5) Description of health product/service offering: For nearly two decades, northern Uganda has been plagued by a civil conflict between the Lord's Resistance Army and the Ugandan government. The conflict has displaced approximately 1.6 million Ugandans; in some districts, 95% of the population is displaced. Insecurity and instability continue to claim lives and deny countless numbers of Ugandans access to basic medical services. IMC operates mobile health clinics in northern districts of Kitgum and Pader where IMC trains government health workers in the delivery of primary health care, as well as the management of supplementary and therapeutic feeding centers, which are used as training sites. In response to the health crisis in Uganda,IMC is implementing emergency health and nutrition programs in 14 settlements (seven in Kitgum and seven in Pader) covering an IDP population of 300,000. Within the context of its primary health care program, IMC manages supplementary feeding programs and therapeutic feeding centers to address the nutritional needs of pregnant and lactating mothers and children suffering from malnutrition. In order to develop a long-term and sustainable program that involves mothers in these districts, IMC has initiated a new approach to managing malnutrition called Community-based Therapeutic Care (CTC). This project involves producing Plumpynut, a protein-based paste, consists of ground nuts sugar, oil, soy and vitamins. IMC is training women's groups to produce Plumpynut locally, and providing the production equipment and raw materials, including installing a local milling unit to grind the nuts and provide them the necessary ingredients to make a Ready to Use Therapeutic Food (RUTF)that has the same nutritive values as Plumpynut. Developing local production of this new recipe promotes sustainability. The project objective is to improve the nutritional status of malnourished children under five.

6) Description of innovation: Traditionally the management of acute malnutrition includes setting up therapeutic feeding centers (TFCs); however, they are difficult to establish, expensive to operate and often have limited coverage, requiring children to stay in the hospital for up to three weeks. CTC integrates supplementary and therapeutic feeding, hygiene and health promotion and food security intervention with an emphasis on outreach and community-based support. CTC uses Ready to Use Therapeutic Food (RUTF)to treat moderately malnourished children, combined with outpatient drug treatment protocols for the treatment of these children at home and small referral inpatient units for those who require more serious treatment. The CTC approach consists of: · A Supplementary Feeding Program (SFP), where a dry ration of Famix or Corn Soya Blend is provided twice per week, as well as health education and basic medical care · An Outpatient Therapeutic Program (OTP), where severely malnourished children are assessed and treated. (The OTP will be run by MoH clinic staff, but given training and support by IMC). · A Stabilization Center (SC) or phase one of a Therpeutic Feeding Center (TFC). The SCs are reserved for acutely malnourished who are not well enough to be treated at home). · Outreach work · Local Food Production. Imported Plumpynut will be used for the program at least for the first 6-8 months. Plumpynut can be produced locally using peanuts, milk powder, sugar, oil and a mineral/vitamin mix. IMC, in collaboration with the French company Nutriset, DDHS Kitgum, MoH Kambala and Makerere Food Technology Faculty, initiated the production of Plumpynut locally in Kitgum. Local production reduces the costs and makes longer-term interventions more feasible. This program is a major breakthrough, empowering the community and enabling the primary stakeholders in that community (the mothers) to treat their children at home.

7) Operational model: IMC focuses on the delivery of primary health care services, and manages supplementary feeding programs in eight centers and therapeutic feeding programs in the centers in the two provinces. IMC has trained female community nutrition workers to identify the malnourished children under five years of age using the Mid-Upper Arm Circumference tape to determine whether to bring them to the feeding centers. IMC also enlists community health workers, who serve as the main link between IMC primary health care services and beneficiaries. IMC works in collaboration with the Ugandan Ministry of Health and other organizations. Activities include: Providing Plumpynut, Rehabilitating malnourished children through CTC; Producing Plumpynut locally with Ministry of Health and the Makere University Food Technology Faculty; Offering health and nutrition education to caregivers within IMC's existing framework of emergency and primary health care; Monthly monitoring of activities within the center together with District Disaster Management Committee staff; Monthly statistics compiled and shared with stakeholders; and Submit monthly, quarterly statistics and narrative report to the DDHS and UNICEF.

8) Human resources: Nutritionists, in collaboration with IMC's medical director, run the CTC program. IMC has six clinical officers for five outpatient therapeutic program sites and one therapeutic feeding center. The SFP program will be staffed by the existing skilled IMC nutrition program staff, which consists of four people: one registrar, one outreach worker and two nutrition field workers. From the program's outset, IMC has also collaborated with the Ministry of Health staff in all IMC's operational Health Facilities. IMC and MoH Staff will also be working with community volunteers, primarily Community Resource Persons and Traditional Birth Attendants (TBAs).

9) Key operational partnerships: United Nation’s Children Fund (UNICEF) is a key partner in this initiative and finances the Ready to Use Therapeutic Food for six months and for the remaining six months Plumpynut requisition will be based on the local production of Plumpynut by women’s groups. As the lead agency for the health and nutrition sector, UNICEF coordinates activities of the various agencies in the two districts to ensure there is no duplication of activities. In addition, the World Food Program will be responsible for transporting the commodities to the distribution sites. IMC will collaborate with the Food Technology Institute of Makerere University and the Ugandan Ministry of Health.

10) Financial Sustainability

          • Fees charged to clients?: No

          • How do you assure affordability?: n/a

          • Earned incomes as a percentage of operating costs: 0%

          • Other funding sources: IMC plans to seek additional funds from institutional and private donors. The project has the potential to become profitable for the local women's groups once the local production mechanism is put securely in place.

          • Strategy for long-term sustainability: IMC's funding structure, timetable, and choice of partners as discussed above, will ensure the fiancial sustainability of the program. In particular, the cooperative agreement with the Ugandan Ministry of Health ensures long- term stability of the program. Furthermore, IMC will ensure coverage for as long as is necessary to ascertain stability and seasoning of the program, and to put in place additional funds as necessary. IMC will provide support until the program becomes self-sustaining.

11) Current and Future Impact

          • Total number of clients: 38,000

          • Clients in the past year: 10,200

          • Percentage of low-income clients: 100

          • Impact: Although the program is still in the pilot stages,IMC has fostered community ties and a sense of ownership in the community. Its community-centered approach to addressing malnutrition encourages self-reliance and a sense of achievement, effects which cannot be easily quantified or underestimated.

          • Overall "market": In its potential for self-sufficiency and the transfer of skills and knowledge among the women, this project has significant potential in other developing countries. IMC is currently exploring the feasibility of a similar program in South Sudan.

12) Scaling up strategy

          • Stage of the initiative: Start Up stage.

          • Expansion plan: This program is still in its pilot stages. At this stage IMC is still buying Plumpynut and producing it as a secondary back up source. In the remaining six months of the project, it will be produced locally if not available by UNICEF (the current primary funder). IMC has been importing the Ready to Use Therapeutic Food from Nutriset in Paris, but the U.K.-based Valid International is in the process of setting up local production of Plumpynut using local chickpea as the base of the recipe. Efforts are being made to integrate the program with other sector programs such as health education, as well as initiating the local production of Plumpynut where appropriate. Where local production is not an option, community based organizers rely on UNICEF donations of RUTF.

13) Policy change: Increased financial support for the creation of innovative food commodities at the local level and local markets to support their distribution.

14) Origin of the initiative: The approach is based on two fundamental observations: that in-patient therapeutic care is not necessary for most malnourished children, and that the traditional therapeutic care priortizes quality of care at the expense of quantity of care. This initiative was led by IMC Uganda country directory Dr. Ravi Bhupathy (CV available upon request). IMC intends to increase its coverage from ten to twenty percent in Kitgum and Pader. To date, outpatient therapeutic feeding programs have been implemented successfully in Ethiopia in 2000, 2003 and 2004 (IMC and Concern Worldwide); North Sudan in 2001 and South Sudan in 2003 and 2004 (SCF-UK) and Malawi in 2002-2004 (Concern Worldwide).

Contact Information:
Stacey Freeman  International Medical Corps
Director of Resource Development
International Medical Corps
(International Medical Corps is a global humanitarian nonprofit organization dedicated to saving lives and relieving suffering through health care training and relief and development programs.)
United States
Website: www.imcworldwide.org