Framework for integration of management of SAM into national health systems

By Katrien Khoos and Anne Berton-Rafael

Katrien Ghoos is the Nutrition Specialist on Management of Acute Malnutrition ,Nutrition Information Systems, Emergencies and Disaster Risk Reduction with the UNICEF Eastern and Southern Africa Regional Office (ESARO). She is based in Nairobi, Kenya.

Anne Berton-Rafael is the UNICEF ESARO Nutrition consultant for this initiative, based in Nairobi.

Both authors have over 15 years of experience on management of acute malnutrition in emergency, post-emergency and development context.

Update credit to: The authors wish to thank UNICEF ESARO, UNICEF HQ and USAID/OFDA for the support to this work. Special thanks also go to the several individuals and their organisations that already provided inputs to the initiative. These are UNICEF (colleagues from Kenya Country Offices and from Regional offices in Dakar and Amman), ACF-F, FANTA, Valid, Carlos Navarro-Colorado (CDC) and Mark Myatt.

Background

A Baby's MUAC is leasured in the rural village of Marat, Anseba Region, Eritrea

In 2010, UNICEF approached VALID International to design and conduct a global mapping review of Community-based Management of Acute Malnutrition (CMAM) with a focus on severe acute malnutrition (SAM)¹. In addition to this global mapping, regional analyses² were conducted and indicated that 13 countries out of 18³ in Eastern and Southern Africa Region (ESAR) had plans to scale up in 2010/2011. As of May 2010, over half (53%) of CMAM programmes were integrated with Infant and Young Child Feeding (IYCF) and Integrated Management of Childhood Illness (IMCI) programmes. All countries had national coordination mechanisms and in only three countries out of 18, were UNICEF the sole RUTF provider. These findings suggested a certain degree of government ownership and sustainability. However, despite roll out through government services in all countries (except Somalia) at the time of the mapping, most of the inputs to CMAM national programmes were still provided using short term external emergency funding. Also, material and technical support often still came from specialised United Nations (UN) and nongovernmental organisation (NGO) staff. Indeed, in 13 countries, more than 50% of RUTF was provided by UNICEF in 2009, and only one country indicated Ministry of Health (MoH) support for RUTF supplies. Transport of these supplies from national to district level largely happened using a parallel system instead of using the national supply chain. In those cases, UNICEF and implementing partners (e.g. NGO’s) organised transport based on available stocks at national level rather than expressed needs at community level. This description around RUTF supplies is only one example to highlight the lack of a sustainable and systematic approach to scaling up CMAM. Not much has changed since the global mapping exercise.

Another consideration is in contexts where prevalence of wasting is relatively low and as in most Southern African countries, closely related to HIV/AIDS. In such scenarios, with little or no dedicated funding available for CMAM, the approach to integrate SAM management into the health system and create or enhance systematic linkages with existing services was thought to be the most cost-effective, and typically the only option, to scale up community based management of SAM.

The Framework

Given the lack of a systematic approach to CMAM scale up identified in the 2009 global mapping and the need for integration into existing services for a sustainable approach, a framework for institutional integration of management of severe acute malnutrition (IMSAM) into national health systems has been developed and is being piloted by UNICEF (see Box 1).

The general objective of the framework is to support countries in assessing gaps, planning priority actions and guide successful and sustainable scaling up of management of severe acute malnutrition through the primary health care system.

For reasons explained below, the scope of this initiative is limited deliberately at this stage of development of the IMSAM framework.

The six WHO health system (HS) building blocks (governance, financing, human resources, supply, service delivery and health information system) are used as the health system entry points in this proposed framework. A series of field tests were scheduled in order to correct irrelevant elements and finetune promising parts, using different national and sub-national contexts and HS functions of the framework.

The proposed framework is relevant also in countries as part of disaster risk reduction (DRR) and/or resilience building approach, where nutrition emergencies are recurrent (e.g. Horn of Africa). As most of these countries have already integrated parts of CMAM into the health system, this proposed framework intends to further guide the identification and coverage of gaps in sustained integration of CMAM.

Components of framework

The framework is composed of three parts:

• benchmark matrix to facilitate assessment
• a tool (visual) to help summarise main assessment findings
• a planning, monitoring and evaluation tool to facilitate yearly and multiyear planning, monitoring and evaluation.

The benchmarks matrix suggests for each of the six HS components, a series of conditions, referred to as benchmarks⁸, that should be in place in order to help attain a sustainable level of IMSAM into the health system (see Table 1 for an overview). Programme staff must take these into account when planning, implementing, monitoring, and evaluating IMSAM. The benchmarks matrix has three levels as planning, implementing, monitoring, and evaluating are approached differently at national, sub-national/district or community level.

*Maternal, newborn and child health ** RUTF supply falls under this catergory

The benchmark matrix can be used vertically by one of the three implementation levels (national, sub-national/ district, and community) or horizontally by HS function, expressed under the six building blocks (governance, financing, human resources, supply, service delivery and health information system).

The way the benchmark matrix is used depends on national or local priorities, identified by all relevant stakeholders, especially by government services responsible and/or closely involved in CMAM. This flexible use should support CMAM programme managers in defining IMSAM technical and financial inputs in health sector audits, programmatic and financial reviews and sectoral reforms. For example, if stakeholders agree that the objective is to assess human resources (HR) for IMSAM, because investment in HRs for the health sector is planned, the assessors can single out the benchmarks for the HR component (see Figure 1 for an example). Meanwhile the community component can be looked at, for example, in preparation for community health policy development discussions or just for regular yearly, or multi-year, planning or evaluation purposes.

Framework in practice

At this stage of development of the approach, the benchmarks are grouped per level and per HS function on excel sheets (as reflected in Figure 1).

Each level of planning and implement ation (national, sub-national/district, community) corresponds to one excel sheet. On each sheet, the first column corresponds to a HS function and its sub-division (see Figure 2). The second column gives the benchmarks/conditions list followed by a column on guidance, if any.

A woman feeds a child a ready-to-use food as part of a UNICEF-supported nutrition programme in Jowhar Camp, Somalia

Different assessors can assess each benchmark/condition separately according to a range of provided possible scenarios (expressed in columns: highly adequate, adequate, present but not adequate, not adequate at all). This allows for objective and quantitative rating compared to the benchmark/ condition for integration.

A column for comments is included, so assessors can add qualitative comments in addition to the rating, explaining why/how/when. The next column will capture the data sources, followed by the score from interviewees and their names.

The last column will indicate the average score, reflected in the visual tool (see Figure 3).

*Average for all HR section results

As obvious from this description, the final results depend entirely on the opinion of assessors. It is therefore essential to include all relevant stakeholders. Ideally, these are HS specialists, CMAM programme managers, M&E specialists, technical and financial partners, etc. Given the importance of including the right people in the assessment, a mapping of actors prior to the assessment is advised (see below). This will limit the risk of biased results.

Using results of the assessment, the feasibility of addressing the identified gaps can be analysed using the planning tool. This planning tool can be used to facilitate comparison of the target result, also present in the benchmarks matrix as the benchmark or condition, with the existing situation, or identified gap (See Figure 4 for an example). Weaknesses, barriers to change and opportunities are identified, interventions proposed and budget and timelines defined. Once this analysis is completed, proposed actions, timeline, cost, etc. can be put together in a yearly or multiyear action plan. Progress on implementation of the action plan can then be monitored on a regular basis.

Suggested process for use of the framework

At this stage of development of the tool, four steps are suggested. They are composed of:

Step 1: Pre-assessment

As indicated, the framework needs to fit context specific needs. During the pre-assessment step, all country specific details will be agreed. These include: a) identification/ mapping of all relevant stakeholders to be invited to support assessment (government services, donors, CMAM partners, etc.), b) agreement of the scope, time frame, budget and dates of the assessment, c) identification of IMSAM and health systems data sources and documents, listing of identified gaps as well as health system strengthening interventions, etc.

Step 2: Assessment using benchmark matrix

MUAC measurement of a child in Jowhar Camp for displaced people in the city of Jowhar, Somalia

This step starts with a literature review of all relevant documents. These can be HR policies, M&E tools used, data collected from facilities, facility registers, quality supervision reports, administrative and budget documents, supply registration lists, review of training curricula, client exit interviews reports, etc. The benchmark matrix is then filled out by different stakeholders or assessors.

It is important to note that this is a self-assessment (important for stakeholders, especially MoH, ownership) undertaken by a group of experts. It is advised to organise group work in a way that the assessors only assess the benchmarks, or conditions, they are expert on. This also helps keep duration of assessment to a minimum, as different groups can work simultaneously. After the group work, the different results will be brought together and discussed as explained in Step 3.

When available information is insufficient, key informant interviews, e.g. health system users, can be organised in order to complete the assessment. In addition, site visits are highly recommended as they allow direct observation of most of the service delivery components (e.g. facility registers, daily availability of services, stock-out, reports….) and therefore reduce the bias in the scoring.

Step 3: Analysis and validation

During the consensus building meeting, the average rating for each condition is given, visualised and results are reviewed. The presentations and final assessment report should include rating and summary of comments, as rating alone cannot capture all aspects of the conditions. For example, the condition could be present but supported 100% by NGOs and therefore not sustainable.

Steps 1 to 3 are closely linked and implemented during the same exercise, while Step 4 can be organised at a different moment after analysis of assessment results.

Step 4: Development of multi-year and yearly action plan

Starting from the identified gaps (conditions that are not fulfilled, benchmarks not reached), the stakeholders will analyse which gaps they want to address, how these gaps will be addressed and within which time frame using the planning tool (shared earlier in Figure 4). This will be captured in the corresponding action plan. From this exercise, yearly and multi-year action plans can be defined, including a corresponding monitoring and evaluation approach.

Stakeholders can decide to repeat all steps or parts on a yearly or multi-year basis as part of monitoring, evaluation and planning of national CMAM programmes.

Expected results

The process is expected to facilitate national ownership, commitment and sustained adequate investment in the management of acute severe malnutrition and to provide a standardised approach for identification of bottlenecks in scaling up of IMSAM across countries. Even, if the approach is meant to be standardised, countries should adapt the framework to their context.

This approach will allow for development of yearly and multi-year costed actions plans and measuring baseline and tracking progress on IMSAM at the three HS planning and implementation levels (national, district and community level) and for the six HS functions (governance, financing, human resources, supply, service delivery and health information system) for each country, but also per region and even globally. This will enhance country level, regional and global analysis, enable quicker and tailor-made support to countries, improve documentation of lessons learned and facilitate advocacy at the different levels.

In addition, countries will be able to expand existing HS contacts to include relevant nutrition services in a systematic manner. For example, given HIV AIDS is an important cause of wasting in Zimbabwe, management of acute malnutrition is ideally linked to Preventing Mother-to-Child Transmission (PMTCT) services and promotion of optimal IYCF practices, as optimal IYCF practices are known to prevent mother to child transmission. This integrated approach will increase coverage of management of acute severe malnutrition but also improve quality of delivered PMTCT services overall. Ideally, linkages should exist at all HS levels and for all HS functions. These include, for example, that costed IMSAM action plans are linked with health sector development plans and Mid Term Expenditure Framework, indicators for measuring CMAM are included in the Health Management Information System, capacity development for CMAM is part of health sector HR development plan or policy, and supply for IMSAM is planned and implemented through the existing HS supply chain.

Ultimately, the approach can be adapted to include management of moderate acute malnutrition, IYCF, micronutrient supplementation or any other nutrition intervention that can be delivered through the health system.

Lessons learned so far

The approach is participatory and inclusive. Through the self-assessment, all partners are actively involved in sharing of experiences and information. This is believed to enhance understanding of importance of IMSAM, improve overall quality of assessment, reinforce ownership and encourage further collaboration.

Despite the long benchmarks list, the approach is not too ambitious. Depending on available information, the assessment can be conducted in one week. By going through the list, stakeholders realise that more areas can qualify for integration than considered initially. In addition, they may discover documents and policies they were not aware of prior to the exercise.

The composition of the assessors team is crucially important. The presence of health system specialists or health system strengthening specialists is essential. It is necessary to get all key stakeholders fully on board. Therefore, in addition to the initial identification/ mapping of stakeholders, preparation meetings with these key stakeholders and follow up discussions are useful.

The appointment of a facilitator and cofacilitator, familiar with the health system and context, is essential to correctly adapt the framework to the local context, to increase ownership and to translate benchmarks to local context whenever needed.

Some of the benchmarks at sub-national/ district or community level directly depend on benchmarks at national level. It may therefore be helpful to conduct national level assessment prior to any other level, or a HS function assessment.

The main limits of the tool are the quality of the data available and the composition of groups of assessors, as indicated earlier. Other aspects to take into account are the different areas covered by the tool. Indeed, not all participants are familiar with all components. In that case, the creation of sub-groups can be useful. Hierarchical and other links between the different participants need to be considered when establishing the groups.

The assessment and planning exercises should be planned and conducted separately.

Issues being addressed

Terminology

Different terminologies are used by different actors and usage varies between countries. Clarification at global level is needed definitions for terms like coverage, prevalence, incidence and CMAM, but also for the different performance indicators

Partnerships

In addition, to UNICEF ESARO, other organisations are also in the process of developing approaches and models to facilitate integration of management of acute malnutrition into the health system. Linkages between these initiatives need to be developed and defined in order to avoid duplication and create complementarity.

HS ‘thinking’

Introduction of the management of acute malnutrition influences overall performance of the health system. Therefore, ideally a health systems thinking approach should be applied in the proposed approach. However, this raises questions about the complexity of the tool, how to assess and address impact on health system functioning, etc. What level of complexity is acceptable for a framework that ‘endeavours’ to facilitate integration by using a fairly easy and quick approach?

Expand to MAM

In developing the framework it was agreed to limit the approach to the management of SAM. Expanding the tool at this initial stage to other nutrition interventions, and especially management of MAM, may have delayed the process and complicated its development. However, management of MAM must be included in the framework as soon as possible. This will definitely require active participation of additional partners (e.g. WFP and implementing NGO’s).

Next steps

Three major immediate next steps have been identified: finalise field testing and tools, create a Technical Advisory Group (TAG) to discuss identified issues and organisation of a face-to-face meeting with regional and global stakeholders in order to reach consensus on aspects of concern and decide on ways forward, including roll out.

Once tools are finalised and countries introduced to their use, the same or a similar approach could be developed for all other nutrition interventions that need sustained integration into HS and/or linkages with IMSAM.

A regional and global database could be set up to capture information on progress on integration of CMAM into the health system. The same M&E system would also allow for follow up on quality and coverage of services.

Conclusions

Although only one test of the framework has been conducted so far (district level in Kenya), the approach looks very promising. The results of this first trial exceeded anticipated outcome, as the approach and content of the benchmark were indicated to be relevant and widely accepted. The test mainly helped in fine-tuning the process. Additional testing will take place over the coming months. This will allow testing the framework in different contexts and using different components. The framework, including manuals and operational guidelines, is expected to be ready for roll out mid-2013.

The authors look forward to continued exchanges, including a larger group of HS and CMAM specialists engaging in the process.

For more information or to engage with this initiative, contact: Katrien Ghoos, email: kghoos@unicef.org, or Anne Berton-Rafael, email: abrafael@unicef.org

¹Field Exchange 41 (2011). Global CMAM mapping in UNICEF supported countries. p10.

²Regional refers to division of UNICEF regions. For example, Eastern and Southern Africa Region (ESAR) includes 21 countries (at the time of global review 20, as South Sudan became independent in July 2011 and joined ESAR at time of independence): Angola, Botswana, Burundi, Comoros, Eritrea, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Somalia, South Africa, Swaziland, Tanzania (+ Zanzibar), Uganda, Zambia, Zimbabwe

³ESAR countries included in this analysis are all indicated above, except Comoros and South Africa (Angola, Botswana, Burundi, Eritrea, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Somalia, Swaziland, Tanzania (+ Zanzibar), Uganda, Zambia, Zimbabwe). It was not possible to have information from Comoros on time. South Africa only implements the in-patient component of CMAM. In this article, all data used refer to analysis of these 18 countries only.

⁴http://www.healthsystems2020.org/content/resource/detail/528/

⁵http://www.wpro.who.int/entity/health_services/health_systems_framework/en/index.html

⁶Available at http://www.who.int/healthmetrics/tools/en/

⁷Among others sources of adaptation are the iCCM Benchmarks and indicators matrix developed by CCM Interagency Task Force available at http://www.ccmcentral.com/?q=indicators_and_benchmarks

⁸Also called golden standards by the WHO/Health matrix