Guidance note on Triage approach: Integration of TSFP into i-bsfp

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1 Guidance note on Triage approach: Integration of TSFP into i-bsfp To sustainably manage moderate acute malnutrition (MAM) in Sudan, it is vital wherever possible to implement both targeted supplementary feeding programme (TSFP) and integratedblanket supplementary feeding programme (i-bsfp) at the same nutrition center - Triage. This approach would enable implementation of nutrition specific interventions that address the immediate causes of malnutrition and also ensure integration with nutrition sensitive activities that address the underlying determinants. 1. Rationale Since the primary focus for both programmes is management of moderate acute malnutrition (MAM), it is therefore preferable to use one center. Using one delivery platform (and nutrition center) means less opportunity cost to mothers/care-givers and better experience for our beneficiaries. More effective triage/diagnosis and better programme coverage Better referral system, less defaulters, better tracing and less relapse Improved cost-effectiveness less staff needed for an integrated structure as both programmes will use the same staff (storekeeper, cleaners, guards, measurers, Data clerk, food distributers and community mobilizers). Objectives Improve effectiveness of MAM prevention and treatment Reduce cost of MAM prevention and treatment Improve programme coverage Managing MAM will still be part of a continuum of care that includes the treatment of Severe Acute Malnutrition (SAM) and community mobilization. All these components are integral parts of the recommended Community-based Management of Acute Malnutrition (CMAM) framework (Figure 1) 1. 1 Target age groups (in accordance with national guidelines): TSFP MAM children (6-59 mo) & undernourished PLW according; i-bsfp Normal children (6-36 mo) and PLW. 1 Figure 1: Triage and referral system within CMAM for i-bsfp and TSFP integration

2 2. Physical set up of the center The AO should map out the existing OTP, TSFP and i-bsfp in their respective State in collaboration with the Nutrition Cluster (and/or SMOH) to establish the strategy for implementation of a triage approach but also identify geographical gaps in coverage of programmes. Active involvement of SMOH is important to ensure that these programmes will evolve into a sustainable component of State/Federal health and nutrition program. The SOP for Nutrition which contains details on the decision making process for implementation of different modalities can also be a reference document for this purpose. Figure 2: Physical set up of the center The triage approach will require capacity building and technical support to CPs particularly those that may have limited capacity in implementing the approach, e.g. SMOH and CBOs. 2

3 Additional Minimum Even where there is no OTP, the priority should be to implement the triage approach, i.e. community mobilization, integrated TSFP/i-BSFP and interlinking with nutrition sensitive interventions (e.g. social safety nets, WASH, food security and livelihood activities). 2.1 Services IN THE COMMUNITY Common - targeted to all age-groups Community mobilization on nutrition, malnutrition, and its identification Identification (MUAC & oedema) and referral of cases of acute malnutrition. As well as follow-up of those who have defaulted from a nutrition program Young children 6-59mo (caretaker) Promotion of appropriate feeding of the sick child Basic promotion and support for optimal complementary feeding and continued breastfeeding for children 6-24 months Lactating mothers Basic promotion of maternal nutrition Encourage regular attendance at MCH and infant growth monitoring Pregnant mothers Promotion and support of early initiation and exclusive breastfeeding Basic promotion of maternal nutrition Basic promotion for consumption of nutritious locally available foods Support and counseling services for early initiation and exclusive breastfeeding until 6 months Encourage regular attendance at MCH for ANC visits and community-based services (i.e. CHDs) Identification and referral of cases of diarrhea, respiratory tract infections and fever Promotion for hand washing with soap, ash, or sand Post-partum vit A Recognition and referral of pregnancy early danger signs Promotion for household drinking water treatment Promote consumption of iron enhancers (i.e. lemon) and fortified or enriched foods (i.e. flours, oil, salt) Specialized promotion for cultivation and consumption of nutritious locally available foods Specialized promotion and support for optimal complementary feeding and continued breastfeeding, focusing on locally available foods/recipes Support for reduced workload and nursing breaks so that women have time for exclusive breastfeeding and care Support for reduced workload and rest Support for formation of relevant support groups (i.e. Breastfeeding, complementary feeding, etc.). Promotion for child stimulation and play Specialized promotion of maternal nutrition Specialized promotion of maternal nutrition 3

4 Additional Minimum Common - targeted to all age-groups Triage Treatment of moderate malnutrition (TSFP) Referral of SAM cases (OTP and SC) Provision and/or promotion of specialized fortified foods Identification and home treatment of diarrhea with zinc and ORS Identification and treatment/referral of common illnesses ( anemia, malaria, and pneumonia) AT THE NUTRITION CENTRE Young children 6-59mo (caretaker) Enroll in i-bsfp (6-35 mo) or TSFP according to nutrition status Vitamin A Lactating mothers Enroll in i-bsfp or TSFP according to nutrition status Pregnant mothers Enroll in i-bsfp or TSFP according to nutrition status Post-partum Vitamin A Multi-micronutrients Deworming Deworming of the mother Promotion of early initiation and exclusive breastfeeding Basic counseling and Multi-micronutrient TT immunizations support for optimal complementary feeding behaviors Multi-micronutrient Full immunization Referral of infants not gaining weight or not suckling/breastfeeding well to inpatient Support and counseling services for early initiation and exclusive breastfeeding until 6 months Nutrition education, health and hygiene promotion (without soap distribution) Adapted and specialized nutrition counseling focusing on locally available foods or products Distribution of household drinking water purification materials Hygiene promotion with soap and home water treatment systems distribution Full immunization coverage Specialized promotion and support for optimal complementary feeding, focusing on locally available foods/recipes Growth monitoring Referral of complicated cases to a higher level care facility 3. Admission and discharge criteria Admission and discharge criteria remain unchanged. The following documents set criteria at Federal level; National TSFP guidelines Operational guidelines on i-bsfp SOP Nutrition 4

5 4. Supplies required General TSFP i-bsfp Anthropometric equipment: height board, weighing scale, MUAC tapes Register for children under five Register for children under three IEC materials Register for PLW Register for PLW Drinking water Ration cards for children under five Ration cards for children under five Immunization guide Ration cards for PLW Ration cards d PLW WHO reference tables Referral slips Referral slips Home visit form Routine medication i-bsfp ration Toys TSFP ration i-bsfp guidelines Cooking pots, Plates, cups, spoons Mats Bags for distribution of rations 5. Delivery platform National TSFP guidelines Ideally the programme should be run from a fixed nutrition center (particularly in camp settings) but where a significant number of beneficiaries live far away from the center (rural settings or sparsely populated communities), a mobile team can deliver services at least once a month to distant communities within the catchment area of the center. Transportation of the mobile team and food should be provided to facilitate this process. Health centers are not ideal for the integrated TSFP/i-BSFP because of the large caseload involved. Therefore nutrition specific centers are preferable with strong referral to OTP/SC. 6. Caseload calculation With this approach, we would be able to scale up high impact interventions for children and women in Sudan through strengthening synergies between various modalities. TSFP caseload: = Caseload = Conversion factor from prevalence to incidence. ( ), where project duration in months. For a 12 months project, ( ) = 2.6 = Global Acute Malnutrition (GAM) prevalence = Target population (6 59 months or PLW) 5

6 = Coverage estimate This caseload estimation includes the OTP cases referred back to TSFP for follow-up. i-bsfp caseload: = Caseload = Target population (6 36 months or PLW) = Coverage estimate Note: The nutrition unit has developed a caseload calculator (Excel) that can be used for convenience. The calculated caseload should be used as a guide and can be adjusted based on monitoring/reporting data from CPs that have ongoing projects. Adjustments made from the calculated caseload should be justified. 7. Staffing 2 Figure 3: Staff structure for integrated TSFP/i-BSFP 2 At a nutrition center where the CP implements OTP as well, the positions of Nutrition Coordinator, Guard and Storekeeper can be cost-shared. 6

7 Basic tasks and responsibilities (none exhaustive list): Nutrition coordinator o Plan and coordinate the overall project implementation o Organize refresher training on TSFP, i-bsfp, anthropometric measurement, nutrition and health counseling for staff. o Prepare a monthly report on all i-bsfp activities o Take a lead role in designing and coordinating the implementation of KAP surveys or any other studies pertaining the programme as required o Coordinate with other stakeholders from the nutrition sector active in the project area and at State level i-bsfp Nutrition assistant o Manage all i-bsfp activities at the nutrition center o Supervise the community mobilizers and assist them to develop the activity plan and monitor its implementation. o Support the establishment of the women clubs and closely monitor their functioning and the messages delivered. o Conduct regular follow up meetings with community mobilizers to assess their performance and to discuss their activity plans. TSFP Nutrition assistant o Manage all TSFP activities at the nutrition center o Work closely with i-bsfp team, SMoH and WFP to ensure that the TSFP protocols are followed. o Supervise the community mobilizers and assist them to develop the activity plan including active screening and outreach. i-bsfp Data clerk o Manage all i-bsfp data at the nutrition center o Ensure all data collected during the screening and routine sessions are recorded in the registration books o Prepare all necessary data for the drafting of the monthly statistical report of the center TSFP Data clerk o Manage all TSFP data at the nutrition center o Ensure all data collected during the screening and routine sessions are recorded in the registration books o Prepare all necessary data for the drafting of the monthly statistical report of the center Measurer o Ensure anthropometric measurements (height, weight, MAUC, oedema) are taken as required to determine nutrition status. Storekeeper o Ensure proper storage and handling of WFP s commodities o Monitor the food movements and ensure that the food issued coincide with the beneficiaries count all the time. 7

8 o Perform regular stock inventory, reconciliation, preparation and maintenance of records in collaboration with the Data Clerk. Food distributor o Manage the mixing, packing and the distribution of dry ration for children (6-35 months) and PLW, as well as the preparation of the wet ration for children accompanying their mothers in Women clubs. o Conduct cooking demonstrations and ensure that preparation of wet ration (porridge) is done according to the hygienic standards. Community mobilizer o Conduct health and nutrition education sessions during women s clubs meetings on appropriate child feeding practices, food preparation and food hygiene. o Ensure all cases of malnutrition are referred to the respective TSFP, OTP or SC. o Carry out home visits to follow up on children who are defaulting from i-bsfp, not gaining weight well in spite of, counseling, or those who are sick or those who have been referred to SC/OTP/TSFP o Assist in implementing activities at the nutrition center during distributions as required Guard o Ensure that all items, equipment and tools at the nutrition center are kept safely. o Maintain order at the center during distribution days Cleaner o Ensure the nutrition center is clean and hygiene and sanitation standards are applied. 8. Reporting CPs should submit separate TSFP and i-bsfp monthly statistical and narrative reports using the reporting templates shared (see guidelines). In TSFP, the reports should contain the number of children discharged as cured, defaulted, died or non-cured while in i-bsfp the report should include number of children in the cohort showing weight gain, loss or static. Annexes Food requirement template Caseload calculator Budget template 8

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