Client: Office of U.S. Foreign Disaster Assistance (OFDA), United States Agency for International Development (USAID)

Recovering child being weighed Photo by Peggy Koniz-Booher

Niger is a Sahelien country with a long history of repeated cycles of famine due to environmental vulnerability and extreme poverty. Niger’s persistent acute malnutrition rate of 12% and chronic malnutrition rate of 50% in 2006 contribute to one of the highest childhood mortality burdens in the world (DHS 2006). The 2005 food crisis in Niger severely strained a struggling national health system with very limited capacity for integrated child nutrition services. Despite recurrent food crises, services for malnourished children in Niger are usually provided by transient relief groups working outside the public health system with little capacity building within the national health system.

In the spring of 2006 the Office of U.S. Foreign Disaster Assistance (OFDA) awarded URC’s Center for Human Services (CHS) a 12-month program grant entitled Rapid Expansion of Nutritional Recuperation Services for Malnourished Children in Nigerien Facilities. Under this project, CHS is leveraging its established countrywide Pediatric Hospital Improvement (PHI) Collaborative, run as part of the Quality Assurance Project, to rapidly expand nutritional recuperation services for acutely malnourished children in 15 district hospitals while building local capacity for improved behavior change communication, screening, referral, and recuperation at district levels. Initiated in 2003, the PHI collaborative works in 32 of Niger’s 43 government hospitals in 64% of Niger’s districts and has made nationally recognized gains in improving the quality of first referral IMCI (Integrated Management of Childhood Illness) services due to its unique improvement collaborative approach and strong partnership with regional and national MOH leadership.

Counseling tool demonstrating active feeding of a sick child

The OFDA-funded program operates in 15 of the 32 MOH facilities participating in the PHI Collaborative, in 7 of Niger’s 8 administrative regions. Working in close collaboration with regional MOH authorities, CHS has worked to:

• Advocate for reduced economic and geographic barriers to access by partnering with regional MOH officials, relief nongovernmental organizations (NGO’s) and local committees working at the community level to reduce malnutrition
• Expand quality recuperation services for severely malnourished children in the 15 district hospitals that participate in the PHI collaborative.  In the majority of targeted facilities, recuperation services were absent prior to 2005-2006.
• Collaborate with UNICEF and Helen Keller International to improve sustainability, quality, and efficiency of recuperation centers (Centre de Recuperation Nutritionnelle Intensif (CRENI’s)) established in 2005/06 in government regional and district hospitals
• Establish new CRENI’s in PHI sites at government hospitals that do not have established nutritional recuperation services for malnourished children
• Strengthen referral/counter-referral mechanisms between primary health and district hospital facilities through a series of district-level workshops to identify protocols and tools for promoting improved referral/counter-referral.  These tools are now being tested in all PHI sites.
• Educate health care providers and caretakers of malnourished children in prevention of, recovery from, and reduced relapse of malnutrition through systematic counseling during the recuperation period using a set of counseling posters developed by CHS.
• Promote use of accessible, affordable local foods and continued breastfeeding during the recuperation period.
• Reduce malnutrition case fatality rates in targeted Nigerien facilities by rapidly introducing and promoting compliance with the new national nutritional recuperation protocol applying modern QI methods at the local level.

• Helen Keller International
• Islamic Relief
• UNICEF

• As of March 2007, 1,936 severely malnourished children have been admitted to program government-run nutritional recuperation centers
• Systematic nutritional screening and behavior change communication activities are now routine in all program facilities using a uniform set of counseling posters as described above.  Proportion of admitted children systematically screened for nutritional status has increased from 0% at baseline to 41% in March 07.  The user-friendly and rapid MUAC (Middle Upper Arm Circumference) is used for initial screening in all participating facilities.
• Overall compliance with recuperation standards in targeted new nutrition recuperation facilities has increased from less than 12% at baseline to an average of 88% as of March 2007.
• The average malnutrition case fatality rate has decreased from an average 29% in the first quarter to 13% in March 07.
• Improved Referral/counter-referral (RCR) capacity for a continuum of malnutrition care is being introduced via quarterly district level RCR workshops.   Proportion of children admitted to CRENI’s referred from a primary health center or the community has increased from a 43% in the first quarter to 55% in the fourth quarter (March 07).

Countrywide in 15 districts in 7 of 8 administrative regions (Tillaberi, Niamey, Tahoua, Dosso, Maradi, Zinder, and Diffa)

Contact Dr. Kathleen Hill at khill@urc-chs.com (Bethesda HQ) or Dr. Maina Boucar (URC-CHS/Niger) at paqchs@intnet.ne.

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