This was going to be a bit of a long, and no doubt tedious, email about the frustrations of trying to do anything in Malawi; about how it feels like treading water with all these development projects liberally scattered all over the place, when in reality these step by step programmes are not going to lead to Malawi developing. Sure, they may help some people, but ultimately they aren’t going to do much in the long term. One school by one school does not equal a South Korea. But, this isn’t going to one of those emails.
Yesterday afternoon I got a little over excited about a meeting at Ministry of Health. It was me, the chief nutritionist at UNICEF, the three from the MoH nutrition team and someone from Valid International. We were there to get a preview on the report a consultant has written on the new nutrition programme for the country, and we chosen few are, or will be, key players in how nutrition activities are shaped in Malawi in the next year. MoH are introducing something called CTC – Community Therapeutic Care, which is a complete package of nutrition including nutrition rehab. units, supplementary feeding and outpatient therapeutic care. It’s pretty exciting stuff, as we’re rolling this programme out from June. WFP wise, we’re scaling back our normal programmes where CTC won’t be implemented, but will scale up where it is. Scary stuff, and my baby – my first all district project! Anyway, there we were discussing reporting methods. In my mind, why introduce a massive new programme which needs good reporting structures when the current reporting structures for nutrition activities don’t work? MoH were suggesting we use the same structures, with a focal person for reporting in each district. Great idea, but it’s what we currently do, and it hasn’t worked for three years. For February I received only 68% of NRU reports, despite calling each focal person in each district. Without complete reports I don’t know if the food is running out, what the total NRU admissions are for the country, what the malnourishment trends are for the month – things we kind of need to know in order to send the correct quantity of food. Anyway, I hitched a lift back to WFP after the meeting with Stanley, from UNICEF. I admit to being quite psyched about CTC, as if it works it’s a really brilliant programme. The trial districts which have it are doing so well. But as Stanley pointed out after an outburst of my youthful enthusiasm, a programme which is so resource heavy is not sustainable, and if it’s not sustainable, then what’s the point?
But now for a few horror tales from Lilongwe. Last week an ICU nurse newly arrived from London found a dead body on the floor of Kamuzu Central Hospital. Welcome to the health facilities in Malawi. I realize this sounds very negative, especially when one of things which I think is so great in Malawi is the idea behind the health system. At any government hospital or clinic free health care is provided to anyone. And it’s true, if you have malaria, or need contraceptives, or antibiotics, you can get them for free in even the most remote facility. The same certainly can’t be said of many sub-Saharan African countries. The problem comes with the lack of drug diversity. For example, an epileptic can technically get free treatment to control fitting, but in reality there is no medication. Similarly, anti-retrovirals are free – a really positive step towards preventing HIV transforming into AIDS, as is neverapine (for prevention of mother to child infection), thanks to a generous donation from the Global Fund. But ARVs for paediatrics are still quite rare and the donation was only supposed to last for three years thereby giving the National Aids Commission enough time to source new funding. But of course, this hasn’t happened yet.
A bit of background information: In Malawi there are government hospitals and CHAM hospitals. CHAMs are any hospitals which are remotely religious; Anglican, Catholic, Presbyterian. The central Christian Hospital Association of Malawi (CHAM) doesn’t have any power over these autonomous hospitals, but there are general similarities: clean wards, a doctor per hospital – which certainly doesn’t happen in the government facilities – and lots of qualified nurses. You can always tell a CHAM before you enter a building because they have beautiful gardens and the smell of unwashed flesh doesn’t meet you as soon as you step inside the compound gate. My favourite two hospitals in the whole of Malawi are CHAMs – one called Kapiri in Mchinji, run by Taiwanese nuns, where the staff beam with happiness, and the Livingstonia Mission hospital, one of the oldest hospitals in Malawi. It has a beautiful nutrition education garden based on the six food groups and a very charismatic and enormous wooden cross wearing administrator.
Like other sectors the health system works in a decentralized way, with the district being the top of the pyramid. Per district there is one district hospital, which has a doctor, maybe a rural health centre with a maternity ward, and then lots of health centres and health posts for outreach work. No where except the district hospital will have a doctor and while there may be a poorly qualified clinical officer dotted around the place (a 3 year course) who will do whatever surgery he thinks he’s up to (butchery springs to mind), the likelihood of someone in a village ever seeing a doctor in their lifetime is extremely slim. At the district hospital will be a whole lot of acronyms – the DHO (District Health Officer – rarely a doctor), the DMO (District Medical Officer), DNO (District Nursing Officer), MCH Coordinator (Maternal Child Health) and in 8 of the 28 districts a District Nutritionist, and that’s it, apart from the odd volunteer doctor from overseas. Okay, so in reality a couple of district hospitals don’t have any doctors apart from overseas volunteers. Thyolo district hospital is nearly run by Medicin Sans Frontieres, and the only doctors in Nsanje DH are supplied by VSO.
At CHAM facilities there will be a doctor, nurses, maybe a nun or two, and enough money to feed their patients vaguely nutritious food and change the bed sheets every week. The problem is that CHAMs charge, not much at all, but enough for most people not to be able to go.
But now onto other things. At the moment the rains have stopped, and with this comes the end of the lean season and the beginning of the summer harvests. According to new government statistics if the harvests of the summer crop go well Malawi has 50% more maize than it needs, and just two weeks a go the ban on exporting maize has been lifted. While this is really fantastic news there begs the questions why we are still supplying food to over 250 health centres for supplementary feeding and 96 NRUs?
This past month I have been conducting a mid-term assessment of the emergency supplementary feeding programme. This programme started in November, and is supposed to run until June, thereby covering the lean season and any hiccups with harvest. In October I assessed health centres for their suitability in implementing supplementary feeding along with a Norwegian nutritionist from UNICEF. We targeted only those districts which showed up as red on the Malawi Vulnerable Assessment Map – districts which are supposed to be most food insecure. This left us implementing the programme in four districts in the Central region and five districts in the Southern region. Emergency supplementary feeding is aimed at tackling only those with moderate malnourishment. The programme has very strict criteria. For under 5 year children admission is only by a MUAC (mid upper arm circumference) of under 12cm, or a weight for height ratio of under 80%. Of course if the children has oedema, due to severe protein deficiency, and therefore has swollen arms, they won’t meet the MUAC criteria. BUT, in these cases the child should be referred for an NRU. Supplementary feeding is not going to help a child with oedema – they need specific therapeutic milks. For pregnant and lactating women admission criteria is only with a MUAC of under 22cm. MUAC is a very useful tool for rapid nutrition assessments. A few weeks a go UNHCR were reporting severe malnourishment in the refugee camp in the South, especially of newly admitted refugees, mostly from Ethiopia, Burundi and Eritrea. My boss, the great Lazarus, went down and conducted a rapid nutrition assessment using MUAC, and for the most part it was highly accurate. Anyway, back to supplementary feeding. UNICEF released money for training of health surveillance assistants (usually 5 in each rural health facility) and the nurse/midwife (usually one per health facility) in November. Trainings of supplementary feeding implementation (admission/discharge criteria, how to distribute food, ration size etc) were done in December, and food was also delivered in December. Ah…that was the month of the maniac distribution plan...happy memories. We had reports in January that some centres had run out of food. This was concerning as the distribution plans are based on two months worth of food. The district based WFP food aid monitors did a bit of checking and discovered that admission criteria were not being followed. So, come mid term assessment and I head up to Kasungu, the district with the most health centres in this programme – a whopping 18 facilities. After many attempts of trying to be charming over the phone to Wales Kazonde, the district MCH coordinator, and therefore technically person-in-charge of this programme, he agreed to accompany me on the entire trip. All WFP nutrition programmes are implemented in conjunction with Ministry of Health. In fact everything we do must be on their request. For example, if a health centre needs more MUAC tapes they must write to requet from UNICEF, as UNICEF is not allowed to give directly. This is essential for government capacity building, and for when we pull out, but most of the time it just makes programmes run less efficiently, and is incredibly irritating.
So the results for Kasungu: 3 out of 18 health centres were implementing the programme properly using the correct admission criteria. One centre had no registers on site. We were told the HSA had gone to an outreach clinic and taken the registers with him. So off we went to find him. Once at the clinic - a horrific 45 drive from the health centre on the dire-est of all dire roads, we were told he had gone back to the clinic. So we returned to the clinic, and of course he wasn’t there. The general consensus was that he was with his girlfriend. It was only 2.30pm. The other centres were admitting perfectly healthy children and seemed to be carrying out a type of general food aid to vast numbers of people – up to 1000 in one case. So, no wonder the food ran out. But this makes me wonder, why could three health centres implement properly and the rest not. After explaining the intentions of the programme and the criteria to one nurse she looked so sad I asked her why. Shame she said, shame at getting it so wrong. But whose fault is it? MoH, the MCH coordinator, us for believing MoH would conduct suitable raining, UNICEF for not following through on the use of their non food items? So when you read statistics of how many thousands of people WFP are feeding think about whether they are the right people. I really think our Country Director hasn’t got a clue about what’s going on in the field. My note for record on this mid-term assessment fuelled a panic with him, where as surely he should be more worried about the lack of any food getting to schools for the school feeding programme in the next two months due to a problem with the out put reporting system, or the fact that for emergency school feeding only 4 out of 123 schools in Nsanje have received their high energy biscuits, and even then the reports are that the staff are stealing the rations?
But things continue as normal in Lilongwe. This past month has included an entire week off work, flat on my back, with a three day fever thanks to some hideous biting insect, although it wasn’t malaria this time (wish it had been – easier to cure). And of course when all you want to do is eat lots of fruit and veg and drink gallons of fruit juice, the supermarket – which actually stocked some exciting broccoli, cauliflower and plums the previous week - decided to be out of everything except the bog-standard tomatoes, onions and cucumber. It was not a good week. However, I did learn to make gnocchi from scratch the following week, which was rather thrilling.
So with all this you might wonder why I have decided to stay for a further year. I may end up regretting this, especially as the last month has proved how basic facilities in Malawi are. A volunteer doctor at Kamuzu had a needle stick injury a few weeks back and had to have the HIV post exposure kit couriered over from the UK as the doctor we are recommended to see didn’t have enough medication. But there are times, especially in the field, when you are driving down a dirt track at about 5pm, with the sun incredibly low and those long, beautiful shadows, and the driver is playing his favourite Enriques Englesias tape, and you’ve finished the job and are heading home. All you can see for miles and miles is funny peak after funny peak, and lots of smiling, laughing children playing on the side of the road, and everything seems right in the world.
Yesterday afternoon I got a little over excited about a meeting at Ministry of Health. It was me, the chief nutritionist at UNICEF, the three from the MoH nutrition team and someone from Valid International. We were there to get a preview on the report a consultant has written on the new nutrition programme for the country, and we chosen few are, or will be, key players in how nutrition activities are shaped in Malawi in the next year. MoH are introducing something called CTC – Community Therapeutic Care, which is a complete package of nutrition including nutrition rehab. units, supplementary feeding and outpatient therapeutic care. It’s pretty exciting stuff, as we’re rolling this programme out from June. WFP wise, we’re scaling back our normal programmes where CTC won’t be implemented, but will scale up where it is. Scary stuff, and my baby – my first all district project! Anyway, there we were discussing reporting methods. In my mind, why introduce a massive new programme which needs good reporting structures when the current reporting structures for nutrition activities don’t work? MoH were suggesting we use the same structures, with a focal person for reporting in each district. Great idea, but it’s what we currently do, and it hasn’t worked for three years. For February I received only 68% of NRU reports, despite calling each focal person in each district. Without complete reports I don’t know if the food is running out, what the total NRU admissions are for the country, what the malnourishment trends are for the month – things we kind of need to know in order to send the correct quantity of food. Anyway, I hitched a lift back to WFP after the meeting with Stanley, from UNICEF. I admit to being quite psyched about CTC, as if it works it’s a really brilliant programme. The trial districts which have it are doing so well. But as Stanley pointed out after an outburst of my youthful enthusiasm, a programme which is so resource heavy is not sustainable, and if it’s not sustainable, then what’s the point?
But now for a few horror tales from Lilongwe. Last week an ICU nurse newly arrived from London found a dead body on the floor of Kamuzu Central Hospital. Welcome to the health facilities in Malawi. I realize this sounds very negative, especially when one of things which I think is so great in Malawi is the idea behind the health system. At any government hospital or clinic free health care is provided to anyone. And it’s true, if you have malaria, or need contraceptives, or antibiotics, you can get them for free in even the most remote facility. The same certainly can’t be said of many sub-Saharan African countries. The problem comes with the lack of drug diversity. For example, an epileptic can technically get free treatment to control fitting, but in reality there is no medication. Similarly, anti-retrovirals are free – a really positive step towards preventing HIV transforming into AIDS, as is neverapine (for prevention of mother to child infection), thanks to a generous donation from the Global Fund. But ARVs for paediatrics are still quite rare and the donation was only supposed to last for three years thereby giving the National Aids Commission enough time to source new funding. But of course, this hasn’t happened yet.
A bit of background information: In Malawi there are government hospitals and CHAM hospitals. CHAMs are any hospitals which are remotely religious; Anglican, Catholic, Presbyterian. The central Christian Hospital Association of Malawi (CHAM) doesn’t have any power over these autonomous hospitals, but there are general similarities: clean wards, a doctor per hospital – which certainly doesn’t happen in the government facilities – and lots of qualified nurses. You can always tell a CHAM before you enter a building because they have beautiful gardens and the smell of unwashed flesh doesn’t meet you as soon as you step inside the compound gate. My favourite two hospitals in the whole of Malawi are CHAMs – one called Kapiri in Mchinji, run by Taiwanese nuns, where the staff beam with happiness, and the Livingstonia Mission hospital, one of the oldest hospitals in Malawi. It has a beautiful nutrition education garden based on the six food groups and a very charismatic and enormous wooden cross wearing administrator.
Like other sectors the health system works in a decentralized way, with the district being the top of the pyramid. Per district there is one district hospital, which has a doctor, maybe a rural health centre with a maternity ward, and then lots of health centres and health posts for outreach work. No where except the district hospital will have a doctor and while there may be a poorly qualified clinical officer dotted around the place (a 3 year course) who will do whatever surgery he thinks he’s up to (butchery springs to mind), the likelihood of someone in a village ever seeing a doctor in their lifetime is extremely slim. At the district hospital will be a whole lot of acronyms – the DHO (District Health Officer – rarely a doctor), the DMO (District Medical Officer), DNO (District Nursing Officer), MCH Coordinator (Maternal Child Health) and in 8 of the 28 districts a District Nutritionist, and that’s it, apart from the odd volunteer doctor from overseas. Okay, so in reality a couple of district hospitals don’t have any doctors apart from overseas volunteers. Thyolo district hospital is nearly run by Medicin Sans Frontieres, and the only doctors in Nsanje DH are supplied by VSO.
At CHAM facilities there will be a doctor, nurses, maybe a nun or two, and enough money to feed their patients vaguely nutritious food and change the bed sheets every week. The problem is that CHAMs charge, not much at all, but enough for most people not to be able to go.
But now onto other things. At the moment the rains have stopped, and with this comes the end of the lean season and the beginning of the summer harvests. According to new government statistics if the harvests of the summer crop go well Malawi has 50% more maize than it needs, and just two weeks a go the ban on exporting maize has been lifted. While this is really fantastic news there begs the questions why we are still supplying food to over 250 health centres for supplementary feeding and 96 NRUs?
This past month I have been conducting a mid-term assessment of the emergency supplementary feeding programme. This programme started in November, and is supposed to run until June, thereby covering the lean season and any hiccups with harvest. In October I assessed health centres for their suitability in implementing supplementary feeding along with a Norwegian nutritionist from UNICEF. We targeted only those districts which showed up as red on the Malawi Vulnerable Assessment Map – districts which are supposed to be most food insecure. This left us implementing the programme in four districts in the Central region and five districts in the Southern region. Emergency supplementary feeding is aimed at tackling only those with moderate malnourishment. The programme has very strict criteria. For under 5 year children admission is only by a MUAC (mid upper arm circumference) of under 12cm, or a weight for height ratio of under 80%. Of course if the children has oedema, due to severe protein deficiency, and therefore has swollen arms, they won’t meet the MUAC criteria. BUT, in these cases the child should be referred for an NRU. Supplementary feeding is not going to help a child with oedema – they need specific therapeutic milks. For pregnant and lactating women admission criteria is only with a MUAC of under 22cm. MUAC is a very useful tool for rapid nutrition assessments. A few weeks a go UNHCR were reporting severe malnourishment in the refugee camp in the South, especially of newly admitted refugees, mostly from Ethiopia, Burundi and Eritrea. My boss, the great Lazarus, went down and conducted a rapid nutrition assessment using MUAC, and for the most part it was highly accurate. Anyway, back to supplementary feeding. UNICEF released money for training of health surveillance assistants (usually 5 in each rural health facility) and the nurse/midwife (usually one per health facility) in November. Trainings of supplementary feeding implementation (admission/discharge criteria, how to distribute food, ration size etc) were done in December, and food was also delivered in December. Ah…that was the month of the maniac distribution plan...happy memories. We had reports in January that some centres had run out of food. This was concerning as the distribution plans are based on two months worth of food. The district based WFP food aid monitors did a bit of checking and discovered that admission criteria were not being followed. So, come mid term assessment and I head up to Kasungu, the district with the most health centres in this programme – a whopping 18 facilities. After many attempts of trying to be charming over the phone to Wales Kazonde, the district MCH coordinator, and therefore technically person-in-charge of this programme, he agreed to accompany me on the entire trip. All WFP nutrition programmes are implemented in conjunction with Ministry of Health. In fact everything we do must be on their request. For example, if a health centre needs more MUAC tapes they must write to requet from UNICEF, as UNICEF is not allowed to give directly. This is essential for government capacity building, and for when we pull out, but most of the time it just makes programmes run less efficiently, and is incredibly irritating.
So the results for Kasungu: 3 out of 18 health centres were implementing the programme properly using the correct admission criteria. One centre had no registers on site. We were told the HSA had gone to an outreach clinic and taken the registers with him. So off we went to find him. Once at the clinic - a horrific 45 drive from the health centre on the dire-est of all dire roads, we were told he had gone back to the clinic. So we returned to the clinic, and of course he wasn’t there. The general consensus was that he was with his girlfriend. It was only 2.30pm. The other centres were admitting perfectly healthy children and seemed to be carrying out a type of general food aid to vast numbers of people – up to 1000 in one case. So, no wonder the food ran out. But this makes me wonder, why could three health centres implement properly and the rest not. After explaining the intentions of the programme and the criteria to one nurse she looked so sad I asked her why. Shame she said, shame at getting it so wrong. But whose fault is it? MoH, the MCH coordinator, us for believing MoH would conduct suitable raining, UNICEF for not following through on the use of their non food items? So when you read statistics of how many thousands of people WFP are feeding think about whether they are the right people. I really think our Country Director hasn’t got a clue about what’s going on in the field. My note for record on this mid-term assessment fuelled a panic with him, where as surely he should be more worried about the lack of any food getting to schools for the school feeding programme in the next two months due to a problem with the out put reporting system, or the fact that for emergency school feeding only 4 out of 123 schools in Nsanje have received their high energy biscuits, and even then the reports are that the staff are stealing the rations?
But things continue as normal in Lilongwe. This past month has included an entire week off work, flat on my back, with a three day fever thanks to some hideous biting insect, although it wasn’t malaria this time (wish it had been – easier to cure). And of course when all you want to do is eat lots of fruit and veg and drink gallons of fruit juice, the supermarket – which actually stocked some exciting broccoli, cauliflower and plums the previous week - decided to be out of everything except the bog-standard tomatoes, onions and cucumber. It was not a good week. However, I did learn to make gnocchi from scratch the following week, which was rather thrilling.
So with all this you might wonder why I have decided to stay for a further year. I may end up regretting this, especially as the last month has proved how basic facilities in Malawi are. A volunteer doctor at Kamuzu had a needle stick injury a few weeks back and had to have the HIV post exposure kit couriered over from the UK as the doctor we are recommended to see didn’t have enough medication. But there are times, especially in the field, when you are driving down a dirt track at about 5pm, with the sun incredibly low and those long, beautiful shadows, and the driver is playing his favourite Enriques Englesias tape, and you’ve finished the job and are heading home. All you can see for miles and miles is funny peak after funny peak, and lots of smiling, laughing children playing on the side of the road, and everything seems right in the world.
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