent moved out of the area for
different reasons.
Graph: Performance of SFP – status of children treated by SFP
4521 70%
64 1%
0 0
1868 29%
Status of Children treated by SFP
Children (m&f) cured
Children (m&f) defaulted
Children (m&f) Died
Children (m&f) Other
Children (m&f) Currentlyin Treatment
Analysis of Nutritional Status in Tharparkar 2014
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Performance of SFP for PLW:
The pregnant and lactating women were screened and out of them 5026 (98.5%) treated by
Supplementary Feeding Program. Total 3462 (68.2%) pregnant and lactating women were cured,
while 27 (0.5%) were defaulted (due to move out of the area) and 1573 (31%) were still getting
supplementary food for recovery.
Graph: Performance of SFP --- Status of PLW after treatment
Food Supplements Distribution:
The food supplement given to children were Ready to Use Therapeutic Food (RUFT) for children
with severely acute malnutrition, the Achamum was given to children with moderately acute
malnutrition. The Multiple Micro-nutrient sachet was given to all malnourished children. The total
number of food supplements supplied to children was higher than the estimated numbers. Total
535200 RUFT packets, 77436 kg of Achamum, and 33104 Multiple Micro-nutrient sachets were
provided to the children.
Graph: Status of Food Supplements distribution for Children
3426 68.2%
27 0.5%
1573 31.3%
Status of Women Treated by SFP
PLW cured
PLW defaulted
PLW Died
Children (m&f) Other
PLW Currently Registered
0
100000
200000
300000
400000
500000
600000
RUTF (# ofpackets)
MM Sachets(# packets)
Achamum forchildren (Kgs)
369266
29541 59083
535200 145%
33104 112%
77436 131%
Food Supplements Utilized by Children Target vs Achieved
Target
Achieved
Analysis of Nutritional Status in Tharparkar 2014
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The food supplements provided to the malnourished Pregnant and lactating women were Wheat
Soya Bean, edible Oil and Multiple Micro-nutrient tablets. Total 77810 kg wheat soya bean, 14108
kg oil and 444000 Multiple Micronutrient tablets were distributed among the malnourished pregnant
and lactating women.
Graph: Status of Food Supplements distribution to Pregnant & Lactating Women
Conclusion:
Tharparkar is a desert terrain, faced drought situation after every 3-4 years due to seasonal
variations. The current data revealed that the nutritional status of children and women is alarming,
and contributing in mortalities. There is a need to provide immediate relief through direct nutrition
specific interventions, especially focusing the most vulnerable women and children. These
intervention should be continued for a certain period until there would be food security and dietary
practices and nutritional status of children and mothers improved. To prevent the mortalities, the
health care services at community level and then at secondary care must be ensured.
The community mobilization through CSOs, technical and resource assistance from larger NGOs,
philanthropists and sustain measures by the Government must be continued for improving the
situation.
There is also need to plan short-term nutrition specific and sensitive interventions, to improve the
nutrition status of the children and women. But there is also need to ensure the food security at
community and house hold level, provision of improve water, accessible health services on long–
term basis.
0
100000
200000
300000
400000
500000
MM Tablets WSB for PLW(Kgs)
Oil for PLW(Kgs)
446000
97657
19531
444000 99.6%
77810 80% 14108
72%
Food Supplements Utilized by PLW Target vs Achieved
Targets
Achieved