Formula for success

After two years’ work experience in Cambodia, Kerry Davies talks about how she set up and carried out a project with local staff to tackle the issues involved in identifying and treating children with malnutrition

Before applying to medical school as a mature student, I spent two years working with the Voluntary Service Overseas (VSO) in Cambodia. The VSO provides advisers to non-governmental and international organisations to work at provincial and central level (box 1). Through VSO I worked as a hospital management adviser for Unicef in a remote hospital in Svay Rieng province. When I first arrived in Cambodia, I was overwhelmed by the size of the problems. I just didn’t know where to begin.

Cambodia is one of the world’s least developed countries with an under five mortality of 12.2% and a life expectancy of 54 years. Only 25% of the rural population have access to clean water and 10% to sanitation.¹ Although severe malnutrition exists in Cambodia it has never been identified as a large problem both in terms of the number of children with malnutrition or staff capacity to manage the child’s treatment. The paediatric staff of Cambodian doctors and nurses highlighted two cases in which they were unable to treat these children because they presented with severe malnutrition, diarrhoea, and severe pneumonia. The staff decided to refer both children to Cambodia’s capital, Phnom Penh, because they did not have the capacity to treat them. One child died before referral.

Firstly, it was clear that the staff did not know how to treat malnutrition. Secondly, the treatment included giving the children formula feeds. The made-up formulas are too expensive to buy so the hospital has to make its own using powdered milk, a vitamin-mineral mix, sugar, and, oil. The vitamin-mineral mix is classified as a drug and this created a problem because the drug supply is so poor. The hospital has had to purchase most of its drugs from the money generated by fees paid by patients. This money is reserved for essential drugs, such as antibiotics and anaesthetics. The hospital staff classified the ingredients required to make the formulas as food substances and not drugs so that patients would have to be responsible for purchasing them and not the hospital. The patients presenting with severe malnutrition are poor and cannot afford to pay for the ingredients to make up the formula feeds. Staff were not weighing or measuring any of the children who were admitted to the paediatric ward, so the real extent of the problem was not known. Many patients were likely not yet diagnosed as having malnutrition.

Development and financing

Firstly, we recognised that we had a problem and needed help. This seems obvious but it is just not done in development fields. Projects are lead by donors, and failures may lead to lack of funding or supplies drying up. The hospital is supported by Unicef but their support is very specific in terms laid down by their donors.

We invited a team of doctors from the World Health Organization and the Cambodian Ministry of Health to assess the paediatric services in the hospital and to give us advice. They said that we did not have the knowledge, capacity, or equipment to treat severe malnutrition. Secondly, we highlighted the death of the child in a report to Unicef and WHO by stressing our limitations and asking for funding. Knowing what type of projects large organisations fund is always worthwhile. Just changing the title to include the words “quality improvement” may often secure funds if it fits the organisation’s mission. This had two positive outcomes. Unicef agreed to fund the project and supply equipment. And WHO was at the end of its financial year and had money to spend on quality improvement projects. It ran a training course on the management of severe malnutrition for staff not only at the hospital but in the whole of South East Asia. This prompted interest from the Ministry of Health and soon malnutrition was high on the agenda for change in Cambodia.

Language problem

On paper everything was wonderful, but back at the hospital the new scales and measuring board gathered dust, and essential supplied were not ordered. Looking back, this was because I had approached the project from my own perspective. Although I thought I had fully understood the whole situation in the context of the culture and of the situation in the hospital, I had not.

After spending considerable time with the staff, one nurse finally admitted that none of them had understood any of the training because it had been in English. The handouts were in English and contained many confusing tables about the classification of malnutrition and the corresponding amounts of formula required. In Cambodia, staff do not readily criticise authority, and it is difficult for them to approach senior staff with their own ideas.

I invited a VSO volunteer who was working as a dietitian in another part of Cambodia to spend two days with the staff to teach them the practicalities of making up the formulas and reading the tables. People working in other regions are often happy to help out as it is an opportunity to travel to different parts of the country and often involves hands-on work instead of computer based work or meetings. The staff, who had never even used weighing scales for cooking, were soon able to make the formulas and work out the correct amounts of formula depending on the degree of malnutrition of the child. Now we knew the height and weight of all the children in the paediatric ward we found that the weight of about 90% of the children was below normal, and about 30% of children had severe malnutrition.

Night staff

When reviewing the project again, we found that children were not receiving their feeds in the night because staff were not available when they should have been. It is easy to judge or blame. In our culture we want to become doctors for many reasons. In Cambodia, the main aim, after a regime of genocide, is to put food into the mouths of their children. Now Cambodia is a peaceful country again but salaries are so low (£11; $20; a17 a month) that staff spend lunch times and evenings working privately to supplement their incomes. A compromise was made. A skeleton staff agreed to be available at night but we also bought wall clocks and trained the children’s families how to time the intervals between feeds. They only woke the staff if there was a problem.

A step further

The hospital’s management team got together with all the staff on the paediatric ward to look at what we had achieved so far, and how we could start to build on these improvements. The staff decided that they wanted training on complementary feeding, giving foods in addition to breast milk, and they were keen to set up a room dedicated to the treatment of severe malnutrition. Other staff wanted training in severe malnutrition because they often had to cover the paediatric ward (at lunch times, weekends, and nights).

In response to this, a three day workshop on the treatment of severe malnutrition was held at the hospital. Staff came from the National Paediatric Hospital in Phnom Penh and gave lectures and practical advice on ward rounds. VSO and Helen Keller International, which fights blindness and malnutrition around the world, gave a presentation on complementary feeding and ran a practical session where staff had to make “borbor” (traditional local rice soup) using the correct ingredients for different age groups.

A small VSO grant was awarded to convert one of the side rooms in the paediatric ward as a dedicated area for treating severe malnutrition and for advice about complementary feeding. The room was prepared with paintings of commonly available food in each of the basic food groups—food for growth, foods for energy, and foods for protection from illness. A picture also showed how to make the local rice soup containing foods from each of the three groups.

Outcome and conclusions

The final outcome of the project was that the staff were well motivated and were keen to treat severe malnutrition. Continued support had enabled them to express their opinions and come up with their own ideas and solutions. The families of the patients were involved in the treatment of their children and felt empowered. They spread the word among the villagers that their children were surviving if they went to the hospital. The bed occupancy rate of the paediatric ward rose from 42% to 137% in six months. The staff are planning to run their own workshop on complementary feeding so they can learn about nutrition and educate mothers before they leave the hospital. Staff from other hospitals come on study tours with a view to setting up their own projects on malnutrition.

1. Unicef. The state of the world’s children 2001: early childhood. New York: Unicef, 2001.