Enabling the Treatment of Severe Acute Malnutrition in the Community: A Study of a Simplified Algorithm and Tools in South Sudan – June 2018 – Final Report – South Sudan



Malnutrition in South Sudan is pervasive due to factors such as widespread illnesses (especially malaria, diarrhea and pneumonia), poor health infrastructure and access to timely and effective treatment, Unrecommended diets widespread for infants and young children and the inconsistent availability and accessibility of a diverse diet. In South Aweil County, the prevalence of Global Acute Malnutrition (GAM) remains above the national average and above the emergency threshold of 15% to 17.7%. A survey by the International Rescue Committee (IRC) in Aweil South County showed that nearly 60% of severely malnourished children were not receiving treatment for severe acute malnutrition (SAM) in static facilities, with caregivers identifying the main obstacles to access to care such as distance to facilities, inaccessibility due to the rainy season and high opportunity costs.

IRC has developed innovative approaches to increase access to treatment for acute malnutrition. Recognizing that long journeys to facilities result in high opportunity costs for caregivers, IRC has developed simplified tools and a simplified SAM treatment protocol to enable low-literate community distributors to treat more malnourished children. near their place. This included the development of a modified Arm Circumference Ribbon (MUAC) with smaller colored areas to monitor progression, regression, and stationary cases and a visual sticker on the scale when weighing children to count the number of ready-to-use therapeutic drug sachets. food (RUTF). Previous studies from Bangladesh have shown promising results in terms of how community-based models for treating SAM can be. However, models for low literacy and crisis-affected settings have not yet been explored.

Goal of the study

To assess the feasibility of community-based distributors in South Sudan providing treatment for uncomplicated cases of severe acute malnutrition at home.

Study period

March – September 2017

Methodology of the study

A total of 60 CBDs from four payams in Aweil South County were selected for training by simple random sampling. All of the selected CBDs were women, had no formal education, lived more than 5 km from the nearest health center, and were accessible during the rainy season. After confirmation of removal from the health facility, three DBCs were excluded and fifty-seven DBCs remained to participate in a six-day training course on simplified tools and the SAM treatment protocol. Immediately after completing the training, CBDs participated in an assessment where they were assessed on their performance in treating a SAM case using a standardized performance checklist. Only the CBDs having obtained a score above the threshold score determined a priori of 80% were qualified to pilot a treatment in the community. Based on their performance scores, 44 CBDs were selected for the implementation of the study.

Between March and September 2017, 44 CBDs admitted and treated 320 children with uncomplicated SAM aged 6 to 59 months. Study staff made bi-weekly supervision visits during which they observed CBD while providing SAM treatment to admitted children. During each performance check, study staff completed a standardized performance checklist to monitor CBD’s ability to correctly use the simplified tools and follow the simplified treatment protocol. Data on the child’s progress and treatment outcome were retrieved from the patient register, including weekly MUAC measurement and number of RUTF sachets distributed per week.


Performance scores calculated from the standardized checklist were collected for the 57 CBD immediately after training. The participants obtained an average performance score of 94%, 91% of the participants passed the a priori determined threshold of 80% and 49% obtained a perfect score. For the 44 best performing CBDs selected for the implementation of the study, the mean score increased from 97% immediately after training to 82% during the first supervised home treatment, but during the last supervised visit, the score had increased up to 94%. Among the key characteristics of CBD (age of CBD, number of years worked as CBD, performance checks carried out), only the number of performance checks had a statistically significant association with the performance score of the last visit of supervision carried out (for each visit carried out, there was an increase in the performance score of 2%).

The rate of CBD-treated children who recovered from SAM to the moderate acute malnutrition (MAM) threshold was 91%, exceeding Sphere’s 75% standard and the remaining 9% failed. The median duration of treatment among those who recovered from MAM was five weeks. The cure rate of children admitted by CBD for treatment of SAM to complete recovery was 75%. The median duration of treatment among SAM cases who fully recovered was 8 weeks. Fifteen percent gave up and 9% did not respond after 16 weeks of treatment. No deaths have been reported. Thirty-seven percent of admitted children were referred, the majority (94%) for a protection protocol that the study team added for children remaining in a MUAC color for four consecutive weeks (as an indicator of problems with underlying health potential). Twenty-nine percent of children admitted for CBD treatment fell into the more severe red PB zone (9.0 – 10.25 cm) on admission compared to the pink PB zone (10.25-11.5 cm). A significantly smaller proportion of admitted children were in the red zone of the outpatient therapy program during the same period.


This study demonstrated that low-literate CBDs in South Sudan were able to treat SAM children at home with high precision using a simplified protocol and tools and achieve acceptable recovery rates. Performance scores were higher among those who received more supervisory visits. The cure rate of children enrolled in treatment met Sphere’s minimum humanitarian standards despite treating children with lower MUAC at admission compared to facility, showing that the deployment of CBD to treat SAM in areas with high prevalence and low access to treatment can lead to earlier treatment finding and timely case finding. Based on the percentage (84%) of children reporting not having recently received treatment and the proportion of children with low MUAC at admission, we suspect that the delivery of CBD treatment improved performance. timely access to care. A larger operational research study will be needed to assess the most effective and efficient monitoring and supply chain mechanisms to operationalize the scale-up of CBD treatment and to quantify the cost-effectiveness of such a program and its impact. on access and coverage.

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