Fighting childhood malnutrition
How an ESTHER partnership builds on past experience
Improving child survival in Tanzania is the goal of Maja Weisser, an infectious diseases specialist from Basel, Switzerland, and Getrud Mollel, a global health professional from Kilombero, Tanzania. The recipients of a CHF 99’862 ESTHER grant to improve screening for childhood malnutrition in Tanzania talk about the benefits of their partnership.
Published: 20. November 2020, Author: Jeannie Wurz
Jeannie Wurz: You were awarded almost CHF 100’000 by ESTHER. Was that for a project that already existed or for something completely new?
Maja Weisser: This is a new project, which connects to a previous one. Getrud had already been involved in setting up a malnutrition project within the St. Francis Referral Hospital, but of course as you’re working in the hospital you quickly realize that the challenges that exist affect not only the hospital but the whole area. This grant is for a completely new idea, but it should fit in the existing structure. It’s concentrating on the district and on prevention and screening, and can benefit from Getrud’s previous experience.
What is the problem or need you’re addressing?
Getrud Mollel: We have been implementing a hospital-based programme for malnourished children since 2016. It is mainly based in one facility, the St. Francis Referral Hospital, which is in the Kilombero district. Over the years we have observed that there is a problem of late presentation of children with malnutrition. This is also supported by a national survey showing that the prevalence of chronic malnutrition is around 31.8% among children 5 years and under in Tanzania.
So from the national survey we know that there is a problem of childhood malnutrition or undernutrition, and the lesson we learned from our facility-based project implementation is that the children are coming late to the facility, which leads to most of them requiring hospital admission instead of outpatient care. This increases their risk of dying from the condition.
How are you addressing the problem through the current ESTHER partnership?
Getrud Mollel: We want to build the capacity of seven health care facilities in the district to screen for and diagnose malnutrition. This will result in fewer referrals coming to the St. Francis Hospital, because the know-how will be transferred to the facilities. We are also going to address late presentation by increasing the screening for malnutrition. We will do community awareness events, index screening and blanket screening for malnutrition among children in the villages where these facilities are based. This is a continuation of our earlier work, and it’s only possible due to a strong clinical platform. The Chronic Disease Clinic of Ifakara is sustained by the long-standing collaboration between the Swiss Tropical and Public Health Institute—the SwissTPH—and the Ifakara Health Institute, or IHI.
How many children are affected?
Getrud Mollel: Kilombero district in South-Eastern Tanzania has a population of about 600,000. From 2017 to the end of 2019 we identified 704 children with malnutrition. More than half of these required hospitalization, and the other half were managed on an outpatient basis and went home. Besides suffering from the morbidity and mortality associated with malnutrition, these children are also at an increased risk of long-term cognitive and physical health impairment. They have a high risk of giving birth to malnourished children later in life, which perpetuates the vicious cycle of poverty.
However, according to our national guidelines, if there is adequate screening and people present for care early enough, you will be able to treat up to 80% of the patients without requiring hospital admission. What we want is to increase the capacity of health centres to screen and treat these cases so that patients do not have to wait until they can afford to travel to St. Francis hospital. The ultimate goal, if malnutrition is adequately screened and managed over time, is hospital admission of no more than 20% of those children.
Are the children malnourished because their parents are feeding them the wrong foods or is it because there isn’t enough food?
Getrud Mollel: There are so many causes of malnutrition. These might include underlying diseases—HIV, tuberculosis, cerebral palsy. But it might also be poverty, the family’s economic situation, which leads to insufficient intake of required nutrients. It could be lack of enough food, or just having one kind of food—for example, carbohydrates. There is also the issue of knowledge—are the parents aware of how a child is supposed to be fed? What nutrients should go into a child’s meal? Can they afford the foods that they need? So it’s really an interplay of factors.
What are you trying to change?
Getrud Mollel: What we hypothesize in our proposal is that malnutrition is a problem that is likely not to affect just one person in the family, especially if there are children under age 5. Thus, if a mother brings a child to a facility and the child is diagnosed as malnourished, we are going to send a community health worker to their home to screen their siblings.
How does this project contribute to health system strengthening?
Maja Weisser: In a previous ESTHER partnership we focused on early diagnosis of HIV in infants of mothers with an HIV infection. We trained healthcare staff in charge of HIV management in peripheral facilities in the Kilombero district. With that project, we developed important contacts and collaborated with the district representatives of the Ministry of Health and implementing partners in the area. So we were able to strengthen collaboration on a regional and national level.
An important contact for this project is the Tanzania Food and Nutrition Center (TFNC), which is the technical arm of the Ministry of Health in matters concerning nutrition in Tanzania. It was through TFNC that Getrud was invited to participate in the review of national guidelines for malnutrition management, and appointed as a national trainer in the management of malnutrition. Sustainability of the partnership relies greatly on collaboration with the Ministry of Health and the key stakeholders that manage health projects in Tanzania.
What do the Swiss partners bring to and get out of the partnership?
Maja Weisser: This partnership is part of a long-term collaboration. The Chronic Diseases Clinic in Ifakara was founded in 2004 with the aim of delivering services to the many patients with HIV/AIDS. It was one of the first rural HIV care and treatment centres in support of the National AIDS Control program. Since then, the four collaborating institutions—Swiss Tropical and Public Health Institute (STPH), Ifakara Health Institute, St. Francis Referral Hospital and also the University Hospital Basel—have been working together to build up and strengthen the platform of the Chronic Diseases Clinic. In addition, such collaborations as the current ESTHER support give us the opportunity to learn from each other. We learn from the way we seek solutions. We learn through dialogue with community members, patients, and healthcare providers. And we learn to identify solutions that are locally feasible and acceptable and can possibly also be extrapolated to other settings.
Do you also conduct research?
Maja Weisser: The current project is an implementational project, but at some point we would like to capture the data and analyze them scientifically. The numbers will allow us to better understand the situation in the district and we will be in a better position to provide evidence-based information to local policy makers.
For me, the innovative part of this project is the Index testing. The concept that if one member of the family is affected, others might be as well, comes from HIV implementational science, and thus from the perspective of infectious disease. However, for undernutrition as well, if you go to the environment, the family, there is a high chance that you’ll find other family members who are affected. If we can show this scientifically, then it could lead to an intervention which would be interesting not only for our area, but for many areas in rural Tanzania, or other rural parts of the world.
What do you hope to achieve through the partnership?
Getrud Mollel: My goal is to initiate sustainable care of malnutrition at the health centre level. This includes early detection and adequate management at nearby facilities, and avoidance of long-distance travel to seek medical care.
Maja Weisser: For a mother, the health and well-being of her children is of utmost importance. If we can show mothers how healthy nutrition contributes to the development of their children, and where they can go for support, everyone benefits. Mothers will pass their experience onto many others, contributing to the well-being of their children, their families, and their communities. With our earlier ESTHER project, we realized that you can really make a difference by bringing partners together. This kind of collaboration is a great opportunity to join forces and to make more out of individual attempts. We’re glad that we can build on our earlier experience.
Getrud Mollel was born and raised in Tanzania. She holds a doctor of medicine degree from Muhimbili University in Tanzania and a master’s degree in Global Health Development from University College London. Since 2016, Getrud has been a researcher and a clinician at Ifakara Health Institute (IHI) in Tanzania, overseeing family-based care for children affected with HIV and actively engaging to strengthen care for malnourished children at the St. Francis Hospital.
Maja Weisser grew up in Basel, Switzerland. As a physician she has specialized in Internal Medicine and Infectious Diseases, concentrating on infections in immuno-compromised hosts. In 2015 she joined the Chronic Diseases Clinic in Ifakara, where she coordinates research activities and supports the team in management of the clinic. Maja divides her time between Ifakara and the Division of Infectious Diseases of the University Hospital Basel, where she leads the clinical consultation service.
Over time, services for tuberculosis, the main co-infection in people living with HIV, were integrated. The One Stop Clinic was built up – a family-centred care model for HIV-affected families, a malnutrition clinic for HIV-positive and HIV-negative children was integrated. Recently, chronic care for non-communicable diseases has been added, such as programmes for patients with arterial hypertension, heart failure and chronic lung diseases. Funding for the CDCI is also a joint action, with major involvement of the Canton Basel-Stadt in Switzerland, national health programs and international partners for HIV programs as well as project-related and research-based grants.