Performance Evaluation of Eleven Severe Acute Malnutrition Community Based Outpatient Therapeutic Care (SAMCTC) Centres in Lusaka District of Zambia

Thumbnail Image
Habulembe, Raider
Journal Title
Journal ISSN
Volume Title
Later in the 1990s, the Community Based Therapeutic Care (CTC) program was introduced first in emergency areas (refugee camps, disaster areas), and later expanded to other locations where severe malnutrition existed. The program has several components including Out-Patient Therapeutic Care Program (OTP). The CTC program aims at treating malnourished children at home while those with complications are referred to inpatient care. The merits of CTC program include timely detection of severely malnourished children in their communities, it uses and builds on existing capacities, and it is an easily accessible service that provides treatment. When it is well implemented, it has the ability to reduce mortality rate among malnourished children to as low as 4.1%. In Zambia CTC program was introduced in 2005 in Lusaka district. It is currently implemented in 25 health facilities. Since 2005, there has not been any study to comprehensively determine its performance. Scaling up of the program has been carried out without adequate knowledge of program performance with regard to the outlined humanitarian minimum standards in the non emergency response (CTC Standards). For this reason, there was need to evaluate the program. This study was undertaken in order to evaluate the OTP component of the CTC program in eleven health centres in Lusaka district from September 2005 to September 2007 The target population were records of children who were discharged from the program from September 2005 to September 2007 and health care staff working in the OTP. Both quantitative (records and self administered questionnaires) and qualitative methods (in-depth interviews and observations) were used. Using multistage sampling, 828 out of the 2424 records were selected for the study using the Population Proportion to Size Sampling (PPS) method. At health facility level, systematic random selection was used to get the records. Health care staff in a health facility were listed and then randomly selected for interview. Based on health facility and sex as indicators for completeness, a non response rate of 3.5% was incurred. Quantitative data was entered in epi data and analysed using SPSS software while qualitative data was transcribed manually. Analysis of data was further guided by proximate determinant conceptual framework. The associations between performance and predictors were measured using logistic regression models and chi-square methods. Performance of the program was determined by the use of composite indicator. Data quality control involving pretesting of tools, training of research assistants and ensuring thorough check of completed questionnaires were done. Prior to data collection, ethical approval was given as part of the process of dealing with humans.The findings established that 86% (n=828) performance rate was achieved by OTP while indicating a contrasting difference of health facility specific performance ranging from 73% to 100% in N’gombe and Matero, respectively. In addition, 60% of children were within the recommended weight gain of above 4 grams per day with a mean weight of 5.7 g per day (±SD 4.89). Seventy five percent of children cured stayed less than 60 days (±SD 22.9%). The defaulter rate was found to be 31% while transfer rate, refusal of transfer and non cure rate percentages were 4.6, 0.1 and 1.9, respectively. The multivariate analysis showed that health facility, source of admission and appetite of the child were found to be significant factors associated with performance, while breastfeeding was also an important factor in univariate analysis. The analysis further showed that the goodness of fit Hosmer and Lemeshow Test (x2, 7 df, p=0.97) on the determinants of performance was used. The cox and Snell R Square and Nagelkerke R Squared indicated that between 39.9% and 61% of variability was explained by the variables in the model. Regarding availability and adequacy of food and logistics it was found that 9.1%, 8.9% 3.0 % and 2.1% of children in the age ranges 5.5-6.9 kg, 7.0-8.4 kg, 8.5-9.4 kg and 9.5-10.4 kg, respectively, received correct amounts of RUTF. About 77% of health care staff observed during the study gave the correct amount of RUTF to children. Other supplies such as height boards were inadequate and transport was poor. Staffing levels seemed adequate although the majority of staff working for the OTP centres were volunteers. The knowledge of staff was rated good (over 60%) after assessing key admission criterion (oedema, MUAC, visible severe wasting), appetite test elements, and outreach follow up. However, knowledge in some component seemed to be inadequate particularly in MUAC and height measurements, child referral, weight gain, appetite test and health education.In conclusion, high level of good performance of OTP associated with several factors which suggests the need for OTP scaling up to other remaining provinces and districts. The factors include source of admission, appetite of the child at admission and the health facility providing the OTP services. These findings are also consistent with the Proximate determinant conceptual framework which depicts that severe malnutrition is caused by poor food utilisation in the body, diseases and other factors such as poor appetite which are also influenced by proximate determinant factors such as feeding practices, food preparation and health seeking behaviour. The status of the proximate determinants and biological factors at admission will influence how good the recovery process of the child will be while in the OPT. Therefore, directing efforts on one factor does not yield much success in addressing mortality in the OTP and malnutrition in general.. The knowledge of staff was fairly good but requires to be intensified especially in the area of infant feeding practices, health information and education, and health care practices. However, this research had a limitation in that almost all data was obtained from the records of children already discharged thus there was no data collected on the socioeconomic factors that may have affected performance of children such as education of the mother, income level, perception of mother on the diseases and others. Although the focus of the study was on management of severely malnourished children, the critical question still remained as, “is it feasible, sustainable and cost effective?”. It is consequently vital to consider carrying out a cost effectiveness study of the program and other factors associated with poor feeding practices among OTP children with particular attention to breastfeeding. In addition there is need to investigate the causes of high defaulter rates in health facilities
Malnutrition , Malnutrition--Therapeutic Care