6. Implementation and management of a feeding centre

Calculating the number of beneficiaries (See Chapter 3, Part III on Screening)

If exact numbers of malnourished children in a population are not known on nutrition survey (see Chapter 4, Part I and II).

Based on a nutrition survey, the target population of the different feeding programmes can be estimated:

- Total population under five = Total population x 20%

- Total population under five x Prevalence of severe acute malnutrition = Total number of severely malnourished children eligible for the TFP

- Total population under - five x Prevalence of moderate acute malnutrition = Total number of children eligible for the targeted SFP.

- Numbers eligible for blanket SFPs depend on which vulnerable groups are being targeted.

Calculating the number of facilities

In order for wet feeding centres to be run efficiently (cooking, feeding, medical and nutritional supervision of the children), feeding centres should not be too big (TFP: maximum 60 - 100 children; SFP: 250 children). The maximum capacity will depend on staff levels and skills and the number of children in intensive care. Above these numbers the programme loses efficiency. With larger numbers of children it is better to increase the number of centres. Moreover, increased numbers of centres allows better geographic accessibility and therefore improved coverage of severely malnourished children.

From this number, the programme needs can be calculated:

- Personnel

- Materials & equipment

Example:

Food availability is very low and is expected to get worse over the next few months.

A nutrition survey has shown high rates of severe and moderate acute malnutrition. Therefore, it is decided to implement a TFP, a targeted wet SFP for malnourished under 5 years and a blanket dry SFP for all children under 5 and pregnant and lactating women.

The actual number of children attending the programme will depend on the accessibility.

Inform the population

Inform the population on the objectives of the programme by organizing meetings with community representatives and during mass screening sessions in the population. A good network of CHWs can also help promote community cooperation.

Construction and location

LOCATION

Feeding centres should be located near a health centre or hospital structure if possible. If there is need for more than 1 feeding centre, their location should be planned to improve accessibility of the programme to the population. Therapeutic and supplementary wet feeding centres need to be within 30 - 45 minutes walk of all the population to be served; dry ration distribution centres should be within a 2 hour walk of all the population to be served.

When several centres for dry feeding are established, it is necessary to choose distribution days carefully and properly identify eligible recipients to avoid double registration.

CONSTRUCTION

· Wet feeding programmes require tents or shelters made out of local materials and plastic sheeting. Buildings should be adapted to climate and the number of people expected to stay during the days and nights. (In refugee populations, the site

should allow for a sudden influx of new refugees). Big tents suffice in emergency situations (25 m² for 12 persons). The whole area has to be fenced off and properly drained (see Annex 17 for lay - out plan).

- A special area for 'intensive care' should be organised in TFPs, where up to twenty children can stay during the early days and nights of their treatment (special areas may also be organized in wet SFPs for treatment of diarrhoea).

· Pharmacy, consultation room.
· Store - room for food commodities.
· Kitchen.
· Dry distribution centres need to ensure a logical flow of people so all registration and monitoring data is collected and food distributed in an efficient way, maximizing patient flow and minimizing food loss (see Annex 17).

WATER AND SANITATION

· Water sources should be protected and chlorinated.

· For wet feeding programmes, a supply of 30 litres of safe water/child/day is recommended, with an absolute minimum of 10 litres/child/day (cleaning centre, cleaning pots and pans, washing hands and children, preparing food, drinking water).

· For dry programmes 0.5 litre/person/day is required for hand washing and drinking - if water sources are not available make sure water is transported to the distribution site.

· A washing area within the wet feeding compound is necessary.

· Latrines can be built at thirty metres distance from the water supply, one for every 50 persons in a wet feeding programme (patients and carers). Bed - pots may be provided in the feeding centre for the smaller children. (Toilet facilities may also be necessary in dry feeding programmes).

Materials and Equipment

FEEDING AND REGISTRATION MATERIALS (See the content of the kits - Annex 22)

If the necessary cooking utensils are not available locally or if the time is limited, specially formulated nutrition kits are available from MSF or OXFAM.

OTHER MATERIAL

· Beds/mats, blankets, bed - nets,
· bed pots,
· lamps, torches,
· waste buckets, etc.,
· fuel (average quantity: 1 m^3 firewood to boil 1000 litres water), - precision weighing scale for KCl (or standard weighing cups).

Staff

Clear job - descriptions, responsibilities and working guidelines for both medical and non - medical personnel are crucial. If job - descriptions and tasks are not clear to the personnel, problems will inevitably arise.

Proper training of both medical and non - medical personnel is essential, before starting the programme. It is better to delay the opening of the centre for some days, until personnel are properly prepared. Continuous on - the - job training and regular formal training sessions for upgrading skills is necessary (see Ref. 11). It is essential to have a good supervision system. This will ensure that, on one hand, trained personnel will keep an adequate level of performance and, on the other hand, it will allow the identification of training needs.

When planning for personnel requirements, do not forget to schedule rest days.

Pharmacy (basic drugs)

Pharmacy requirements are for TFPs:

- Ringer's lactate or Hartmann solution
- ORS (sachet per 1000 ml)*
- Antibiotics (ampicillin, cotrimoxazole) (see Essential Drugs Guidelines, Ref. 8)
- Mebendazole (100 mg tab)*
- Metronidazole (250 mg tab)
- Chloroquine (100 mg tab or 150 mg tab, depending on the national protocol)*
- Vitamin A (200,000 IU cap)*
- Ferrous sulphate (200 mg tab) + folic acid (0,25 mg)*
- Folic acid (5 mg tab)*
- Mineral and vitamin <<cocktails>>
- Potassium chloride (powder) (If no mineral mix available.)
- Vitamin C, B. and multivitamins*
- Measles immunization materials: vaccines, cold chain (fridge in hospital and coolboxes)*
- Aspirin* (300 mg or 500 mg)
- Paracetamol* (100 mg)
- Nystatin (250,000 IU)
- Quinine (200 or 300 mg, depending on the national protocol)
- Benzyl Benzoate* (25%)
- Tetracycline eye ointment* (1%)
- Chlorexydine / Cetrimide*
- Zinc Oxide cream

* may also be required for SFPs

Follow-up of defaulters

Through careful registration in the attendance register, and a clear definition of a defaulter (absence during two consecutive days), defaulters can be detected immediately. Home - visits by the nutrition outreach workers should be scheduled to follow up defaulters.

· Do not reprimand mothers: try to find out the reason for drop - out; they may have very good reasons (work, other sick family members). Or mothers may not attend because their children fall sick in which case it is essential to convince the mother of the importance to come to the feeding centre with the child. Sometimes a solution can be found with the help of the community.

· A frequent reason for drop - out is because mothers do not feel comfortable in the feeding centre and lose motivation to attend. Proper accommodation (i.e. shelter from the sun and rain, clean latrines with adequate privacy and adequate food and water), a friendly atmosphere and continuous explanation to the mother on the course of treatment are essential in preventing drop - outs.

· Another reason for drop - out from the programme may be that the mothers do not like the food offered to them in the centre (HEM, porridge). The provision of food, cooking materials and fuel to mothers to prepare their own meals might make daily attendance to the programme more attractive. Moreover, provision of foods can provide an opportunity for nutrition education.

· If the reason for drop - out is the death of the child, it is important to include that child in mortality surveillance figures.