DAKAR, 7 June 2010 (IRIN) - A lack of transport, pastoralist lifestyles and pressure on women to prepare fields for harvest mean severely malnourished children are being taken out of therapeutic feeding programmes before their treatment is complete, say aid agencies.

In some remote rural areas, health centres, where treatment takes place, are too far away for families to reach at all.

One in five severely malnourished children registered in Médecins Sans Frontières (MSF) feeding programmes in Zinder and Maradi provinces in the south drop out because they are travelling from Nigeria, said MSF head Patrick Barbier.

Treating severe malnourishment takes up to eight weeks of intensive feeding, on average, says Save the Children.

Despite drop-outs, week-on-week the number of severely malnourished children being registered in therapeutic feeding programmes is on the rise, with a jump of 8,000 cases just last week, says the UN Children's Fund (UNICEF).

Aid agencies have admitted 84,000 severely malnourished children into care since the beginning of the year, said Flora Sibanda-Mulder, nutrition cluster coordinator for UNICEF in the capital, Niamey.

Save the Children's head of programmes in Niger, Severine Courtiol, warned that in the remote southeastern province of Diffa, where the organization works: "We are seeing the situation get worse and worse. People have no coping mechanisms left – they have exhausted most of their food stocks... Even though we [Save the Children] are managing to cope, the situation is likely to deteriorate over this month and next."

The organization plans to extend its nutrition support to all health centres in the Diffa districts in which it works.

Why drop-outs and non-attendance

In Zinder and Maradi: "It takes the children and their mothers too long to go back and forth to the centre. Husbands don't want their wives and children to stay there in the centres unaccompanied for long periods of time; and it's the start of the harvesting season - women prepare the fields - so they are being called home," Barbier explained.

However in parts of Diffa, many families find it hard to access health centres at all.
In some areas, 70 percent of villages are more than 15km from health centres, with some villages 50km away, said Courtiol.

"It can take three days to walk there [to the centre] and three days to walk back, so by that time they have to leave again," she said.

Global acute malnutrition rates in Diffa province were the highest in the country, at 17.4 percent, according to the last survey in June 2009. New surveys are under way and figures will be available in coming weeks.

Many pastoralist families in northern Diffa do not stay put, so cannot be reached, she said. "We may return to a site one month later and find the village has disappeared... It makes following up on severe acute malnutrition [SAM] cases very complicated."

Children undergoing intensive feeding ideally need to be monitored weekly to ensure they are gaining weight, have no other health complications, and that the high-calorie food they are given is not being diverted to other family members.

Save the Children is trying to improve referrals of severe cases between health centres and hospitals, but in Diffa the telephone network is weak, so communication is challenging.

NGOs are plugging some of the gaps of health staff and medicines at some hospitals. Children under five and pregnant women ostensibly receive free healthcare in Niger, "but even if it is free, you still need enough medicines to be able to provide it", said Barbier.

Seeking solutions

With some cases, Save the Children gives one-month's worth of treatment at a time to mothers who cannot come weekly. "We are studying various alternatives to adapt to the geographical constraints we face so we can reach as many children as possible," Courtiol told IRIN.

The NGO is also considering setting up referral systems between health centres, and health posts at the village level so families on the move can access rations and a medical check-up wherever they are in the vicinity.

Programming in such a harsh environment is expensive - the NGO needs a much higher budget in Diffa than in other regions. "We are studying all these options. We are learning. The programme is a lot of work for a limited population but even if it's complicated we should work there because every child has a right to food and health," said Courtiol.