Under What Circumstances Should an NRC Be Built?
In deciding whether an NRC will be required, planners should consider two factors: the expected number of beneficiaries and the potential of existing local facilities.
- Number of local beneficiaries
If the problem is limited to a few cases of malnutrition, it is usually possible to have them admitted to a local health facility. Serious nutritional emergencies involving large populations, in contrast, produce a heavy "demand" for nutritional care. In this case, the establishment of facilities designed expressly to meet that demand must be considered.
- The potential of existing local facilities
The degree to which local facilities can meet demand varies from one situation to the next. It should be noted that in most developing countries, the relevant health services, particularly pediatric services, are already overburdened. A massive influx of patients suffering from severe malnutrition and requiring 24-hour care exacerbates an already precarious situation.
When the number of beneficiaries exceeds the capacity of the local facilities, the construction of autonomous NRCs must be contemplated.
What Kind of NRC Should Be Built?
Theoretically, an NRC should be able to provide all the types of NRP that treat the severe forms of malnutrition. For practical reasons, however, the usual procedure is to construct units differently depending on whether the beneficiaries will be treated on a residential or outpatient basis.
• Day-care NRCs operate for a limited period of the day. However, since beneficiaries must be given at least four meals a day for effective nutritional rehabilitation, such centers should operate for 8-12 hours a day.
• 24-hour (residential) NRCs are able to accommodate cases of severe malnutrition which necessitate the implementation of category II NRPs. In terms of organization, they are similar to hospital facilities, with a permanent staff working in three eight-hour shifts, a night nurse, etc.
Medical Services in the Centers
Medical personnel are necessary in all NRCs, although their importance depends on the type of NRP implemented in the center. For category I NRPs, medical services are limited to ambulatory care for the most common medical problems, though provision should be made for referring cases that are beyond the center's medical capacity - either to the closest local hospital or a residential NRC.
For category II NRPs, a greater medical presence is required, owing to the seriousness of the medical problems so often associated with acute malnutrition. Care must be taken, however, not to fall into the trap of pediatric hospitalization, in which the feeding aspect becomes secondary to the purely medical aspect. Here again, the size and level of the medical staff will depend on whether the most serious cases can be referred to the local hospitals.
• Certain preventive measures are imperative:
- immunization against measles
- the systematic administration of vitamin A
- protection against the cold
- the organization of health-education meetings for mothers
• Other measures are less important:
- the systematic treatment of intestinal parasitic infestations (mebendezole, only for children over 12 months of age).
- immunization against other communicable diseases 74
74 Health workers should seize the opportunity of easy access to the children under their care to immunize them according to the procedures recommended in the framework of the Expanded Program of Immunization (EPI).
Areas of Responsibility in a Nutrition Rehabilitation Center
The Practical Organization of an NRC
Numerous manuals offer organizational blueprints for setting up an NRC. 75 Some general principles (management of large groups, adaptation of architectural features to activities) will be discussed in Chapter 5 ("Medical and Surgical Care").
75 Among the best known are:
C. de Ville de Goyet et al., The Management of Nutritional Emergencies in Large Populations (WHO, 1978);
Oxfam's Practical Guide to Selective Feeding Programmes (Oxfam, 1984);
Annex 6, "Therapeutic Feeding," in Ron Ockwell, ed., Assisting in Emergencies (UNICEF, 1986), p. 260. Médecins sans frontières, Nutrition Guidelines, 1st Edition, 1995.