Translational Health Research Institute, School of Medicine, Western Sydney University, Sydney, NSW 2560, Australia.
Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, VIC 3004, Australia.
Int J Environ Res Public Health. 2021 Aug 29;18(17):9113. doi: 10.3390/ijerph18179113.
Community-based management of severe wasting (CMSW) programs have solely focused on exit outcome indicators, often omitting data on nutrition emergency preparedness and scalability. This study aimed to document good practices and generate evidence on the effectiveness and scalability of CMSW programs to guide future nutrition interventions in South Sudan. A total of 69 CMSW program implementation documents and policies were authenticated and retained for analysis, complemented with the analyses of aggregated secondary data obtained over five (2016-2020 for CMSW program performance) to six (wasting prevention) years (2014-2019). Findings suggest a strong and harmonised coordination of CMSW program implementation, facilitated timely and with quality care through an integrated and harmonised multi-agency and multidisciplinary approach. There were challenges to the institutionalisation and ownership of CMSW programs: a weak health system, fragile health budget that relied on external assistance, and limited opportunities for competency-based learning and knowledge transfer. Between 2014 and 2019, the prevalence of wasting fluctuated according to the agricultural cycle and remained above the emergency threshold of 15% during the July to August lean season. However, during the same period, under-five and crude mortality rates (10,000/day) declined respectively from 1.17 (95% confidence interval (CI): 0.91, 1.43) and 1.00 (95% CI: 0.75, 1.25) to 0.57 (95% CI: 0.38, 0.76) and 0.55 (95% CI: 0.39, 0.70). Both indicators remained below the emergency thresholds, hence suggesting that the emergency response was under control. Over a five-year period (2016-2020), a total of 1,105,546 children (52% girls, 48% boys) were admitted to CMSW programs. The five-year pooled performance indicators (mean [standard deviations]) was 86.4 (18.9%) for recovery, 2.1 (7.8%) for deaths, 5.2 (10.3%) for defaulting, 1.7 (5.7%) for non-recovery, 4.6 (13.5%) for medical transfers, 2.2 (4.7%) for relapse, 3.3 (15.0) g/kg/day for weight gain velocity, and 6.7 (3.7) weeks for the length of stay in the program. In conclusion, all key performance indicators, except the weight gain velocity, met or exceeded the Humanitarian Charter and Minimum Standards in Humanitarian Response. Our findings demonstrate the possibility of implementing robust and resilient CMSAM programs in protracted conflict environments, informed by global guidelines and protocols. They also depict challenges to institutionalisation and ownership.
社区主导的严重消瘦管理（CMSW）项目仅专注于退出结果指标，经常忽略营养应急准备和可扩展性的数据。本研究旨在记录 CMSW 项目的良好实践并生成有效性和可扩展性的证据，以指导南苏丹未来的营养干预措施。共鉴定并保留了 69 份 CMSW 项目实施文件和政策，作为分析的补充，并对 2016-2020 年（CMSW 项目绩效）五年至 2014-2019 年六年（消瘦预防）期间获得的汇总二次数据进行了分析。研究结果表明，CMSW 项目实施的协调非常有力且协调一致，通过综合协调的多机构和多学科方法及时提供高质量的护理。CMSW 项目的制度化和所有权面临挑战：卫生系统薄弱，卫生预算脆弱，依赖外部援助，以及基于能力的学习和知识转移的机会有限。2014 年至 2019 年期间，消瘦的患病率根据农业周期而波动，在 7 月至 8 月的淡季期间仍高于 15%的紧急阈值。然而，在此期间，五岁以下儿童和粗死亡率（每 10,000 人/天）分别从 1.17（95%置信区间（CI）：0.91，1.43）和 1.00（95%CI：0.75，1.25）下降至 0.57（95%CI：0.38，0.76）和 0.55（95%CI：0.39，0.70）。这两个指标均低于紧急阈值，因此表明应急响应得到了控制。在五年期间（2016-2020 年），共有 1,105,546 名儿童（52%为女孩，48%为男孩）被收治到 CMSW 项目中。五年汇总绩效指标（平均值[标准差]）为恢复率 86.4%（18.9%），死亡率 2.1%（7.8%），违约率 5.2%（10.3%），无恢复率 1.7%（5.7%），医疗转归率 4.6%（13.5%），复发率 2.2%（4.7%），体重增加速度 3.3（15.0）g/kg/天，项目住院时间 6.7（3.7）周。总之，除体重增加速度外，所有关键绩效指标均达到或超过了《人道主义宪章》和《人道主义应对最低标准》。我们的研究结果表明，在全球准则和协议的指导下，在长期冲突环境中实施强大和有弹性的 CMSAM 项目是可能的。研究结果还描绘了制度化和所有权方面的挑战。
