Action Against Hunger

Health and Nutrition Department

Kabul IMAM Program (D5T Project)

Monthly monitoring report to KPHD

  Name Position
Report submitted to: Dr. Abdul Wakil Ahmadi Kabul Provincial Public Health Director
 Dr. Sayed Mohammad
Report submitted by: Nutrition program Manager
Munir Fatemi
Period covered: Jun – Sep 2018 ( 4 months) 
Submission date: 11/11/2018  

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 1. Main recommendations to KPPHD

Main challenge Recommendations

HFs staff are not present or available for
OJT.
HFs staff interest is very low for the
implementation of OPD SAM program. 
(They mentioned without incentive they
can’t support OPD SAM)
Nutrition counsellor implement OPD
SAM beyond their JD due lack of support
of HFs staff in most of HFs.
 KPHD/HF directors to inform HFs staff to participate
in OJT with full attention and to give priority according
to ACF plan (one day per week per person).
KPHD to motivate HFs director to provide roving plan
for HFs staff (Doctor, nurses and midwives) to
implement IMAM / OPD SAM in the targeted HFs.
 KPHD to monitor more regularly HF performances.
 KPHD to remind HF directors HF are in charge of
implementing with support only from ACF and remind
nutrition counsellors JD

 KPHD to revise JD of HFs staff (Doctor, Nurses and

HFs staffs are not always respecting ACF
midwives) to add nutrition related activities.
supervisory team decision regarding
 KPHD inform HFs staff to provide support to ACF
IMAM implementation. (What to do /
supervisory team trough HF directors.
who is supposed to do it / when to do it
 KPPHD to participate to more joint monitoring visits/
etc.)
supervisions with ACF.
RUTF diversion by HF staff
( by bringing force on NC to deliver SAM
 KPHD to investigate all HF concerned and take
cards for their children without child being
appropriate disciplinary measures, and strengthen
screened/ by giving less than prescribed
monitoring visits frequency;
ration to child/by declaring cured children
being defaulters to take discharge ration )
HF names in section 5.
Attempts from some HFs to hire their
 KPHD to investigate all HF concerned and put as stop
relatives in place of current NC by
to those pressures and remind HF directors that
pressuring NC
recruitment process was jointly conducted and
(Rishkhor, Dorahi Paghman, Khoshal mana
validated by PNO and ACF.
and Rahman Mena)
 KPHD to send an official letter to all HFs staff for
The 26 HFs are not respecting official
implementation of IMAM activities in the targeted HFs.
working hours; average length of opening
 KPHD to ensure that HFs staff are respecting official
is of 4:30 hours.
working hours in the targeted HFs.
 KPHD to plan monitoring visits after lunchtime to
HF staff came late to HFs in the morning
check randomly HFs staff presence and working hours.
and left HFs early in the afternoon ,
 ACF to allow nutrition counsellors to adjust themselves
nutrition counsellors were not able to stay
with HFs staff, as it is not possible for women to be
at HFs alone
alone in HFs as there is no any HF staff.

2. Context

ACTION AGAINST HUNGER is currently implementing a Common Humanitarian Fund program, named
“Multi sectoral tailored response to conflict affected internally displaced people (IDPs) and/or at risk
communities in Ghor, Kabul and Hilmand respectively, with particular focus on hard to reach and/or
complex operational districts in Afghanistan”. The project has a three tiers approach: Nutrition/Health -
Water, Sanitation and Hygiene and Protection – Protection and Gender mainstreaming.

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In Kabul, this project is the follow-up of a first program implemented from May.17 to April.18 aiming at
supporting Integrated Management of Acute Malnutrition (IMAM) scaling-up in 26 urban Health Facilities
(HFs) of Kabul. ACF is providing support to Kabul PPHD, direct implementer of IMAM scaling-up. This
year, gender and protection components have been added to the initial rational.

For the coming months of implementation (for Kabul, implementation from May.18 to Dec.18 only), the
main activities to be implemented at HF level are:
 Out Patient Department (OPD) Severe Acute Malnutrition (SAM) services in 26 HFs in South and
West Kabul performed by Nutrition Counsellors (KPPHD staff) trained, supervised and paid by
ACF;
 Growth monitoring promotion for under 2 years children & screening for 2 – 5 years children;
 Performing of IYCF consultation to PLWs by nutrition counsellors;
 On the job training (OJT) and formal training of HF staff (including Nutrition Counsellors) on
IMAM, care practices, gender and protection mainstreaming;
 Nutrition counselling and Health Education sessions for mothers of under 5 years old children (U5)
and Pregnant and Lactating Women (PLWs) focusing on 1000 days, including Infant and Young
Child Feeding (IYCF), delivered by HF staffs;
 Ensure Nutrition Counsellors are able to detect protection concerns (including GBV) while
providing nutrition counselling, for those cases to be referred by ACF to appropriate structures,
ensuring feedback closing loop.

At community level, the main activities will be:

 Community screening and Mother MUAC strategy (training mothers of U5 on malnutrition
screening) by Community Volunteers;
 Home IYCF sensitization performed by Community Volunteers;
 Community Volunteers, Health Shura members, Community Leaders and Mullahs sensitization and
induction on care practices, IYCF, gender and protection;
 Participate in community level dialogues related to GBV with key community members including
health Shura, community leaders, Mullahs and Community Volunteers to explore and sensitize on
the following issues:

1. Way of life and current practices on GBV

2. Causal attributions of GBV
3. Change phase – which demographics are ready for behavior change related to GBV
4. GBV behaviors and its determinants
5. Barriers, benefits and resources for GBV behavior change
6. GBV approach and activities reflecting data collected through 1-6
7. Facilitate the process of change related to GBV behaviors, beliefs, systems
8. Sustaining changes – community sensitization and health facility capacity building
9. Evaluation of the changes identified on GBV, and
10. Recommendations for future programming.

 Set-up of a referral system with NGOs working in KISs, to ensure SAM U5 access malnutrition
treatment and PLWs/ care takers benefit from nutrition counselling and health education sessions
at HF level (including training NGOs on IMAM);
 Support NGOs operating within KISs to include malnutrition screening if any mass vaccination
campaign;
 Train NGOs operating within KISs on care practices, gender and protection mainstreaming to
ensure their staff are able to detect protection concerns (including GBV) while providing nutrition
counselling, for being able to refer cases to appropriate structures, ensuring feedback closing loop.

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 3. Main achievements during 4 past months

OPD SAM admissions

All admissions - Gender

breakdown
1000
900
800
700
600
500
400
300
200
100
0
May-18 Jun-18 Jul-18 Aug-18 Sep-18

Total New Admissions New Admissions - MALE

New Admissions - FEMALE

Between June (month where NC started their duty, May admissions being only handled by HF staff with
ACF supervision) and September 2018, 2,804 U5 were admitted as SAM or 3,133 since beginning of
project 2nd year.
Cured rate is 90.8%, while defaulter rate is of 9% and death rate 0.1%.

Community screening
During these 4 months, community volunteers screened 15,984 U5 children (7,842 boy & 8,142 girl). 507
U5 children have been referred to nearest HFs and 477 U5 children arrived to HFs (94%). Out of those
477, 456 U5 children were correctly screened (95%) by CVs as being SAM and were admitted to the
program.

During these 4 months, the 116 community volunteers supported by ACF conducted refresher training to
4,703 mothers and trained for the first time 6,285 mothers on malnutrition screening (MUAC and edema).
Since May, 3,664 U5 were screened by mothers, 361 being identified as SAM. 96% of those children
arrived at HF level. When screened, 94% were admitted as SAM.

Growth monitoring
During these 4 months, 8,296 U2 years’ children benefited from first visit of GMP, 3,593 children have an
appropriate increase in weight and height, while 1,515 children are not fitted in weight and height.
During these 4 months, 12,894 children from 2-5 years’ children were screened at HFs, 9,441 children
have good nutrition, 2,274 children detected as MAM, 972 children detected as SAM.

IYCF counselling
During these 4 months, 16,103 PLWs benefited from face to face IYCF counselling form Nutrition
counselors at HFs level. In the meantime, 9,196 PLWs received key IYCF messages from community
volunteers at community level.

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During these 4 months, 1,896 health education sessions have been conducted, 36,656 women (21,972
PLW and 14,684 non-PLW caretakers) benefited from health and nutrition related topics and key
messages shared with them, their attention requested to keep in mind these messages and requested
them to spread & share with their communities as well and they promised to do so.

Formal trainings
- Two days care practice/ gender/ protection mainstreaming training conducted to community
volunteers and 116 CV trained in four batches, this training was organized by ACF.
- One-day care practice/ gender/ protection mainstreaming training conducted to 158 Health
Shura members (106 male & 52 female) in six batches, this training was organized by ACF.
- One-day care practice/ gender/ protection mainstreaming training conducted to 186 community
volunteers members (171 male & 15 female) in five batches, this training was organized by ACF.
- One-day care practice/ gender/ protection mainstreaming training conducted to 11 mullahs, this
training was organized by ACF.
- Two days care practice/ gender/ protection mainstreaming training conducted to HFs staff and 70
staff (20 male MD, 8 female MD, 16 midwives, 11 female nurses and 15 male nurses) trained in
two batches, this training was organized by ACF.

4. Capacitation findings

Supervision frequency sum-up

# of supportive # of Joined
S/ Type of Code of supervision Supervision
Zone District Name of HF
N  HF HF done in 4 with KPHD
months in 4 months
1 South 7 Alluddin BHC 159 16 0
2 South 7 Aqa Ali Shams BHC 152 16 0
3 South Bagrami Bagrami CHC 35 16 0
4 South 7 Bene Hesar BHC 34 16 0
5 South 7 Chehel Sotoon CHC 1767 16 0
6 South 4 Deh Danaa CHC 108 16 0
7 South 7 Dogh abad BHC 175 16 0
8 West 5 Dorahi Paghman CHC 1669 16 0
9 South Bagrami Damane Kamari BHC 2314 16 0
10 West 6 Gul Khana CHC 1673 16 1
11 South 3 Jamal Mena CHC 151 16 0
12 West 5 Khoshal Mena CHC 1668 16 0
13 West 14 Khwahja Musafir CHC+ 2956 16 0
14 West 13 Kakarr BHC BHC 2954 16 0
15 West 3 Mirwais Maidan CHC 164 16 0
16 West 13 Pol e khoshk CHC 3044 16 0
17 West 6 Qala e Bakhtiar CHC 1675 16 0
18 West 6 Qala e Bahador Khan BHC 2953 16 0
19 West 6 Qala e Muslim CHC+ 2955 16 0
20 West 13 Qala e Wahid CHC 3043 16 0
21 West 6 Qala e Wazir Chardehi CHC 1231 16 0

5
 22 South 8 Rahman Mena DH 2313 24 1
23 South 7 Reshkhor CHC 3047 16 1
24 South Bagrami Shena BHC 35 16 0
25 South 7 Wasel Abad CHC 1676 16 0
100 Bestare Dashte 18
26 West 13 DH 170 0
Barchi
TOTAL 105 4

Supervision findings per HF

During these 4 months, ACF team (1 PM, 1 DPM, 7 supervisors) ensured each HF was visited once a week
and OJT have provided during each supervision to HFs staff.

Supervision and OJT feedbacks per HF

Supervision results comparison between May and September 2018

A baseline supervision was conducted as of May 2018. At that stage NC were under training at ACF office;
HF staff were in charge alone of OPD SAM and IYCF counseling with support from ACF supervisor once a
week per HF. Global score of the supervision is of 48% (48% of total points). In September, NC had taken
their position for 4 months. Supervision score is of 84%, or 40% increase, proving efficiency of NC
approach.

Supervision scores per number of HF comparison at

baseline and mid-line
16
14
12
14
12
10
8 9 9
6
3
4 5
2
0
Under 50% Between 50 and Between 60 and Between
0 76 and Between
0 90 and
59% 75 % 89% 100%

Nb of HF May.18 Nb of HF Sept.18

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 5. Nutrition Counsellors pilot follow-up

HR monitoring
No particular issue was faced with NC on an HR point of view except the fact that two nutrition
counsellors (NCs in Rishkhoor & Gual Khana HFs) have terminated, due to unknown reasons. They left
their duty without any official information to HF/ACF/KPHD.

Global lessons learned and recommendations

 Without NC, supervision score was of less than 50%. With NC, after only 4 months, while HF
staff has been trained for 8 months, supervision score is of 84%.
 Keeping NC in Kabul set-up is essential to ensure IMAM quality implementation;
 NC are doing more than their JD, gaping for HF staff lack of time, or interest, or presence within
official opening hours.
 HF staff commitment is weak for the implementation of IMAM program; their JD should be
revised and include IMAM.

6. Overall challenges met at HF level

Lack of motivation, interest and commitment of HF staff

 NC are not more technical in nutrition than other HF staffs (were trained for 25 days on screening
and counselling). However, due to lack of HF staff support, NC do more than their JD (distributing
RUTF, do health consultation) .as out of 26 HFs, only 4 dedicated a staff to IMAM.
 HF staff are not sufficiently present when OJT delivered once per week (not present or only for a few
minutes, after long discussion in each HF to convince them) – they are not technically capable of
implementing IMAM for the majority.
 Some HF director are not supportive to ACF supervisory team and encouraged HF staff not to
cooperate with ACF team.
 Lack of coordination between different section of HF to refer U5 children & PLWs to screening room
to benefit from the relevant service.
 HF staff are leaving early and came late to their duty; NC are not able to stay alone in HFs as no one
staying after a certain time;
 HF guards did not clean screening room regularly, NC and ACF supervisors asked many times guards
support which remained unsuccessful in some cases;
 In most HFs, the pharmacist is not present or willing to keep & distribute RUTF from pharmacy and
said it is not their work to take additional responsibility.

Lack of resources (space/HR/drugs)

 No prescription of routine medicine to newly admitted OPD SAM children in most HFs. HF staff
mentioned that they do not have medicine for nutrition BNFs (shortage of drug most of the time).
ACF has to deliver to HF SAM systematic treatment.
 Caseload too important for NC to see all beneficiaries while HF is opened only half day – beneficiaries
are waiting sometimes very long and for nothing;
 No proper space or room allocated for screening/ counselling room. NCs are not able to provide IYCF
counselling to mothers with confidentiality, which impairs quality of the activity and will of women to
attend such counselling;
 Joined monitoring visits have to be done on a quarterly basis at minimum by KPHD (1 done per
month only for past 4 months);

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 Sometime HF director assigned some staff to implement OPD SAM program, but HF staff were not
present to do so, or they did not act according to standards of IMAM protocol and guideline.

Challenges specific to particular HFs

 NC & ACF nutrition supervisor requested support of guards for queue management in Rahman Mena
hospital, but guard did not support their request and due to more crowed and no queue management
NC did not able to handle her job properly.
 Head of Mirwais Maidan clinic is against implementation of nutrition activities in mentioned HF, he
mentioned the program disturbing our other activities, He did not allow nutrition consoler to admit
more SAM children in OPD SAM program, and he has to approve each child document.
 HF staff did cured some defaulted children and they took RUTF ration for themselves and reported to
ACF patients as cured. As well sometime for absent children (like some BNF did not come on the due
date or missed one another planned visit), HF staff did the same, they recorded that BNF receive
RUTF on the planned visit and took RUTF for themselves ( Khoshal Meena & Dorahi Paghman HFs).

Solved
Exist till
during
Main challenges met at HF level HF Name end of Remarks
current
month
month
- #1 is
1. All 26 HFs did not respecting official working existin
hours. g
2. Director of Rahaman Mena hospital did not - # 2 is
support the program (he did not introduce any existin
staff from hospital to do OPD SAM, no guard g
supported queue management of BNF. - # 3 is
3. No HF staff available to implement OPD SAM in existin
most HFs, only in four HFs introduced staff for g
OPD SAM. - # 4 is
4. HF staff came late to HFs in the morning and existin
left HFs early in the afternoon, only NC is not g
able to stay for full day, as there is no any staff - # 5 is
All HFs.
of HF. existin
5. Low interest of HF staff for implementation of g
IMAM program most HFs. - # 6 is
6. HFs staff are not present or available for OJT existin
and ACF supervisors asking many times from g
them to have participate actively in the OJT. - # 7 is
7. HFs staff are not always respecting ACF existin
supervisory team decision regarding IMAM g
implementation (what to do /who is supposed to - # 8 is
to it /when to do it etc.) existin
8. HFs staff interest are very low for the g
implementation of OPD SAM program. - # 9 is
9. Nutrition cousnellors are implementing OPD existin
SAM in 20 HFs. g

1. Illegally expectation & request of HF staff for - # 2 is - # 1 is

RUTF form NC to provide OPD SAM card. - Rishkhor solved. existin
( Rishkhor, Dorah-e-paghman, Khoshal khan & CHC g
Rahman Mena) - Dorah-e- - # 3 is
2. HF staff did not give full ration of RUTF to BNFs Paghamn existin
and keep some sachets of RUTF for themselves ( CHC g

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 Gul khana & Dorah-e-paghman) - Rahman
3. Not allocated suitable room or place for Mena
screening room ( Dorah-e-paghman, Jamal - Khoshal
Mana, Pole-khusk and chilsitoon). Mena CHC.
- # 4 is
4. Head of Mirwais Maidan clinic is against - Gul Khana
existin
implementation of nutrition activities in CHC
g
mentioned HF, he mentioned the program - Jamal Mena
disturbing our other activities, He did not allow - Pole-eKhusk
nutrition consoler to admit more SAM children - Chilsiton
in OPD SAM program, and he will approve each - Mirwais
children document. Maidan

June to Sept 2018 current challenges met by ACF - Kabul IMAM program
Not respecting opening hours Lack of support
HF HF (7:30 - 4:30) towards
# HF name implementation
type code
of IMAM program
June July August September
(Average of 4
months)
1 Jamal Mena CHC 151 08:30 - 1:00 08:30– 3:00 08:30–02:30 08:30– 2:00 Supportive
Mirwais
2 CHC 164 09:00 - 12:00 09:00 - 01:00 09:00 - 01:00 09:00 - 12:00 Not supportive
Maidan
3 Deh Danaa CHC 108 08:30 - 01:00 08:00–02:00 08:30-01:30 08:30– 12:00 Not supportive
Khoshal Very not
4 CHC 1668 9:00 - 12:00 9:00 - 12:00 9:00 - 12:00 9:00 - 12:00
Mena supportive
Dorahi
5 CHC 1669 9:00 - 12:00 9:00 - 12:00 9:00 - 12:00 9:00 - 12:00 Not supportive
Paghman
6 Gul Khana CHC 1673 09:00 - 12:00 09:00 - 12:00 09:00 - 01:00 09:00 - 01:00 Not supportive
Qala e Wazir Partially
7 CHC 1231 8:30 - 12:00 8:30 - 12:00 8:30 - 12:00 8:30 - 12:00
Chardehi supportive
Qala e
8 CHC+ 2955 09-00- 02:00 09-00- 02:00 09-00- 02:00 09-00- 02:00 supportive
Muslim
Qala e
9 Bahador BHC 2953 9:00 -12:00 9:00 -12:00 9:00 -12:00 9:00 -12:00 supportive
Khan
1 Qala e
CHC 1675 09:00 - 12:00 09:00 - 1:00 09:00 - 1:00 09:00 - 12:00 supportive
0 Bakhtiar
1
Bene Hesar BHC 34 08:30 - 1:00 08:00–02:30 08-30 – 02:30 08:30– 02:00 Very supportive
1
1
Reshkhor CHC 3047 08:30 - 1:00 08:30 - 1:00 08:30 - 1:00 08:30 - 1:00 Not supportive
2
1 Chehel
CHC 1767 08:30 - 12:00 08:30–01:00 08:30–01:00 08:30–1:00 Not supportive
3 Sotoon
1 Aqa Ali
BHC 152 9:00 - 12:30 09:00 - 01:00 09:00 - 01:00 09:00 - 01:00 Not supportive
4 Shams
1
Wasel Abad CHC 1676 8:30 - 12:00 08:30–01:00 08:30–12:30 08:30–01:00 Not supportive
5
1
Dogh abad BHC 175 09:00 - 12:00 09:00 - 12:00 09:00 - 12:00 09:00 - 12:00 supportive
6
1 Partially
Alluddin BHC 159 09:00 - 12:00 08:30–01:00 08:30–02:00 08:30–01:00
7 supportive
1 Rahman Very Not
DH 2313 08:30 - 01:00 08:00–03:00 08:00–03:00 08:00–03:00
8 Mena supportive
1 100 Bestare
DH 170 08:00 - 1:30 08:00 - 1:30 08:00 - 1:30 08:00 - 1:30 supportive
9 Dashte

9
 Barchi
2 Qala e
CHC 3043 08:30 - 12:00 08:30–01:00 08:30–12:00 08:30–01:00 Not supportive
0 Wahid
2
Pol e khoshk CHC 3044 9:00 - 12:00 9:00 - 12:00 9:00 - 12:00 9:00 - 12:00 Not supportive
1
2
Kakarr BHC BHC 2954 08:30 - 11:30 08:00–01:00 08:00–12:00 08:00–12:00 supportive
2
2 Khwahja Partially
CHC+ 2956 08:00 - 12:00 08:00 - 1:30 08:00 - 1:30 08:00 - 1:30
3 Musafir supportive
2
Shena BHC 35 8:00 - 12:30 08:00–01:30 08:00–01:30 08:00–01:30 supportive
4
2
Bagrami CHC 35 8:00 - 1:00 08:00–03:00 08:00–03:00 08:30–02:30 supportive
5
2 Damane
BHC 2314 8:30 - 12:00 08:30–01:00 08:30–02:00 08:30–01:30 supportive
6 Kamari

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