FINAL REPORT

EVALUATION OF
INTEGRATED MANAGEMENT OF ACUTE
MALNUTRITION (IMAM)
&
INFANT AND YOUNG CHILD FEEDING (IYCF)
PROGRAMS

21st to 29th of May 2013

Yvonne Grellety – Hélène Schwartz

TABLE OF CONTENTS
I. INTRODUCTION ............................................................................................................................... 1
II. BACKGROUND ................................................................................................................................. 1
II.1 Organisation of the health sector ........................................................................................... 1
II.2 Nutrition situation................................................................................................................... 3
II.3 IMAM Protocol ........................................................................................................................ 3
II.4 Infant and Young Child Feeding (IYCF) .................................................................................... 4
III. SCALE-UP ..................................................................................................................................... 6
III.1 Integrated Management of Acute Malnutrition ..................................................................... 6
III.2 Infant and Young Child Feeding .............................................................................................. 7
a. Formation of the Mother Support Groups ............................................................................. 7
b. Community-IYCF training ........................................................................................................ 8
IV. METHODOLOGY .......................................................................................................................... 9
IV.1 Methods used ......................................................................................................................... 9
IV.2 Execution of the mission ....................................................................................................... 10
a. Selection of the districts for evaluation ................................................................................ 10
b. Selection of the health facilities............................................................................................ 11
c. Organization of the mission .................................................................................................. 11
IV.3 Constraints ............................................................................................................................ 12
V. EVALUATION FINDINGS................................................................................................................. 13
V.1 Implementing partners ......................................................................................................... 13
a. Activities ................................................................................................................................ 13
b. Constraints ............................................................................................................................ 15
c. Challenges ............................................................................................................................. 16
V.2 The District Health Management Team ................................................................................ 17
V.3 IMAM activities ..................................................................................................................... 21
a. Active screening .................................................................................................................... 21
b. Passive screening .................................................................................................................. 22
c. OTP ........................................................................................................................................ 23
d. Stabilisation centre ............................................................................................................... 26
V.4 IYCF activities ........................................................................................................................ 27
a. Operating mode of the Mother Support Group ................................................................... 28
b. Activities of the Mother Support Groups.............................................................................. 29
c. Sustainability of the Mother Support Groups....................................................................... 29

i
VI. CONCLUSION ............................................................................................................................. 30
VII. OVERALL RECOMMENDATIONS ................................................................................................ 31
REFERENCES .......................................................................................................................................... 32
ANNEX 1 – Calendar of the evaluation mission .................................................................................... 33
ANNEX 2 – IYCF interview questionnaires ............................................................................................ 35
Annex 3 – List of the IYCF monthly indicators ...................................................................................... 40
ANNEX 4 – Summary of the SC evaluation............................................................................................ 41

LIST OF TABLES
Table 1 – IYCF scores for Sierra Leone, 2010-2011 ................................................................................. 5
Table 2 – Number of health structures offering IMAM services (Scale up) by district and year, SL, the
number of patients treated and the use of RUTF per patient steps of implementation (source UNICEF
SL) ............................................................................................................................................................ 6
Table 3 – Methods used for data collection ........................................................................................... 9
Table 4 – IMAM and IYCF Characteristics of the districts visited.......................................................... 10
Table 5 – Implementing partners supporting the IMAM and IYCF activities in the 4 districts visited . 10
Table 6 – Number of health facilities and community members visited .............................................. 11
Table 7 – Activities implemented by each partner ............................................................................... 13
Table 8 – Summary of the evaluation of the OTP ................................................................................. 23
Table 9 – Some nutrition indicators, district of Bombali – Kenema – Moyamba, May 2013 ............... 24
Table 10 – Number of Mother Support Groups interviewed ............................................................... 27

LIST OF FIGURES
Figure 1 – Organogram of the Ministry of Health and Sanitation .......................................................... 2
Figure 2 – Steps followed to form and train the mother support groups .............................................. 7
Figure 3 – IYCF cascade training.............................................................................................................. 9
Figure 4 – Flow of RUTF from the order to the delivery at PHU level .................................................. 18

ii
ACKNOWLEDGEMENTS
We would like to thank the UNICEF Nutrition team (Faraja Chiwile, Mueni Mutunga, Arika Nagata,
Joseph Senesie, Hamjatu Daian Khazali and Walton Beckley) for their availability, the organization of
this mission and for the data and information sharing in regards to IMAM and IYCF programs in
Sierre Leone.

A special thanks to Arika Nagata, Joseph Senesie and Hamjatu Daian Khazali who accompanied us in
the field and help either with the data collection and/or translation during the mothers support
group interviews.

We thank all the partners (ACF, HEDO, SILPA and WHI) for facilitating the evaluation by coming to
the field with us and by answering our questions.

Thanks to the Nutrition Division of the Ministry of Health and Sanitation and their staff in the field
(District Nutritionists) for the open discussion we had regarding these 2 programs.

iii
LIST OF ACRONYMS
ACF Action Contre la Faim
ACT Artemisinin-based Combination Therapies
ARI Acute Respiratory Infection
BCC Behavioural Change Communication
BFHI Baby-friendly Hospital Initiative
BMI Body Mass Index
CHC Community Health Center
CHO Community Health Officer
CHP Community Health Post
CHW Community Health Worker
CI Confidence Intervals
c-IYCF Community-Infant and Young Child Feeding
CMAM Community based Management of Acute Malnutrition
CMV Combined Minerals and Vitamins
CSB Corn Soya Blend
CUG Close User Group
DHMT District Health Management Team
DHS District Health Sister
DLO District Logistic Officer
DMO District Medical Officer
DMS District Management Store
DN District Nutritionist
DSA Daily Subsistence Allowance
EBF Exclusive Breast Feeding
EPI Expanded Programme on Immunization
F75 Therapeutic Milk for Phase 1
F100 Therapeutic Milk for Transition Phase
FP Family Planning
GAM Global Acute Malnutrition
HEDO Human and Economic Development Organisation
HIV Human Immuno-deficiency Virus
IEC Information Education Communication
IMAM Integrated Management of Acute Malnutrition
IMCI Integrated Management of Childhood Illness
IMNCI Integrated Management New-born and Childhood Illness
IP International Partner
IPF Inpatient Facility
IYCF Infant and Young Child Feeding
LMIS Logistics Management Information System
MAM Moderate Acute Malnutrition
M&E Monitoring and Evaluation
MCH Mother and Child Health
MCHP Maternal and Child Health Post

iv
MICS Multiple Indicator Cluster Survey
MoHS Ministry of Health and Sanitation
MSG Mother Support Group
MUAC Mid-Upper Arm Circumference
NGO Non-Governmental Organization
NU Nutrition Unit
OJT On-the Job Training
OTP Outpatient Therapeutic Programme
PCA Program Cooperation Agreement
PHU Peripheral Health Unit
PWLM Pregnant Women and Lactating Mother
PMTCT Prevention of Maternal To Child Transmission
REACH Reinforce efforts to address child malnutrition
RUTF Ready to Use Therapeutic Food
SAM Severe Acute Malnutrition
SC Stabilization Center
SECHN State Enrolled Community Health Nursing
SFP Supplementary Feeding Programme
SMART Standardized Monitoring and Assessment of Relief and Transitions
SNAP Sustainable Nutrition and Agriculture Promotion
SST Supplemental Suckling Technique
SUN Scaling-Up Nutrition
TB Tuberculosis
TOC Training of Counsellor
TOF Training of Facilitator
TOT Training of Trainer
UNICEF The United Nations Children's Fund
WCARO West and Central Africa Regional Office
WFP World Food Programme
WH Weight for Height
WHI World Hope International
WHO World Health Organisation
WHZ Weight for Height Z-score

v
 I. INTRODUCTION
The Republic of Sierra Leone is divided into four administrative regions: the Northern Province, Eastern
Province, Southern Province and the Western Area; which are subdivided into fourteen districts (including
Western Area Urban and Western Area Rural); which are themselves divided into 149 chiefdoms.

UNICEF Sierra Leone has promoted the participation of NGOs in the implementation of development
programmes in the country. Since 2009, UNICEF supported the Ministry of Health and Sanitation in Sierra
Leone to scale-up high impact nutrition interventions in the country. Given the nature and constraints of
governmental Human Resource the involvement of NGOs was crucial if the scale-up was to be a success.
Since 2009, UNICEF has engaged 14 NGOs across the country and provided over USD 3,700,000 to partners
to implement nutrition projects [1].

Since 2009, Infant and Young Child Feeding (IYCF) and Integrated Management of Acute Malnutrition
activities (IMAM) activities are part of a single package promoted by UNICEF and partners in all districts.

An evaluation of the IMAM program was conducted in March 2010 [2] followed by a review of the existing
comprehensive framework for large scale promotion of adequate IYCF practices in Sierra Leone in May
2010 [3]. These evaluation / review provided recommendations to improve both IMAM and IYCF programs,
in terms of implementation and scaling-up.

The main purpose of the current evaluation is:

 To identify and understand the achievements and constraints of the UNICEF funded Nutrition
programme including the challenges faced by the implementing partners
 To assess the quality, effectiveness and sustainability of the programmes funded by UNICEF and
implemented by partners.

As the evaluation looked at the IMAM and IYCF programs separately, the findings are reported separately.

II. BACKGROUND

II.1 Organisation of the health sector

The health sector is based on a decentralized system, with representatives at national, regional, district and
community level.

The ministry of Health and Sanitation is divided in to two wings: the professional wing headed by the
Director General of Medical Services and the administrative wing headed by the Director General of
Management Services. Under the Director General of Medical Services, there are five technical divisional
directorates responsible of technical guidance. IMAM and IYCF programs are under the Primary Health
Care Directorate as illustrated in the organogram below:

1
Figure 1 – Organogram of the Ministry of Health and Sanitation

Honorable
Minister
POLICY

Deputy
Honorable
Minister

Director General Director General

of Medical of Management
Services Services
TECHNICAL GUIDANCE

Director of Director of Director of Director of

Director of Food Hospitals & Director of Human
Primary Health Planning & Drug & Medical
and Nutrition Laboratory Nursing Resources
care Information Supplies
Services
Program
Managers Support Services
(IMAM, IYCF, …)

14 District
Nutritionists Financial
Resources
OPERATIONS

(DHMT)

Community
Health Officer
(PHU)

The central level is responsible for development of health policy, strategic plans and formulation of
guidelines. It is responsible for resource mobilization, supervision, monitoring and evaluation of health
services.

There are 14 health districts in the country; each of them is run by a District Health Management Team
(DHMT). The DHMT under the leadership of the District Medical Officer (DMO) is responsible for the
planning, organization, management, implementation, monitoring and supervision of health programmes
in the district (with the exception of hospital and laboratory services). The DHMT is composed of: 1 DMO, 1
District Health Sister, 1 District Nutritionist, 1 Environmental Health officer, 1 WASH officer, 1 M&E officer,
1 Disease Surveillance officer and 1 Community Mobilisation officer.

In each district hospital is a Hospital Management Committee headed by either the Medical
Superintendent in the case of regional/provincial hospital or by the Medical Officer-in-charge in the case of
a district hospital.

At the community level, Peripheral Health Units (PHU) such as Maternal and Child Health Posts (MCHPs),
Community Health Posts (CHPs) and Community Health Centres (CHCs) are responsible for the delivery of
primary health care in those communities. The CHCs are headed by Community Health Officers, who also
supervise all health activities at the MCHPs and CHPs. In total there are 1,200 PHUs countrywide.

2
 II.2 Nutrition situation
A national nutrition survey was done from June to August 2010 based on SMART methodology and
showing 7.6% GAM (7.0 to 8.1% CI) and 1.7% SAM (1.4 to 2% CI) for a population of 5,746,800 (17.7%
represented by the less than 5yrs). If the survey is correct, this indicates between 71,000 and 82,000
children with GAM and 14,000 to 20,000 children with SAM.

A coverage survey was done by Valid International from February to April 2011. Only 3 out of the 14
districts surveyed achieved moderate coverage classification of point coverage: these were the districts of
Kenema, Pujehun and Bo. For period coverage, half of the districts reached moderate coverage (Bombali,
Kono, Kenema, Bonthe, Pujehun, Bo, Western Area Rural). However scaling up was the aim of the IMAM
programme in Sierra Leone in order to respond to the call for rapid scaling up as the advocated way
forward (see paragraph scaling up).

II.3 IMAM Protocol

The first attempts to create a national protocol for Management of Acute Malnutrition started in 2006. At
the end of 2007, the protocol was finally validated and an agreement to use ready to use product was
undertaken by the Ministry of Health, for in and out-patient treatment. This protocol was then revised in
2010 in order to incorporate the new WHO growth standards. This version was reviewed by the evaluation
team as part of the preparation of the evaluation. Here below are the main comments:

The topics are addressed in an appropriate order but the chapter on “monitoring and evaluation” is missing
and Regional recommendations given in the Dakar Report [4] are ignored. Even though the chapters are
well organised the protocol has been edited to introduce numerous contradictions and incoherencies
throughout the protocol.

In terms of moderately malnourished children, it is recommended that they attend a Supplementary

Feeding Programme in a health centre; however, this often overloads the work of the health team
unnecessarily; the appetite test as well as a CMAM number should not be recommended for this group of
children - it is not clear if both WHZ and MUAC criteria should be used or not for admission. BMI for MAM
in adults is very difficult to take and MUAC should be preferably used. A weekly ration is recommended,
which again overburdens staff, instead of fortnightly. Iron and folate is recommended to be given daily
instead of weekly – there is already quite a high dose of both iron and folate in the CSB. The target weight-
gain table as a criterion for discharge should not be used for SAM and was never used for MAM children.
MAM children should not be referred to the SC but to the paediatric ward and the IMCI protocols should be
used to treat these children. This section of the protocol needs to be completely revised.

In the chapter “OTP”, it seems that the protocol only admits children from 6 to 59 months of age; this
should not be the case. SAM patients of all ages should be treated, it would be unethical to refuse
treatment to a 6 year old child for example –This is in particularly the case for severely wasted HIV patients.
The appetite test is not precise enough to check for failure to respond to treatment and the other criteria
should be routinely checked. Two hundred kilocalories per kg per day is an excessively high daily ration to
dispense, this encourages sharing and as the average gain of weight for the cured patients is only 4 to 5
g/kg /day we know that their intake is at most 125 kcal/kg/d (see chapter “Evaluation Findings”, p.25)
which is not a lot compare to the number of sachets per week given. One hundred and seventy kcal per kg
per day is perfectly adequate and will save a considerable amount of RUTF (see IMAM generic protocol,

3
version 2011) - this recommendation was made in 2010 during evaluation mission conducted by WCARO,
but was either ignored or not accepted. The height should not be taken weekly. For routine treatment in
OTP, very high dose of Vitamin A is no longer recommended for SAM children and should not be given for
persistent diarrhoea – there is sufficient vitamin A incorporated in the RUTF, F75 and F100.
Chloramphenicol should not be used as a second line antibiotic treatment in OTP. Indeed, children who
need second or third-line antibiotics should be transferred to IPF (SC) and not kept in OTP. For the criteria
of discharge, it is not clear if MUAC or WHZ or both are needed. Where MUAC is used a cut-off of
>=115mm is far too low as a unique criteria of discharge and will result in large numbers of relapses.

In the IPF (SC) section of the 2011 protocol, it is recommended to take weight and height twice a day! This
is absolutely wrong. Height should only be taken one during the whole of the admission and weight once
per day. The MUAC criteria for admission of adults is inappropriately high (it is wrong). The number of
feeds in Phase 1 is limited to 6 feeds per day however some children need more than six feeds (in particular
patients with refeeding diarrhoea) and this needs to be added in the protocol. The Phase 2/rehabilitation
phase section of the protocol can be put in the annex as it is now rarely used, the patient being transferred
to the OTP at the end of transition phase. The recipes in the annexes for F75 & F100 are wrong in terms of
scoops of CMV: this is very dangerous - it is not 2 but ½ scoop per litre of reconstituted milk. The section on
“complications” is a straight “copy and paste of an outdated version of Pr. Michael Golden’s protocol”; this
has been substantially revised and updated and made available to both UNICEF and the Government of
Sierra Leone, this is not referenced and the concepts are omitted entirely. The antibiotic treatment needs
to be totally revised and additional common complications added. The chapter on infections does not take
into account the problem of SAM children. For the criteria of transfer from phase 1 to transition, the
patient should not be still on treatment of complications. Children less than 6 months old chapter is again a
straight copy-paste of an outdated version of Pr Michael Golden’s protocol and needs to be updated.

Conclusion: It is unclear why the protocol has been edited to introduce numerous mistakes, many of which
are confusing and some dangerous. Clearly the protocol needs to be revised urgently, no more staff should
be taught this protocol and scale-up should only be attempted after there is up-to-date protocol and clear,
unequivocal teaching materials available. The criteria of discharge for SAM children are dangerously low
and are far below all recommendations made by expert bodies (generic protocol and WHO); the treatment
of SAM in the OTP should not be strictly reserved for 6 to 59 months old children but for all malnourished
patients over 6 months of age. The antibiotics treatment in SC needs urgently to be revised1.

II.4 Infant and Young Child Feeding (IYCF)

The IYCF programming guide [5] developed by the Nutrition Section of UNICEF New York in 2011 mentions
that a comprehensive approach to IYCF involves large-scale action at national level, health system and
community levels, including various cross-cutting strategies such as communication and actions on infant
feeding in the context of emergencies and HIV.

1
In addition to the protocol, an abbreviated manual is used for the training of the OTP: this manual has many different versions
with edits. I was not able to check which was the latest one. Changes were made several times. This only serves to cause confusion
among the trainers and trainees. The existing manuals need to be revised and a single up-dated and correct manual distributed.
4
The government of Sierra Leone developed a National Guideline and Strategy on IYCF in 2009 that
recognizes and adopts the key elements of the Global Strategy on IYCF, the World Health Assembly’s
Innocenti Declaration for the Protection, Promotion and Support of Breastfeeding, and the International
Code of the Marketing of Breast Milk Substitutes (BMS) [6]. However, this document still needs to be
completed, updated and an action plan developed to operationalize this strategy. IYCF is also mentioned in
the Food and Nutrition Policy and Implementation Plan both documents developed in August 2009.

Regarding the health system level, lactation management training based on the Ten Steps of the Baby
Friendly Hospital Initiative (BFHI) and on establishing breastfeeding has been conducted in hospital and
PHU level; but, without a strong monitoring and evaluation system in place, this initiative has been barely
sustained.

In parallel, IYCF has been strengthened at community level where mother support groups have been
formed and trained first on BCC approaches and in a second time on c-IYCF counselling methods.

In 2010-2011, UNICEF New York conducted a comprehensive IYCF situation assessment in 65 countries [7]
that focused on 7 areas: National level IYCF actions, Health services IYCF actions, Community level IYCF
actions, Communication on IYCF, Complementary feeding interventions/components, IYCF in exceptionally
difficult circumstances and IYCF monitoring and evaluation. Each action areas were scored based on
performance and scores ranged from 0 to 10.
The scores for Sierra Leone are summarized in the table below:

Table 1 – IYCF scores for Sierra Leone, 2010-2011

2
Areas Score (/10) Qualitative results
National level IYCF actions 6 Fair
Health services IYCF actions 2 Poor
Community level IYCF actions 6 Fair
Communication on IYCF 6 Fair
Complementary feeding interventions 2 Poor
IYCF in difficult circumstances 5 Fair
IYCF monitoring and evaluation 4 Fair

While most of the areas need to be strengthened, it was stated that a special attention should be put on
the health services level and on complementary feeding interventions.

2
Colour scale interpreted as follows: Red = 0-3 [“Poor” – very low number of key IYCF actions implemented]; Orange = 4-6 [“Fair” – low number of
key IYCF actions implemented; Green = 7-8 [“Good” - average number of key IYCF actions implemented]; Purple = 9-10 [“Very good”– High number
of key IYCF actions implemented].

5
III. SCALE-UP

III.1 Integrated Management of Acute Malnutrition

Table 2 shows the scaling up by year since December 2007, beginning of the integration of IMAM in the
health structures. In June 2013, 50% of the health structures were offering IMAM services.

Table 2 – Number of health structures offering IMAM services (Scale up) by district and year, SL, the number of
patients treated and the use of RUTF per patient steps of implementation (source UNICEF SL)

Dec Dec Dec Dec Dec Dec May June Coverage

Districts PHUs
07 08 09 10 11 12 13 13 OTP/PHU

BO 117 0 5 12 21 21 21 21 58 49.57%
BOMBALI 101 5 5 11 21 21 21 21 51 50.5%
BONTHE 56 0 5 7 17 17 28 28 28 50%
KAILAHUN 79 0 5 7 7 14 14 14 40 50.635%
KAMBIA 65 5 5 7 10 10 34 34 34 52,5%
KENEMA 121 0 5 9 20 20 61 61 61 50.41%
KOINADUGU 68 0 5 7 15 15 34 34 34 50%
KONO 84 0 5 7 11 17 17 17 32 38.1%
MOYAMBA 94 0 5 7 15 15 40 40 49 52.13%
PORT LOKO 102 0 5 7 15 15 52 52 52 50.98%
PUDJEHUN 71 0 5 7 13 13 34 34 34 48%
TONKOLILI 96 5 5 10 16 16 16 16 48 50%
WESTERN AREA 105 5 5 7 33 41 53 53 53 50.48%
TOTAL structures 1159 20 65 105 214 235 425 425 574 49.53%
TOTAL patients
27,796 15,853* 33,753**
reported
RUTF procurement in
21,200 37,312 11,606
carton
*program only functional for 6 months
** monthly reports underreported

If the monthly reports database in 2010 was almost completed with the total number of treated patients,
in 2011 the IMAM program was suspended for a period of 6 months. In 2012, the number of OTPs
increased and also to scaling up; however the total number of patients3 were underreported in the
database due to missing monthly reports. Only the 2010 database can be used for further calculation. In
2010, about 0.76 carton of RUTF was used for each child treated, which is approximately the expected
usage. For year 2011 and 2012, it is impossible to calculate the consumption of RUTF due to the incomplete

3
database 2012
6
monthly reports’ database. To be able to accurately be aware of monthly reports missing, columns within
the database should be added: observed monthly reports - expected monthly reports - date of opening of
the centre, RUTF stock in – RUTF stock out – RUTF balance.

A verification exercise followed by verification of OTP caseloads took place in 2012 – 2013 in order to
improve the quality of the programme. Conducted by the MOH and UNICEF, it was done by students
trained for a period of 2 days and supervised by higher grades colleagues. The students participated in the
training with the field work and then took a test; each district had a different test. Surprisingly in
Moyamba UNICEF requested ACF to conduct their own verification and they came up with 20% cases that
were not supposed to be in the programme.

After this exercise in 2012, the amount delivered was cut by half due to the results of verification only in
the month after the verification. For the other month it was based on report from DNs which indicated
lower numbers than the request. This resulted in frequent stock-outs, due both to the reduction in
numbers as a result of verification but break in supply pipeline, inappropriate allocation by health staff
which lead providing small amounts to cases and late reporting. These interruptions of the program lead to
a totally inadequate amount of RUTF dispensed per treatment.

A training of the District Nutritionists in 2012 was conducted by Valid International (Anne Walsh) in order
to train them on how to make a projection of consumption. On-the-job training was recommended in 2012
except when new centres are opened (scaling up). The help of UNICEF for the scaling up training is of great
help for the concerned districts.

III.2 Infant and Young Child Feeding

a. Formation of the Mother Support Groups

Up to now, the way IYCF was implemented in Sierra Leone, do focus mainly on the community level and
not so much on the health facility level, due to a training ban in 2012 from the Minister of Health putting
on hold the training of the health workers. This is the reason why the steps described below are referring
mainly to the community level.

In October 2009, the implementation of IYCF activities started in 12 districts. These activities focused
mainly on the community level with the training of at least three mother support groups per chiefdom.
The training package included training on BCC approaches and training on BCC for various topics related to
nutrition, hygiene, diarrhoea and social aspects such as gender but did not include the IYCF counselling
package.

The training has then been expended to all districts in Sierra Leone and by December 2010 a total of 9
mother support groups per chiefdom were formed [3]. In 2012, the IYCF counselling package was
introduced to all MSG. In 2013, the plan is to scale-up the MSG nationally by having one MSG per villages.
This has already started in Moyamba district where 1429 MSG were trained. The steps followed to form
and train the mother support groups are summarized in the figure below:

Figure 2 – Steps followed to form and train the mother support groups
7
 Facilitate backyard Formation of MSG at community level (3 to 9 per chiefdom):
gardening • Chosen by the community
implementation • Volunteer
• Agree with the IYCF messages
Distribute seeds

Facilitate the creation

of village/group savings
and loan schemes to
Training of the members of the MSG on BCC by the IP
facilitate animal • Nutrition
revolving fund • Hygiene
• Diarrhoea
Provide counselling • Social aspects
cards and linkages with
nutrition sensitive
environmental
sanitation and hygiene Training of 2 members of the MSG by the IP on:
- CTLS • c-IYCF counselling
• Screening of SAM
Teach the members
how to make soap

Provide bicycle to the

community screeners
Training of the members of the MSG by the trained members on:
• C-IYCF counselling
• Screening of SAM (not all IP)

b. Community-IYCF training

In 2011, 4 UNICEF staff and 2 MoHS staff participated to a Master training on c-IYCF counselling in Nigeria
and Zimbabwe and formed a group of Master Trainers for Sierra Leone. Following this training, the group
organized a Training of Trainers for 24 participants (1 nutritionist and 1 supervisor per NGO and 1 MOHS
IYCF focal person) in Freetown.

In 2012, these trainers, after having exercised their counselling skills during field practice have trained 132
facilitators (9 monitors and 3 supervisors per NGO and 1 DHMT nutritionist per district) under the
supervision of the master trainers. In August 2012, the facilitators trained 18 members of the mother
support groups on c-IYCF counselling skills in each of the following districts: Kono, Kenema, Kambia and
Bombali. Another session of training took place in September in the remaining districts except in Bo and
Bonthe districts.

By end of October 2013, all formed mother support groups should have at least 2 members trained on c-
IYCF counselling package, meaning 2,700 counsellors in total for the country.

The trained members of the mother support groups have to realise 10 counselling sessions under the
supervision of the monitor/facilitator before being able to train the rest of the group on c-IYCF counselling
package. The counselling cards are distributed only to trained members.

The IYCF cascade training is illustrated below:

8
Figure 3 – IYCF cascade training

Pool of 4 Master Trainers (national level)

TOT – District level

NGO: 1 Nutritionist and 1 Supervisor + 1MOHS IYCF focal person
2011

Pool of 24 Trainers (national level)

TOF – District level Under supervision

NGO: 9 Monitors and 3 Supervisors + 1 DHMT Nutritionist of the master
trainers

Pool of 132 Facilitators (district level)

TOC – Community level Under supervision

2 members/mother support group, 9 MSG/chiefdom of the national
2012 / 2013

trainers

Pool of 2,700 Counsellors (community level)

TOC – Community level Under supervision

All members of the mother support group, 9 MSG/chiefdom of the Facilitators

Pool of Counsellors (nationwide)

In addition, CHW and the members of the MSG (in certain districts) have been trained to conduct active
screening of malnourished children in the community, either by organizing a screening session or during
home visits.

UNICEF and implementing partners are also planning in the coming months to train the health workers of
each PHU on the c-IYCF counselling package.

As mentioned earlier, lactation management training based on the Ten Steps of the Baby Friendly Hospital
Initiative (BFHI) and on establishing breastfeeding has been conducted in PHU level in 2009 but was not
sustained, mainly because of the vertical approach of this activity, UNICEF leading the process.
Consequently, this activity was not recognized by the MoHS as such and as soon as UNICEF stopped its
monitoring, the activity ceased.

To revive this part of the IYCF comprehensive strategy, plans have been set up to train graduated nurses on
IYCF and deploy them to the hospitals, with their main task (60%) being to focus on BFHI.

IV. METHODOLOGY

IV.1 Methods used

The UNICEF Sierra Leone office requested the support of WCARO to conduct an evaluation of the IMAM
and IYCF programs. The evaluation used a combination of methods, detailed in the table below:
Table 3 – Methods used for data collection

9
Qualitative methods Quantitative methods
Literature review
Individual interview Analysis of existing quantitative data (database)
Mother Support Group interview
Observation
The literature review included national documents including the nutrition policy, strategy and
implementation plans and documents held by the UNICEF Country Office. The interviews and observations
were done directly in the field and allowed us to triangulate these data with those obtained from the
literature review and the analysis of the quantitative data.

IV.2 Execution of the mission

a. Selection of the districts for evaluation

The districts were selected by UNICEF Sierra Leone, based on the level of scale-up for both IMAM and IYCF
activities, the presence or not of an implementing partner with a signed PCA with UNICEF and community
activities on-going until April 2013.

In addition to the health facilities included in this evaluation, one SC and one OTP were also visited in
Freetown.
The table 4 present the IMAM and IYCF characteristics of the districts visited.

Table 4 – IMAM and IYCF Characteristics of the districts visited

OTP
Number of Number of Number of Number of
IMAM Number of SC Geographical
chiefdoms PHU OTP SFP
Coverage
Moyamba 14 98 40 1 49 50%
Kenema 16 121 61 2 121 50%
Bombali 13 101 23 3 0 20%
Kono 14 84 17 1 5 20%
Number of
Number of Number of Number of Number of IYCF Scale-up
IYCF Community
chiefdoms MSG trained supervisors field monitors (MSG)
Screeners
Moyamba 14 1429 400 4 28 100%
Kenema 16 144 1120 4 16 <20%
Bombali 13 130 500 3 10 <20%
Kono 14 144 560 5 16 <20%

Both IMAM and IYCF activities started in 2008-2009 with the support of an implementing partner. Each
implementing partner covers an entire district and implements both activities, with an exception for
Moyamba district.

The table below gathered the implementing partners involved in this evaluation and give information on
the starting and ending date of the PCA with UNICEF:

Table 5 – Implementing partners supporting the IMAM and IYCF activities in the 4 districts visited

10
 End of PCA with
IP Supporting IMAM Supporting IYCF Started
UNICEF
Moyamba ACF CAUSE-Canada 2008 Dec 2013
Kenema HEDO HEDO 2009 Apr 2013
Bombali WHI WHI 2009 Apr 2013
Kono SILPA SILPA 2009 Apr 2013

b. Selection of the health facilities

The selection of the health facilities was done by UNICEF together with the district nutritionists and
implementing partners, depending on the day of evaluation visit and days which OTP was operational. If no
OTP was working in the district on the day of the visit, the evaluation team focused on checking the charts,
the knowledge of the officer-in-charge or nurse-aid and the stock of the nutrition products and materials.
We particularly visited PHU and MSG in both hard to reach areas and easy to reach areas.

The number of health centres with OTP activities, Stabilisation Centres (SC) and community members
visited is summarized in the table below:

Table 6 – Number of health facilities and community members visited

Number of OTP Number of Number of MSG Number of Number of

OTP visited activities the SC visited interviewed Community community
day of the Screeners members
visit interviewed interviewed
Moyamba 4 4 1 6 1 0
Kenema 4 4 2 4 1 1
Bombali 4 4 3 2 2 0
Kono 1 0 1 7 0 0

c. Organization of the mission

The mission lasted 14 days, from the 19th of May to the 1st of June. The two first days were dedicated to the
literature review and briefing sessions with UNICEF staff and partners supporting the four selected districts.
The evaluation team met with ACF, CAUSE-Canada, HEDO and WHI; SILPA was not present. The meeting
focused mainly on activities, opportunities, challenges and constraints faced by the implementing partner.

The field visit lasted 9 days, starting on the 21st of May. In each district visited, the evaluation team first
met with the DMO and/or the District Nutritionist to collect general information on the implementation of
the activities and the constraints and challenges faced by the district level.

Due to the short period of time allocated for the field visit and the specific expertise of the evaluation team
members, it was decided to split the evaluation team into two, each team focusing on one component of
the evaluation:

 Team 1 composed of Yvonne Grellety (Nutrition Consultant, expert in IMAM), Arika Nagata
(Nutrition Specialist – UNICEF Sierra Leone) and Joseph Senesie (Nutrition Officer – UNICEF Sierra
Leone) focused on the IMAM activities
11
  Team 2 composed of Hélène Schwartz (Nutrition Specialist – IYCF Regional Focal Point UNICEF
WCARO) and Hamjatu Daian Khazali (Nutrition officer – UNICEF Sierra Leone) focused on the IYCF
activities and in particular the community component.

However, in order to cover the four districts and bearing in mind that the link between the two activities is
crucial, the evaluation team visited two districts together (Moyamba and Kenema) and then split so the
team 1 went to Bombali while the team 2 went to Kono. The calendar of the mission is detailed in Annex 1.

In each district, the evaluation team was accompanied by the District Nutritionist and the IP.

For the interview, the evaluation team completed specific questionnaires for each activity assessed (see
Annex 2), as described below:

 DHMT: Programme questionnaire for the District Nutritionist

 IMAM4: 1) OTP questionnaire for the out patients’ management, 2) SC questionnaire for in-
patient care,
 IYCF: 1) Mother support groups questionnaire, 2) Community Screener questionnaire.

Due to logistic and organizational reasons, the health facilities, the mother support groups and community
members were informed in advance of the evaluation visit.

For the interviews at community level, questions were asked in English and translated in the local language
by the UNICEF Nutrition Officer. Answers were written directly onto the questionnaire forms.

IV.3 Constraints
The short period of time in the fields and the lack of prepared documents concerning the IMAM5
programme slowed down the whole process.

The evaluation took place in 2 of the 3 districts visited in 2010; Moyamba had not been evaluated before.
One OTP and three SCs were previously visited in Kenema district and Freetown.

The OTPs were chosen because of the day they were open. This allowed us to see them functioning but it
was also difficult to question the supervisors who were busy with patients; this slowed the evaluation
process.

The SFP programme had to be limited to the ex-SAM follow-up in 2 of the 3 districts and it was never the
SFP day during our visit. There was no SFP in Bombali.

4
The IMAM questionnaires used were based on the supervision checklists developed in the IMAM generic protocol.
This was done on purpose in order to field test these checklists
5
The 2 verification reports, the audit report, the training material for the District Nutritionist, the latest edition of the
IMAM abbreviated manual
12
 V. EVALUATION FINDINGS
Since 2009, UNICEF supported the Ministry of Health and Sanitation in Sierra Leone to scale-up high impact
nutrition interventions in the country. Implementing partners were involved in the scaling-up of IMAM and
IYCF activities since the beginning but due to funding constraints, UNICEF Sierra Leone stopped the
partnership with most of the NGOs in April 2013. This will certainly have a significant impact on the
programs, but it is too early now to assess the magnitude of this impact.

In this part of the report, we will try to answer the questions raised in the ToR namely achievements,
constraints and challenges faced by the IP on one hand and quality, effectiveness and sustainability of
these activities on the other hand.

V.1 Implementing partners

The implementing partners in the 4 districts visited are namely: ACF and CAUSE-Canada (Moyamba
district), HEDO (Kenema district), WHI (Bombali district) and SILPA (Kono district).

As mentioned earlier, each partner covers an entire district for both IMAM and IYCF activities with an
exception in Moyamba district where two implementing partners are working together. Up to December
2012, ACF was in charge of the IMAM activities and CAUSE-Canada of the IYCF activities including the
community screening. However, following a SQUEAC survey showing low coverage rate of the IMAM,
CAUSE-Canada handed over the screening activities to ACF.

a. Activities

The five implementing partners for IMAM and IYCF (ACF, CAUSE-Canada, HEDO, SILPA and WHI) started
their support to the nutrition activities in 2009.

The expected results of the cooperation stated in the last PCA are:

1. Increased coverage of community mobilization activities with special emphasis on hard to reach
communities
2. Increased quality of OTP services as per national standards in XX PHUs with OTPs in the targeted
district
3. Increased MSG capacity of IYCF counselling for mothers with children under two years
4. Increased community involvement in the promotion of exclusive breastfeeding and appropriate
complementary feeding practices
5. Support to the MOHS routine MCH week campaigns and world breastfeeding week activities

To reach these goals, the IP implemented several activities both at community and health facility level. The
table below lists the principal activities implemented.

Table 7 – Activities implemented by each partner

ACF CAUSE- HEDO WHI SILPA

Canada
OTP supervision    

Transport/voucher for transfer   

End-user monitoring of RUTF     

13
Organize and facilitate training for 
  
the MSG (2 members by group)
Facilitate MSG meeting    

Monitor counselling sessions 

  
during home-visits
Food demonstration    

Backyard gardening    

Provision of seeds    

Village or group saving loans    

Monitoring of the community 

  
screeners
Screening of SAM done by the MSG 
 
members
Soap making 
Provide IYCF counselling during
 
school visits

From this table, we can notice three main differences between the 5 implementing partners’ strategy:

 As mentioned previously, CAUSE-Canada is not involved in the IMAM activities. The monitoring of
the OTPs and the community screeners is done by the IMAM implementing partner (ACF).
 SILPA has started to train some MSG on income generating activities like soap making which allows
the MSG members to sell the soap and/or use it for hygiene sensitisation sessions.
 Both CAUSE-Canada and SILPA are involved in school sensitisation sessions on IYCF targeting the
teenage mothers and fathers in the secondary schools.

In term of community screening, each implementing partner supervises several hundred of community
screeners. Those are all volunteers and are asked to conduct active screening on a quarterly basis. Except in
Moyamba district, most of the community screeners are part of the MSG (in communities where there is a
MSG) and therefore benefit from the activities in place in the group.

From the interviews conducted in the field, it appeared that having one partner supervising the community
screening and another one supporting the MSG is not ideal in term of strengthening the link between the
community and the health facilities. Four MSG out of six interviewed in Moyamba district did not know the
existence of the community screeners while in the other districts the community screeners if not part of
the MSG were at least known by the MSG members. The role of the community screener is fundamental to
ensure that malnourished children detected in the community are referred to the nearest PHU and
followed by the MSG.

To extend the sensitisation on adequate nutrition practices in the secondary schools is a huge opportunity
to sensitize adolescents on the importance of good feeding, especially in districts where teenage
pregnancy is high (Moyamba and Kono district are one of them). This strategy should certainly be extended
to all districts.

14
In term of monitoring, each partner has a nutritionist dedicated on monitoring and supportive training of
the health staff responsible of the OTP activities. One of their roles is also to supervise the supply chain,
making sure that the requested quantity of RUTF and drugs are delivered at the district level and on to the
health facility level. They also have 1 IYCF monitor per chiefdom based at community level and at least 1
IYCF supervisor covering 4 chiefdoms. Apart from collecting the community screeners’ report, the monitors
are reporting on 11 indicators on a monthly basis. The indicators are listed in the Annex 3.

The monitors are responsible of participating to the MSG meeting at least once a month, facilitating group
sessions and supervising the community screeners’ activity. The number of the MSG meetings varies from
one to four meetings per month, depending entirely on group’s decision. This close monitoring which
seems heavy for the IP is key for the success of the MSG activities. When looking at the MSG formed in
2009 in Kono district (these MSG were the most advanced in term of group management) intensive
monitoring activities are needed on at least 4 to 5 years before the MSG starts to be autonomous.

Besides the monitoring done by the IP, UNICEF Sierra Leone has started to implement decentralized
monitoring for nutrition activities by conducting a baseline (beginning of the UNICEF PCA) and an endline
(end of the UNICEF PCA) survey using rapid evaluation methodology [8]. It allows following the IMAM and
IYCF indicators’ evolution on a yearly basis and having an estimate of the program’s coverage. This tool was
elaborated and used for the first time in 2012, it is therefore a bit early to evaluate it but it can certainly be
used to re-orientate the activities if needed privileging those that do not positively evolve. It is an
interesting tool that would deserve to be evaluated after a longer period of use.

Recommendations for UNICEF and IP:

 Community screeners should be part of the MSG and monitored by the IYCF implementing partner
 Extend the IYCF sensitization to secondary schools in all districts
 Exploit further the decentralized monitoring tool

Recommendations for IP:

 Keep doing intensive monitoring of the MSG and community screeners

 Decrease the intensity of the monitoring for those who acquired good group management skills
and train new ones (based on demand)

b. Constraints

When interviewing the implementing partners, the main constrain for them is the lack of transport
especially for the IYCF monitors. On average a monitor is responsible of 9 MSG and even more in districts
where the IYCF activities were scaled-up. Some of them were provided with motorcycles but not all of
them which do not facilitate their tasks especially in hard-to-reach areas.
The lack of transport is also a challenge for the community screeners as they are covering several
communities/villages. Some of them received bicycles but the maintenance of those seems to be a real
challenge. All the community screeners interviewed reported that their bicycle was out of use.

15
The lack of proper funds is equally a constraint. Most of the implementing partners entirely depend on
UNICEF fund to run the IMAM and IYCF activities which represents a major obstacle to the sustainability of
these activities. As long as IMAM and IYCF will not be included in the pre-service curricula, monitoring and
supportive supervision are essential to ensure a minimum quality service. The district nutritionists having
no transport from the district (only the region has vehicle) rely almost entirely on the IP for supervising
activities. Without UNICEF fund, the monitoring and supervision of the nutrition activities will stop which
will be detrimental for the nutrition program.

c. Challenges

One of the main challenges faced by the implementing partners is how to monitor the nutrition activities
and ensure good quality services when scale-up at district level. For instance, in Moyamba district, CAUSE-
Canada has to monitor 1429 functional MSG, while HEDO in Kenema has to monitor 1120 community
screeners.

Long distances are also a major challenge knowing that in some district it could take more than 3 hours’
drive to reach a PHU from the main town. The existing OTP facilities are insufficient to cover an entire
district particularly in remote areas resulting in high defaulting of caregivers. In addition, during the rainy
season, some hospitals, PHU and communities are completely isolated due to roadblock.

Incentives seem to create problems especially where there is a partner giving monetary incentive. Apart
from the MSG interviewed, one of the IP reported that some members are leaving the MSG to join another
community group where they receive monetary incentive.

The government is about to endorse a CHW strategy that would probably help to regulate the incentives
given to the community workers. However, if this strategy is endorsed as it is actually, it will still let room
for discrepancy.

Extract from the CHW strategy [9]:

Motivations for Community Health Workers are both monetary and non-monetary. CHWs are Volunteers.
However, MoHS recommends that they ALL receive a standard minimum motivation package. The MoHS
has defined this minimum motivation package to include, for purposes of identity, standardised T-shirt,
badge, caps; and for cultivating a sense of achievement, certificates/awards and letters of recognition.

Recommendations for UNICEF:

 Keep supporting (financially and technically) the IP for the nutrition activities (IMAM and IYCF)
 Provide motorbikes to IP monitors especially in districts where IYCF are planned to be scaled-up
 Advocate with the MoH to ensure that district nutritionists can get a transport for monitoring and
supervision visits
 Organize exchange visits between partners to allow knowledge sharing

16
 V.2 The District Health Management Team
We visited the DMO and the DN in each district; in Kenema and Bombali districts, we met the same DN in
2010. The DN’s job description is in the Ministry of Health and Sanitation National Operational Handbook
for Primary health care 2004. In Kenema and Makeni, the DN had their own vehicle because they are
regional/ district towns. As only the DN of the region is supplied with a vehicle, the DN of Moyamba and
Kono districts had no dedicated transport. They all had one or two focal points according to the size of the
district. The 4 DNs were trained on IMAM and two of them (in Moyamba and in Kono) were trained on
IYCF. Supervisions are made with or without the help of the International Partner (IP) and because of the
proximity of the SC, the DNs regularly do supervision visits to the SC.
The high rotation of staff is a real concern for each district for both the SC and the OTP. This is the concern
of several DHMTs - but there is a large variation between districts. For example the DMO of Bombali stated
that in the coming year 40 MCH aids will leave to join the SECHN school of nursing, and there will be
attrition of staff for other reasons as well. Transfer to the nursing school is so attractive that the DMO
considers that it will paralyse the health system of Bombali and not only prevent further scaling up of
nutrition services but may jeopardise all the programs offered by the health system. If undue emphasis is
given to scaling up nutrition then this has the potential for all the other functions of the health service to
be scaled down due to lack of human resources. However, he stated that it would only last for this coming
year6. There is a real urgency to integrate nutrition in general and the protocol in particular into both the
school of nursing and the curricula of the doctors. It is partly done but not adequately or totally. If this is
done, then when the newly trained graduates will augment the system and at that stage make scaling up,
whilst maintaining quality, feasible. Scaling up has to take into account the availability of trained staff to
understand and implement the program without compromising all the other equally essential services (eg
vaccination, IMCI, Maternal health, etc.). The new assigned staff have to be trained on-the job by the DN
with the help of the IP nutritionist.

The transport of the patients from the OTP to the SC is facilitated by travel voucher given by the IP7. Free
communication is implemented by the NGO MRC for Bombali district and by CUG (Close User Group) for
Kenema.

A problem is that the SAM number is changed at each step of the treatment if the child goes from OTP to
SC and then back to OTP. It is not clear how many times he/she is counted as a new admission; it is
certainly minimized due to the supervision of the DN and the IP but this point should be addressed.

The monthly reports are usually submitted on time at district level according to the DN. However the
database of 2011 and 2012 are incomplete and impossible to verify because the date of opening of the
OTP/SC as well as the expected and the observed monthly reports are not recorded. There are often stock-
outs of RUTF and this information is also missing in the database.

A list of the materials that need to be replaced was prepared and the material is to be distributed according
to the Food and Nutrition Directorate and UNICEF-Freetown.

6
The MoHS will stop the aid nurse to join the SECHN school in 2014.
7
Except in Kenema where the PCA with HEDO stopped.
17
The Supplementary feeding programme was implemented in Moyamba, Kenema and Kono but not in
Bombali because of the SNAP programme. Surprisingly, the programme is rationed by limiting it to admit
20 children per month whatever the magnitude of the needs or numbers of patients. The SF program only
uses the WH chart; there were frequent stock-outs of products in 2012 (despite the ethically questionable
decision to ration the program irrespective of needs).

District monitoring and supervision and the RUTF consumption

The “Free health care” initiative is in charge of the transport and delivery of the RUTF from the central to
the district level; the DMS is in charge with the DN and the DLO to deliver the RUTF to each PHU since
2010. But at the moment the responsibility is still under the responsibility of the FHCI.

The projection of RUTF needs is made by the DN who contacts the Food and Nutrition Programme MoHS
(CMAM officer for OTP) if there is a problem of shortage. She is supposed to transmit the information
immediately to the UNICEF team in Freetown (see figure 4).

Figure 4 – Flow of RUTF from the order to the delivery at PHU level

UNICEF:
check of the
NU: CMAM projection by
2 the Nutrition Free HC
Officer check of Supplies
Freetown the projection 3 Team (cartons)
(sachets)
by the DN
4 5
(cartons)

1 month
1

District DN: Projection DMS: arrival of the

supplies (sachet)
6
Readjustment = 2 mo +
according to the 1 mo Bufferstock
7
supplies (cartons)
3 to 4 wks
8
OTP
Supplies to PHU
in carton

Everywhere we went stock-outs were a major problem. The DN and the IP were very well aware of the
situation; however UNICEF and National Food and Nutrition Programme MoHS was often not informed (for
example in Kenema and Moyamba districts). UNICEF thought that there was a one month buffer stock in
the District Management Store (DMS) whereas in reality there was no buffer stock in Moyamba and only a
few cartons of RUTF in Kenema (and no F100 in stock). According to UNICEF, the DN and the IP were
supposed to immediately remake a new projection of supplies when they found out that there was no
buffer supply in the DMS. This was not the case and remained unsolved. The DN had sent an e-mail to the
person in charge in the National Food and Nutrition Programme MoHS in Freetown but no action had been
taken.

18
The DN did inform her senior advisor at the National Food and Nutrition Programme MoHS by email.
However, connection, communication problems, mismanagement of the email inbox, overwhelming work
load or other problems handicapped the whole programme and brought it into disrepute with the
beneficiaries. It would be inappropriate if all relied upon one functionary – and the program would halt if
this person was ill, on leave, attending meetings or absent for any other reason. Exchange of information
between UNICEF, the Nutrition Unit and the concerned partners (IP) for stock-out should be a priority –
and a “hot line” should be established. A surveillance system of the stock out as well as the flow of patients
has to be reinforced: Free health care – MoHS – UNICEF.

Confusion, difficulties and disagreement also arose between the different partners because of the software
used: the software of the MoHS calculated the delivery of RUTF in sachets and the projections made by
UNICEF and MoHS were in sachets and then rounded to cartons. This created problem of readjustment:
“Free health care” had to readjust quantities in sachets to cartons and the central store had to open
cartons of RUTF to adjust the quantities back to sachets. Then the District Logistic Officer and the DN had
to readjust the projections made by the DN, UNICEF and the NU for the delivery when it reaches the DMS
and afterwards the PHU.

Due to previous excessive use of RUTF, a verification exercises was undertaken in all the districts and
consequently a decision was made to decrease the deliveries by up to one half (it is unclear who was
responsible for this decision with the potential for destroying the program). A lot of centres had their
supply suddenly reduced by 50% as a penalty. This step mainly impacted the patients and their families
within the districts. For example, the consumption was calculated as 80 sachets per month per child. If the
caseload at the end of the month was 20 according to the monthly report, the new consumption was 80
sachets*20 patients*3mo. = 32 cartons, and this was then reduced by half if the “verification report”
showed 50% less caseload during the verification exercises done by the students. The quality of the
students’ data does not appear to have been assessed8.

We were asked if it is not possible to extrapolated survey results to calculate the caseload. However,
according to experts, this is very inaccurate, nearly always overestimates the caseload and does not take
into account changing circumstances since the precise time of the survey – for example the effect of
seasonal changes in caseload. Thus, the only way should be by close supervision, verification that there are
no “ghost-patients” or double registration and on job training.

Conclusion

The DNs are the key persons for supervision and on job training; without this cadre of staff the program
will not succeed. In each of the 4 districts visited fuel or vehicle problems were frequent impeding their
ability to undertake supervisions visits; in particular for isolated OTPs or SCs.

8
The students were trained for 2 days with one day practical session; a test was administered and only 10-15 out of
30 who performed well were selected to participate. 2-3 top candidates were selected as supervisors. UNICEF staff
provided spot check in most places including Moyamba.

19
Scaling up presented an opportunity to retrain the newly allocated staff within the structures and the new
OTPs.
To minimize the detrimental effect of rotation of staff the only way is to integrate the IMAM protocol and
the pathophysiology of severe malnutrition into the curricula of all the health professionals involved:
nutritionists, nurses, aid nurses and doctors.
It should be recognised at every level from the Minister of Health to the most peripheral worker that a
stock-out dramatically affects defaulting, enrolment and coverage detrimentally, but it also disrupts the
treatment of the most vulnerable children and will cause death.

Recommendations for UNICEF:

 Keep the support of the IP to help the DN to supervise the opening of the new OTPs and conduct
OJT until the scaling up and the rotation of new untrained staff is established.

 Add to the monthly report database the expected and received monthly reports, the date of
opening of the centres and the RUTF consumption (Stock-in, stock-out, balance)

 The RUTF delivery should be for a 3-month period in the PHU: each delivery has a cost particularly
during the rainy season and the length of time for delivery is increased.
 The stock should be calculated taking into account the variable used by the MoHS software
“challenge” (in sachet) after calculation of consumption in sachet rounded into cartons to avoid
opening of cartons before dispatch from Freetown.

 A “one month buffer-stock” is an absolute necessity in the district and the PHU. The different steps
of the logistic channel have to be taken into account: it takes at least one month from ordering
from a PHU to receipt of the delivery. If it is ever decided again to reduce by 50% the quantity
according to the verification exercises, first there should be total transparency of these exercises
conducted by the students after a 2 days training, second, the student data should be checked
independently and third the penal reduction should be removed as soon as the monthly reports
become realistic and the consumption and becomes approximately 0.75cartons per child treated
and lastly the problem should be corrected at the concerned level and not applied as a blanket
penalty upon the whole program9.

 OTPs with bad performance should be clearly identified and OJT and supervision visits intensified

Recommendations for the MoHS

 Elimination of dysfunctions including stock-outs, delayed replacement of materials, failure to

allocate fuel for supervision, inadequate training and replacement of trained staff with

9
For example, the consequence of the verification report was 50% reduction in the districts of Kenema and Bombali.
20
 inexperienced and poorly trained staff (rotation) should be the key priorities that the DN should
focus on with the DHMT and the higher authorities10;
 Allocate a vehicle for each DN with allocated fuel as long as inadequate pre-service training is in
place according to the turn-over of staff and the scale up of the OTP and SC.
 Implement monthly standardised report for the DN’s achievements to improve the coordination
between national and district level.

 Need of a specific strategy when there is a stock-out of therapeutic products at district level but
also at SC and OTP. There is no point to scale up and then to have increased frequency of stock-
outs in the districts because of an increased strain on the logistics.
 The supplies of the material should be distributed as soon as possible: poor quality materials
increase mistakes.

 Scale up should not be attempted when there is a high rate of rotation of staff with replacement by
inexperienced and untrained persons.
 To minimize the detrimental effect of rotation of staff the only way is to integrate the IMAM
protocol and the pathophysiology of severe malnutrition into the curricula of all the health
professionals involved: nutritionists, nurses, aid nurses and doctors.

Recommendations for PHU and hospitals

 Attribute a SAM number on ALL the tools including the growth monitoring chart of the child after
clear definition of the SAM N° - Do not change every year to 01 again without adding the last 2
numbers of the year for the registration number ex: 024-12 for year 2012 if the registration
number is 024.

V.3 IMAM activities

a. Active screening

The community screening is done by volunteers called “community screeners”. They are not receiving any
incentives but some were given bicycles from the IP depending on the distance they have to cover to reach
the villages they are responsible for. Their main task is to conduct active screening at community level once
quarterly. Most of them do report on screening activities to the implementing partner, consisting mainly on
communicating the number of children screened and among them the number of children moderately and
severely malnourished. When detecting children with acute malnutrition (moderate or severe), they refer
them to the nearest PHU. Unfortunately, except in Moyamba district, they do not fill any referral form

10
Without this being on a firm footing it will not be possible to roll out or scale up the programme without
considerable help from several International/implementing Partners who have the necessary expertise
21
when they refer a child. It is therefore extremely difficult to evaluate their work as we do not have any data
on the number of children referred who effectively reach the PHU and the number of children correctly
diagnose as malnourished.

Active screening is also done by some members of the MSG but there is no report nor referral slips used.

Recommendations for the IP:

 Provide referral slips to the community screeners and ask the officer in charge in the PHU to collect
and keep them
 Periodically analyse the screening data against the referral slips

b. Passive screening

The passive screening information is recorded in the U5 clinic registration book; weight and height are
measured for each child less than 5 years of age and then WHZ is calculated, however this last step is often
not completed because of the workload, time constraints and also because of the lack of training or/and
rotation of staff: in 2 of 4 PHUs visited the column in the register was blank and the WHZ was not
calculated or calculated later. Also the MUAC was not part of the routine screening and if taken was not
written in the register because of lack of space.

Often drugs were prescribed without taking into account that this child was a SAM child and that some
standard treatments and dosages were harmful for these patients. The SAM screened child sometimes was
not automatically referred to the IMAM programme and recorded in the OTP register. There also was no
link between the community screeners’ referral and the passive screening register.

Recommendations:
 MUAC should be the PRIMARY method used for passive screening; only children with a MUAC less
than 125mm should have their Weight and Height taken and their Z-score calculated11.

 All the staff should have personal MUAC tapes supplied to them
 The link between the community screeners and the passive screening and the IMAM programme
should be established and documented;
 The administration of drugs for SAM children should not be addressed in the U5 register but the
child should be referred to the OTP programme immediately.

 The register should be adapted to a more efficient screening strategy.

11
This is particularly important for children going to the U5 clinic at hospital level and sent as SAM in the Paediatric
Ward (see the generic protocol version 2011).
22
 c. OTP

The summary of the evaluation for Moyamba, Kenema and Bombali districts is presented in table 8 and 9.
Kono district was not included because the team in this district concentrated mainly on IYCF activities. The
OTPs were visited during their day of operation where possible: we were then able to verify the number of
patients and estimate the caseload at this time of the month and to compare it with the previous monthly
report. The interviews were done during the consultation which was sometimes not easy for the staff or
the supervisor of the OTP because of their workload.

Table 8 – Summary of the evaluation of the OTP

Staff running the OTP MCH aid or SECHN with CHW/Community Screeners
Training All trained in the last 2 years
Protocol In Moyamba = 4/4 – Kenema: 3/4 – Bombali: only posters or abbreviated
manual
Tools In almost all the OTP, some materials had to be replaced (length board - old
MUAC.)
Referral No information on how the child came to the OTP
Flow of patients - organisation Lack of organisation in particular for some centres: taking the weight using pans
– note the weight on a piece of paper and then mixed with other: mistakes
were found in 6 of 11 OTPs visited.
Criteria of admission No major error in the calculation: 4/193 error which is very good;
Admission MUAC average MUAC: 108mm
Admission WHZ average WHZ: -3.1
Number of oedema cases 10/193 = 5% with a higher number in Bombali and after Moyamba
Appetite Test (AT) The AT is often qualified as “Good” on the charts even if children died the next
day or went to the SC. The AT needs more explanation. And was inadequately
administered.
Respiration rate Difficult to check in healthy patients.
Frequency of the measurements The height/length was only taken when it was highlighted on the OTP
charts, even if the length of time between one visit and the next one
was longer than a month.
Examination written Yes
Routine drugs Given if present – If stock out of amoxicillin, sometimes replaced by
cotrimoxazol
Outcomes Often written as “good” or “SFP”; but in fact the child was not admitted in the
SFP because of the restriction of caseloads by WFP:
Bombali: 6 MAM & 20 SAM over 41 – Kenema: 11 MAM & 15 SAM over 57 –
Moyamba: 13 MAM & 39 SAM over 75.
Often written cured in the register: for 25% of them, no information
Absence 50% have an episode of absence due to stock out in Bombali and
Kenema districts with no space left on the charts for almost all of the
patients. Almost never any space left on the OTP charts for Kenema
and Bombali districts.
Home Visit None were documented or written on the chart.
Stock card Updated but some errors in 2/3 OTP centres. RUTF are written on the stock
carton and sachet; not easy to check your stock. Need to be revised.
Internal transfer to the SC Changes of SAM N° which makes traceability of the children impossible from
Active to Passive screening – Passive screening to OTP - OTP to SC – SC to OTP –
OTP to SFP
Monthly report Error of addition in some OTPs – often corrected by the DN and signed (the
23
 most common error was the n° beginning of the month which did not
correspond to the number at the end of the previous month)
Archive of the charts Classified by type and month of discharge and not by SAM N°. This did not
simplify the evaluation. It took times to put them by registration/SAM N° and
some charts were missing.
Regular meeting With the community teams: HCD - CHW – Community screeners – MSG - etc.
District meeting Every month or 2 month according to the distance of the centre
Stock out Even during a stock out, the records showed that some children increased
weight and even lost oedema! The question arises whether these are recording
errors or real “cures” with no treatment.
Weight during stock out Bombali: 14/16cases increase weight - 5 increased by >=400g
Kenema: 35/44 increase weight and 6 >= 600g
Weight gain during absence Moyamba: 19/23 increase weight (absence without stock out).
Amount of RUTF given one or more Bombali: (n= 40) 20=ok; 3 were given more; 17 were given less;
time Kenema: (n=60) 41 ok; 16 more; 11 less;
Moyamba: (=76) 56 ok; 8 more (2 give F100); 12 less.
Remarks A lot of charts had a massive weight and/or MUAC gain after a week (even up to
2kg) or after stock out with no action taken or remarks made

194 discharged OTP charts from the last months were entered on excel and analysed using SPSS and Excel.
Table 9 shows some results. It was impossible to triage the charts by SAM number and the results are only
for indication.

Table 9 – Some nutrition indicators, district of Bombali – Kenema – Moyamba, May 2013

Indicators Bombali (n=43) Kenema (73) Moyamba (77) All (193)

Admission weight average 6.8kg 7kg 6.5 6.7
Discharge MUAC average for the 120mm (+/-5) 120mm (+/-6) 122.5mm (+/-13) 121mm (+/-9)
cured (mm)
Discharge WHZ average for the -1.7Z (+/-1.5) -1.5Z (+/-1.7) -1.5Z -1.5Z (+/-1.5)
cured (Z)
Discharged cured (n) 14 41 47 102
Length of stay for the cured 27days (+/-15) 112days (+/-60) 42days (+/-26) 68days (+/-55)
12
(days)
Rate of weight gain for the cured 5g/kg/d (+/-3) 4.5g/kg/d (+/-7.5) 5.2g/kg/d (+/-2.5) 5g/kg/d (+/-2.9)
(g/kg/d)

The gain of weight is around 5g/kg/day. However, we know that for each 5 kcal/kg/d above maintenance
the gain will increase by 1g/kg/day using RUTF or F100. If you have an average of 5g/kg/d of weight gain,
this means that the total intake will be 100kcal/kg/d to maintain body weight and an additional then
5kcal/g/d for each gram/kg/d of weight gained thus these children have taken 100kcal/kg/d plus
(5kcal*5g/kg/d) = 25kcal/kg/d: thus the total energy intake of the children was 125kcal/kg/d of RUTF plus
any family food consumed by the children. This means that a minimum of 37.5% of the RUTF that is
dispensed is being used for other purposes – particularly sharing within the family. If we decrease the

12
Consequence of the previous stock out.
24
ration to 170kcal instead of 200kcal, this should not change the rate of weight gain but will decrease the
number of sachets given to each child and hopefully reduce the intra & extra household sharing13. If the
child has an average of 6.7kg, his/her consumption is 2sachets per day * 30 = 60 sachets per child per
month: this represents for the whole year of 2012: 60sachets*33000=1,980,000/150 cartons = 13,200
cartons – if you used 80sachets per month, this will be: 80sachets*33000=17,600 cartons, this means
4,400sachets less. Ethiopia – Niger – Ivory Coast – etc. have since the beginning of their IMAM program
used 170kcal/kg/d per SAM out patients. Ethiopia did a study in 2007 to compare both 200 and 170kcal
table and did not find any difference of gain of weight.

If the IMAM programme was using both WH or MUAC admission and discharge criteria for SAM children,
the Supplementary Feeding Programs (SFP) was only using WH; the ex-SAM cured children were supposed
to be followed after discharged in the SFP for 3 months. However to check if all the supposed children were
in the SFP programme was not easy first because the SFP register was not easy to use for its format, the
column allocated was very small and good eyes were required to read the names and the date of
consultation; weight was only written once a month and apart from the name, there was no link between
both programmes. Because the SFP programmes were limited to of a fixed number of children (and
Pregnant/Lactating Women), few ex-SAM children were admitted to the programme; if they were
admitted, the numerous stock-outs of Supercereal (CSB+) or RUSF were so frequent and unpredictable that
it made the follow-up of SAM children completely inadequate.

The SFP ration was of 2.8 KG for 15 days for a daily ration of 250g of Supercereal and 20g of oil. The day of
SFP was different to the OTP day so it was impossible to see and evaluate this program in depth. This
means that the discharged children were often discharged with a MUAC less than 125mm from the SAM
programme.

However with all the stock-outs rationing and restrictions the programme was still working after a fashion
for a small number of patients – the staff reported that the community had a system (“bush telegraph”) to
know if there were or not a stock out.

Recommendations:

 Improve the organisation of the OTP (anthropometric measurements, shelves for the different
registers, table and chairs)

 When using Salter scale, basin should be used instead of hanging pants
 WHZ should only be calculated at admission and then the target weight should be used (see
generic protocol version 2011). This would decrease the workload and the errors.
 Appetite test is only needed if the child is not gaining weight same for the respiration rate

 Admit the child in the health structure where the first SAM diagnose is made (see generic protocol
version 2011)

13
the Valid/Fanta calculations are excessive, wasteful and encourage sharing
25
  OTP chart should be revised adding the SAM and registration N° - the referral from – the number of
sachets given and the number of empty sachet given back – the health education – home visit –
transfer to the SC and back – failure to respond to treatment

 Link with the SFP should be made and documented if any follow up of the cured ex SAM patients.
 There should be more accuracy of the reporting: monthly report should have the stock for the main
drugs and RUTF consumption

 Archiving of the charts should be by SAM N°

 OTP/PHU supervisor far from the district town should be compensated for travelling to attend
regular monthly meeting at district level.

 A “user friendly summary guide” including a list of drugs that should not be given to the SAM
children should be available in all OTPs.

 Amoxicillin should be given/order in tablets or syrup but not in capsule

 The amount of RUTF to give per class of weight should be decreased to 170kcal/kg/day

It was impossible to do a deeper analysis of the discharged children and the consequence of the numerous
stock outs that happen during year 2012 but it certainly should be done.

d. Stabilisation centre

We saw 5 MoHS Stabilisation Centres and 3 private ones. It is certainly the private ones which needed
attention with exception of Ola During SC which had a lot of problems. The multi-charts have some
problems like twice the surveillance – nothing to indicate the phases – no graph for the weight. Register
are used in each facility for admission and discharge. However the SAM number is not respected and
changed for each facility: it is more a registration number. Four SC over 8 had the protocol; one SC had the
1999 WHO modules and Magbente was using their own revised version of the protocol (2007). Only one
structure did not have drinkable water for the mothers: they had to buy water. One SC was using the old
High Energy Milk (HEM) but was incorrectly calling it F100. Six of the 8 SC had updated stock cards. Five
over 8 SC run out of F100 and were lacking of an accurate scale of 10 to 20g precision. The Supplemental
Suckling Technique for the less than 6 months was rarely accurately done: training and demonstration
centre is needed. Toys were not seen during our mission. The SC information collected during the
evaluation is summarized in Annex 4.

Recommandations for the SC (when needed):

Makeni governmental SC:

- Dr Kamara trained in 2007 worked for MSF – needs refresher training;
- Nurses should not rotate every 6 months – a rapid solution should be found.
- Passive screening in the U5 clinic should be improved;
- Material: Urgent needs of a good accurate scale (10 to 20g precision) for the follow up of the
complicated cases and less than 6 month babies.
Kenema governmental SC:
- CHO needs to be retrained – good potential
26
 - Posters need to be updated and as well as a user friendly summary guide
- Supplemental Suckling Technique should be introduced

Freetown Ola During governmental SC

- Intensive OJT supervision for the whole staff including doctors has to be done;
- Nursing aids should stop using reconstituted High Energy Milk and should not confuse this with
F100 on the charts;
- The centre should NOT be used to teach students in its present state – it must be upgraded before
receiving students.

Magbente SC – Panguma SC – Kamakea SC:

- The private SCs are not free; there is no need to do routine laboratory exam: they should be limited
to the absolute essential ones; the use of expensive and not free drugs should be examined.
- For Panguma, the new doctor should be urgently trained with particular attention to the less than
6 months SAM protocol.

Overall Recommendations for the SC:

 The IPF tools and protocol need to be revised, in particular the sections on antibiotics and on
complications.
 Posters and user-friendly summary guide should be available
 Proper scale with 10g precision has to be available in each SC as soon as possible;
 The rotation of staff should be kept to an absolute minimum – and the only reason for “rotation”
should be the person leaving that centre;
 The SS Technique should be introduced in all the SC, with the help of Dr Kamara
 Stock out of any therapeutic products (F75 – F100 – RUTF) in the SC should not happen.
 There is NO need to do routine lab exam and then charge the patients in the private SC.

V.4 IYCF activities

In total 18 mother support groups were interviewed in 4 districts. The number varies from one district to
the other depending on the time available, the distance to reach the community and the number of person
in the team. For instance, in Bombali district, team 1 was concentrating on IMAM activities and had time to
interview only two MSG and two community screeners. The detailed is presented in the table below:

Table 10 – Number of Mother Support Groups interviewed

Number of MSG Number of members present / Total number of members in the MSG
interviewed 1 2 3 4 5 6 7
Moyamba 6 7/15 8/15 7/15 3/10 2/10 1/10
Kenema 4 14/23 7/19 8/18 10/27
Bombali 2 8/15 8/18
Kono 6 16/25 14/15 23/31 30/30 29/30 30/30 28/30

27
 a. Operating mode of the Mother Support Group

The evaluation of the MSG did not focus on the quality of their activities as such. The aim was more to
understand what work and what need to be improved.

The interviewed MSG were not formed at the same time; some were formed in 2009 while others were
formed in 2012. However, the interviews with the MSG members revealed that the income generating
activities, the benefits they get from the group (vegetables from the backyard garden, group loan, etc.),
animal revolving funds and the recognition by the community were the major components to maintain
members together in the group and make the group operational.

On the 18 interviewed MSG, the majority of them welcomed new members and only 4 MSG said that
members left the group. The main reasons were that they were unable to pay the contribution for the
group saving loan (3 MSG) or marriage (1 MSG). This information shows that the groups were working
pretty well and that each member found a self-motivation to stay in the group. The new members joined
the group because of its good reputation in the community. In some communities where there was no
MSG, people were asking the implementing partners to come and help them to form one. When asking
them why they want to form a MSG the main answer was “because this group is good for the community
and it helps the members with income generating activities”.

Some interviewed MSG were very impressive. These particular groups can probably function with a less
intensive monitoring which could allow the implementing partners to support new MSG in the district.
These new groups should be formed based on the demand of the community.

The counselling cards were perceived as a reward within the MSG. However, in most of the MSG met, new
members have been trained but the counselling cards were not distributed to all of them mainly because
the IP did not make a request to UNICEF for a new set of cards. Members had therefore found a way to
overpass this problem. They exchanged the cards between themselves, depending on the counselling
session’s schedule.

We were not able to participate to any individual counselling or group counselling sessions but most of the
members were able to explain the messages delivered by the counselling cards. They recognize the added-
value of the group to solve problems together with the monitor from the implementing partner. The
majority of the members mentioned that they have learnt a lot during the training about breastfeeding and
complementary feeding but also about the importance of hygiene and sanitation. However, most of them
recognized having difficulties to convince the community members to change their behaviour, especially
men.

Recommendations for the IP:

 Propose various income generating activities to all MSG

 Distribute counselling cards to all trained members who practised at least 10 counselling sessions
successfully
 Train the health facilities staff on c-IYCF to increase their involvement in this activity

28
 b. Activities of the Mother Support Groups

The selection of the MSG members is a key factor to ensure that IYCF messages reach the right persons and
have an impact on the behavioural comportment change. The Sierra Leone’s program has taken this into
consideration when forming the MSG. Indeed, each group interviewed was composed of 10 to 31
members, including lactating women, pregnant mother, teenage girls, TBA, men and even religious leaders
and PHU in charge in some communities. Each member has been selected based on volunteering and
willingness to help the community to develop itself.

In big catchment areas, MSG members were coming from different villages in order to have at least one
delegate by village of the catchment area.

The main tasks of the MSG members are community sensitization, house-to-house counselling and group
counselling sessions. However, the majority of them said that house-to-house counselling was more
efficient mainly because in the group session, not all the invited participants came and it was easier to
speak and convince women and household members in face-to-face discussions. However, not all women
accept to be part of an individual counselling session, the main reason being the lack of time.

In the best MSG counselling could be extended to other skills such as Care for Child Development. There
are several studies that prove that Care for Child development improves the cognitive and psychomotor
development of young children and accelerates the healing of those who are ill. IYCF counselling does
already include responsive feeding as part of care for child development approach. It would therefore be
interesting to reinforce this component in MSG ready for that.

Most of the members of the MSG are producing vegetables thanks to the backyard garden and seeds
provided by the IP but most of them admitted that they were using the vegetables for selling. . However, in
some of the groups changes were starting to happen and they were saying that they were keeping now
some vegetables to feed their children and sell the rest.

When the decentralized monitoring for nutrition activities will be done in each district, we will be able to
follow on a regular basis the evolution of the changes of the behaviour. This will be very helpful to redesign
the activities and focus on the most needed ones. Up to now, baseline and endline surveys have been
carried out only in Bombali district.

Recommendations for UNICEF & IP:

 Introduce Care for Child Development (CCD) counselling in MSG ready for it
 Keep monitoring IYCF activities
 Carry out decentralized monitoring (baseline and endline) in every district

c. Sustainability of the Mother Support Groups

When asking the MSG members on what can be improved in term of IYCF, they all had more or less the
same requirements however surprisingly few of them asked for direct incentives (3 MSG out of 18). The list
below shows the priorities in order from the highest to the lowest:

 Agricultural tools
 Micro-credit
29
  Seeds
 Income Generating Activities including machine to produce oil or gari, sewing machine, soap
making
 Identification for recognition by the community: badge, cap, t-shirt, etc.
 Rain gear, umbrella, boots, torch light
 Life stock
 Financial support to buy some tools, seeds, etc.
 Counselling cards for those who do not have a set / Training of more MSG / Refresher training /
Incentive / Motorbike
 Room to meet

In one of the best interviewed MSG there was at least one literate person keeping record for the group
saving loan, writing notes for the record at each meeting, etc. They were able to save an impressive
amount of money and were able to buy a goat to each member with the money saved. This group was very
advance in term of autonomy compared to the other ones and the only difference we could notice is the
literacy of some members.

When asking the implementing partners about the problem they have encountered with the MSG, the
main one was the problem of leadership within the group. This was felt also during the evaluation. Some of
the MSG leaders needed to be advised and coached by the IP's monitor to manage the group effectively.

The problem of different incentives given by different NGO was also raised as some members of the MSG
moved from one group to another one according to the incentives provided.

Recommendations for UNICEF & IP:

 Link the MSG with agricultural partners (FAO, UNIDO, etc.) to enhance the agricultural activities
within the MSG
 Link the MSG with education partners to propose literacy classes for the interested members and
introduce of the MSG to care for child development activities
 Link the MSG with protection partners especially for teenage mothers
 Provide ID (badge, cap, t-shirt, etc.) to the members of the MSG
 Provide rain gear to the members of the MSG

VI. CONCLUSION
This report is not a verification report, but also not a detailed in-depth evaluation of each centre visited
due to the short time - but it gives an overview of the IMAM programme, its strength and weaknesses and
gives specific recommendations.

The IMAM activities are now well accepted by the community and health professionals, even though the
frequent stock-outs that occurred during these last 2 years have severely disrupted the program. It is
extraordinary to see the small effect that a stock-out has on the recorded gains of weight of the SAM
children. This is completely unexpected – but given the gross unrealistic variation of the recorded weights

30
(up to 2kg gains and losses each week!) it is impossible to tell whether these are real figures or the result of
poor measurements/recording.

The other bottleneck is the leakage of RUTF which has detrimental effect on the moral of the nutrition
team at national level as well as within the partners and the donor; the direct consequence is a stock out of
the different nutrition products and drugs at district level; it is almost happening every 2 months in the
visited districts. This can really be the failure of a programme like this.

In term of IYCF, a lot of work has been done since 2009 and the strategy designed for the MSG seems to be
the right one. Even if these groups still need to be empowered to become sustainable and autonomous, it
seems that they could make a difference in term of prevention of malnutrition. However, for this to
happen an equal focus should to be put on PHU and hospitals to ensure that all levels disseminate the
same messages to the community.

VII. OVERALL RECOMMENDATIONS

 Revision of the IMAM protocol

 Scale-up will only be successful if the problems identified in this report are first addressed

 Retrain all the staff involved in IMAM to the revised protocol and the use of the tools
 Revise the method of verification involving all levels

 Revise and finalize the IYCF national strategy

 Train health workers on IYCF. The training should start with health workers already engaged in IYCF
activities

 In districts with high micronutrients deficiencies, IYCF activities must be coupled with distribution
of micronutrients powders (MNPs)

 Continue supporting the IP for implementation of the IYCF strategy

31
REFERENCES
1. Terms of Reference for Evaluation of Partner Implemented Nutrition Projects in Sierra Leone

2. Evaluation Report, March 2010. Independent Evaluation of Management of Acute Malnutrition.

Yvonne Grellety and Hélène Schwartz

3. UNICEF, May 2010. Trip Report, “review the existing comprehensive framework for large scale
promotion of adequate IYCF practices in Sierra Leone”. Christiane Rudert

4. Report of a meeting to harmonise the criteria for monitoring and evaluation of the treatment of
acute malnutrition in West and Central Africa, Dakar, December 2010. M Golden, Y Grellety, F
Tchibindat, H Schwartz

5. UNICEF, 2011. Programming guide: Infant and young child feeding. UNICEF: New York.

6. MoHS, 2009. IYCF National Guideline and Strategy

7. UNICEF, 2010-2011. Results of 2010-2011 assessment of key actions for comprehensive infant and
young child feeding programmes in 65 countries. UNICEF: New York.

8. UNICEF Sierra Leone, 2012. Level 3 Core Indicators Handbook - Tools and indicators for monitoring
and evaluation of IYCF & CMAM programs
9. MoHS Sierra Leone, June 2012. Policy for Community Health Workers in Sierra Leone

32
ANNEX 1 – Calendar of the evaluation mission

Date Time Activities Venue

19:15 Arrival (Pick up and Aberdeen Bridge to
Saturday 18, May
Accommodation for Helene SIMPLE GOAL GUEST
2013
Schwartz) HOUSE
21:10 Arrival (Pick up and Aberdeen Bridge to
Saturday 18, May
Accommodation for Yvonne SIMPLE GOAL GUEST
2013
Grellety) HOUSE
11:00 am Preparation with programme UNICEF Office
Sunday 19, May 2013
staff
07:30 am Pick-up from hotel SIMPLE GOAL GUEST
HOUSE
8:00 – 8:30 Meeting with Chief of CSD Chief CSD office
10:00 –11:00 Meeting with the The Representative’s
Monday 20, May Representative and Deputy office
2013 Representative
11:00 –12:30 Meeting with partners UNICEF conference
room
14:30 –17:00 Meeting with the Food and MoHS
Nutrition Programme MoHS
07:30 Pick up from hotel SIMPLE GOAL GUEST
Tuesday 21, May HOUSE
2013 09:00 –10:30 Meeting with Nutrition Unit UNICEF conference
room
11:00 –12:00 Visit Ola-During Hospital
14:00 Travel to Moyamba for 2 teams
Field Trip
Date Team 1 CMAM Team 2 IYCF
Visits of the District Nutritionist and the DHMT
Visit of the District Management Store and DLO
Wednesday 22, May 2013 Bauya OTP and MSG
Static OTP and MSG
Gandorhun SC Moyamba MSG
ACF team visit
Sunbehun OTP and MSG
Thursday 23 May 2013
Moyamba Junction OTP and MSG
Travel to Kenema and stay in Paloma Hotel
Visit of the DHMT and the DMO
Giema OTP and MSG
Friday 24 May 2013
Torkpomdu OTP and MSG
Majihun OTP and MSG
Visit of the DMS and DLO
Saturday 25 May 2013
Kenema SC and MSG

33
 Panguma SC and MSG
Travel to Kono
Travel to Makeni
Visit of the DN + Kono SC
Magbente SC
Sunday 26 May 2013 Literature review
Makeni SC
Kono OTP
Bumpeh MSG
Monday 27 May 2013 Kamakae SC
Njala MSG
Bongenna MSG
Makeni Lol OTP Betema MSG
Kalangba OTP
Tuesday 28 May 2013
Visit to the Manager in Charge Konbayendeh MSG
of Magbente SC
Visit to the U5 clinic of the Gvt
Hospital and Dr Kamara in Tomemburg MSG
charge of the SC
Wednesday 29 May 2013 Visit to the DMS and the DMO of
Kangama MSG
Bombali
Makama OTP Kangama OTP
Travel to Freetown
Date Time Activities Venue
SIMPLE GOAL GUEST
08:00 Pick-up from the hotel
HOUSE
08:30 –13:30 Field visit Western Area OTP Field Visit
Monday 30, May Meeting with the nutrition unit
2013 14: 00–16:00 to discuss the findings and Conference room
recommendations
Debriefing with Regional Advisor
16:00 –17:00 Chief CSD office
Nutrition Felicite Tchibindat
SIMPLE GOAL GUEST
08:00 Pick up from Hotel
Tuesday 31, May HOUSE
2013 09:00 –10:00 Meeting with the Chief CSD UNICEF Office
10:00 –17:00 Report writing
SIMPLE GOAL GUEST
09:00 Pick up from Hotel
HOUSE
Wednesday 01, June Discussion with the nutrition
2013 unit on how to best improve UNICEF conference
10:00 –12:00
adherence to protocol and room
rational utilization of RUTF

34
ANNEX 2 – IYCF interview questionnaires

QUESTIONNAIRE MOTHERS SUPPORT GROUP

Date :_____/_____/______ District : ________________ Village : _____________________

Referral OTP : ______________________________________

Personne/s interviewed and position within the MSG:

- -

- -

- -

- -

When did you join the Mother Support Group? _______________________

How were you selected?

_______________________________________________________________________________________
_____________________________________________________________________________

What are the advantages for you to be part of a MSG?

_______________________________________________________________________________________
_____________________________________________________________________________

What are the disadvantages for you to be part of a MSG?

_______________________________________________________________________________________
_____________________________________________________________________________

How many times per month do you meet with the MSG? _________________________________

Apart from this meeting, what is your role in term of IYCF? _________________________________

_______________________________________________________________________________________
______________________________________________________________________

How long does a meeting last (on average)? ____________________________________________

What do you think about the MSG meeting? (duration/efficacity/learning/…)

_______________________________________________________________________________________
_____________________________________________________________________________

35
How much time does this activity take you per month ? ___________________________________

What do you think about it (too long, would be happy to spend more time on it)?
_______________________________________________________________________________________
____________________________________________________________________________

According to you, how can the MSG/IYCF be improved?

_______________________________________________________________________________________
_____________________________________________________________________________

What are your expectations?

_______________________________________________________________________________________
_____________________________________________________________________

Are there some IYCF points that you have difficulty to explain to other/to understand?
_______________________________________________________________________________________
_____________________________________________________________________________

Do you have any tools for IYCF activities? YES NO

If yes, what kind of tools?

_______________________________________________________________________________________
_____________________________________________________________________________

Do you screen children for malnutrition? YES NO

If yes, how do you do?

__________________________________________________________________________

If the child is malnourished, what do you do?

__________________________________________________________________________________

If the mother does not want to go to the SFP or OTP, what do you do?

__________________________________________________________________________________

Do you do any report for this activity? YES NO

If yes, to whom do you send the report?

_________________________________________________________________________

Do you have a mobile phone ? YES NO

Do you know the community screener in your village? YES NO

36
What do you think of the MAM/SAM treatment?

_______________________________________________________________________________________
_____________________________________________________________________________

What do you think about RUTF and CSB?

RUTF______________________________________________________________________________ CSB
_____________________________________________________________________________

Any complain from the mothers about these programs?

_______________________________________________________________________________________
_____________________________________________________________________________

How do you do to involve father and mother-in-law in the sensitization?

_______________________________________________________________________________________
_____________________________________________________________________________

Do you have a Village Saving Loan in your village? YES NO

If yes, what do you think about it?

__________________________________________________________________________________

Do you receive any compensation from the community for the work you do related to IYCF?

__________________________________________________________________________________

37
 QUESTIONNAIRE COMMUNITY SCREENERS

When have you been trained on screening? ______________ By whom? _______________________

Do you have a supervisor? YES NO

If yes, who is he/she? _____________________ How often are you supervised? ________________

Do you receive any motivation/remuneration? YES NO If yes, by whom? ________________

If yes (money), how much? ______________________ If yes (in kind), what? ___________________

Do you have a bicycle? YES NO From whom did you get it? _____________________________

How many screening do you do per month? ____________________

How many children do you screen on average per month? ________________

Do you fill a screening report? YES NO

If yes, to whom do you send it? ________________________ How? _________________________

How often? _______________________________

What do you do when you detect a severely malnourished child?

_______________________________________________________________________________________
_____________________________________________________________________________

What do you do when you detect a moderately malnourished child?

_______________________________________________________________________________________
_____________________________________________________________________________

If the mother refuses to go to the OTP or SFP, what do you do?

_______________________________________________________________________________________
_____________________________________________________________________________

Do you communicate with the PHU when referring children? YES NO

If yes, what mean of communication do you use? _________________________________________

After referring a child to the OTP, do you have any feedback about the admission of the child? YES NO
If yes, by whom are you informed? ________________________________________________

If the OTP did not admit the child, what do you do? ________________________________________

Have you already encountered a child who has abandoned the program? YES NO

If yes, how did you know that the child abandoned?

38
_______________________________________________________________________________________
_____________________________________________________________________________

Do you do some home visiting? YES NO

If yes, what is the reason for the home visit?

_______________________________________________________________________________________
_____________________________________________________________________________

Do you write any home visit report? YES NO

When a child has been discharged from the OTP, do you still have a role to play?
_______________________________________________________________________________________
_____________________________________________________________________________

What is your relationship with the MSG in the community?

_______________________________________________________________________________________
_____________________________________________________________________________

What do you think of this program?

_______________________________________________________________________________________
_____________________________________________________________________________

Do you have any suggestions to improve the program?

_______________________________________________________________________________________
_____________________________________________________________________________

39
Annex 3 – List of the IYCF monthly indicators
1. % of villages in CMAM catchment area with at least one active volunteer screener and referral of
SAM cases per chiefdom

2. % of children in CMAM catchment areas screened at least 3 times a year for acute malnutrition

3. % of SAM children referred for treatment who actually attend SC and OTP

4. % of MSG with at least 2 members trained on IYCF counselling and active group facilitation skills

5. % of women with children less than 6 months that report at least one contact with MSG

6. % of women with children 6 – 24 month reporting to have 2 contacts with MSG

7. % of women with children less than 24 months reporting to have sex during breastfeeding

8. % of MSG with active participation of men in MSG activities

9. % of MSG with at least one trained male IYCF counsellor as member

10. % of MSG with at least one unmarried teenage mother as member

11. % of communities in the target communities that have a MSG / chiefdom

40
ANNEX 4 – Summary of the SC evaluation

SC’Name Makeni Kamakwea Magbente Kenema Panguma Moyamba Freetown

MoHS SC Private SC Private SC MoHS SC Private SC MoHS SC Ola
During
MoHS SC
Staff 6 SECHN – 1 CHO 1 nurse 1 CHO 3 SECHN 3 SECHN 9 nurses
4 nursing aids – 5 nurse aids 2 senior 9 nurses 1 untrained 3 nursing
1 doctor - nurses 3 nursing aids doctor aids
5 nursing 2 nursing aids 2 cleaners
aids
Rotation Every 6 months Change of the No ? New nurse
trained nurse
Training 1/6 nurses OJT only 2007 2010 2009 – 2010 OJT only by 2/9 trained
Doctor trained Needs at least 4 the IP and staff
in 2007 days OJT DN Dr not
trained
Structure Service next to Service far Good Part of the Ok Ok
the Paediatric from the PW PW
Ward (PW)
Needs cleaning
Passive In the Under 5 They do not From the ? ? In U5 clinic Dr (OPD)
screening clinic but no know how to OTP or admit used the
length board – assess the spontaneousl old NCHS Z-
no WHZ & degree of y score table
MUAC done - no oedema in the IMCI
14
oedema check book for
hospital
Look up No RUTF feeding F100 in TP with F100 look Yes Ok Ok F100
tables table in 8 and 6 and 5 up table - written but
Transition Phase feeds No RUTF in fact it is
(TP) feeding not F100
table in TP
Posters Nothing on Old poster on Old ones to Yes Ok Ok Not the
<6mo babies & F100 prepare the right ones
complications - F75 with
mix with old the scoops
posters
Multi-chart Filled Run out – so made Filled Yes Ok OK Yes but use
charts Then got also the PW
the right ones, files for
however still using each
their own old ones patient.
Laboratory Routinely Routinely Yes Systematic No Routinely
test done stools lab test:
– WBC – expense on
Malaria test the mother
bill
Products F100 – F75 – F75 – RUTF No F75 – RUTF No F100: use of F75 - F100 – F75 - F100 – No F100
RUTF resomal No F100: use RUTF RUTF RUTF
No F100 of powder
milk bought
in the market
Routine Sometimes no Free drugs All used Amoxicilline Nothing is Ok Use
drugs artesunate for given: patients without free - everything -

14
According to Dr in charge, some SAM children admitted in PW instead of SC
41
 cerebral malaria buy in the taking into Doctor not
– give quinine – drugstore & account the trained
nd
2 line WHI reimburse protocol –
antibiotic: them Amoxicilline
gentamicin is free
Other drugs Becovit - zinc Paracetamol Promethazine Becovit All the
paracetamol - zinc Chloramphenicol zinc different
metronidazole – metronidazol gentamicine ketoconazole drugs
chloramphenicol e-becovit – ceftriaxone praziquantel that should
– cotrimoxazole zinc – phenobarbitone metronidazole not be used
- ceftriaxone metronidazole Paracetamol
quinine-
vitamine C
Preparation Ok but use the Ok Ok except Ok No
of the feeds scoops and water too
water too hot hot
Feeding Use spoons Give porridge & Use of Use of spoons – Use of Need
family meal spoons Introduce F100 spoons feeding
from Phase 1 to in TP and then table of 8
discharge RUTF feeds for
small babies
P1 Only 6 feeds Only 6 feeds Should be ?
able to
switch from
6 to 8 feeds
if needed
TP Use always Use of F100 Use of HEM
F100 for 1 to 2 but write
days F100 on the
No table for TP multicharts
for PPN
Type of exit Not written on Often not Ok but a lot
the chart written of deaths in
Missing May
Information

42