Integration of the management of severe acute malnutrition in health systems: ACF Guidance

By Rebecca Brown and Anne-Dominique Israel

Rebecca Brown is Strategic Technical Adviser with ACF Paris

Anne-Dominique is Senior Nutrition Adviser with ACF Paris

The management of severe acute malnutrition (SAM) has improved substantially in recent years. However, despite these improvements coverage remains shockingly low. There has been a realisation that treatment can only be achieved at scale by ensuring the availability of and access to treatment at all levels of the health system and community (task shifting).

In most contexts, and outside of nutritional emergency situations, a direct non-governmental organisation (NGO) intervention approach is no longer feasible or appropriate. Awareness of the need to tackle SAM in non-emergency contexts and to integrate this within existing health services is increasing. In many countries, programmes to treat SAM now fall under the responsibility and leadership of the Ministry of Health (MoH) and its subnational authorities. This facilitates the treatment of SAM within the system as part of a basic healthcare package.

This new approach implies that stakeholders, particularly previous direct implementers such as NGOs, must adapt their way of working to achieve proper integration of the management of acute malnutrition. For NGOs, this has meant a fundamental shift in approach, from direct implementation and often running CMAM programmes in parallel to health ministries, to supporting the health sector at every level in managing all aspects of acute malnutrition. For example, a project to document Action Contre la Faim (ACF) International’s programmes found that in 2011, 80% of ACF missions were supporting the MoH in integrating CMAM. Five years previous, the exact inverse was the case with around 80% of CMAM programmes implemented directly by ACF.

Despite the recognition of the importance of switching to a more horizontal and long term approach, implementing agencies that specialise in acute malnutrition management are still often struggling to make this happen. Various adaptations need to be made to how CMAM programmes are managed and funded, in order to move towards programming embedded in national government systems. For example, NGOs with a history of direct intervention in SAM management now need to review staff skills, i.e. the type of skills required to take a more ‘hands-off’ approach that focuses on training, capacity building and supporting health workers and community-level agents. Good skills in negotiation, training and mentoring are now required, as well as a credible medical or nutritional training and experience in the management of SAM; skills in service delivery alone are no longer sufficient. Moreover, NGO staff are now often physically located within the health system (at regional or district MOH offices, for example) to foster stronger working links and to ensure MOH ownership and leadership of the CMAM integration process; these staff need to have some understanding of how the health system works. There is still a serious gap between health professionals dealing with mother and child health and those dealing with nutrition issues. In the past, international NGO (INGO) staff lacked experience of working within and trying to strengthen national health systems. INGOs lacked the institutional culture and instincts needed for this.

As CMAM is scaled up, full integration through health system strengthening has still not taken place. One of the most important challenges identified in recent months is the capacity of all the partners to truly understand and plan integration within health systems that must first be strengthened. The need to mitigate potential adverse effects of CMAM intervention on a weak health system has so far not being adequately addressed. Health system strengthening strategies based on systematic approaches have not been supported sufficiently. There is vast room for improvement in this field. Even at the CMAM Conference in Addis Ababa, although all participants claimed that CMAM should not be implemented as a vertical approach (and where for the first time, WHO’s six building blocks of Health Systems (HS) were mentioned), the challenges faced by government, UN agencies and international NGOs to increase access to treatment were still discussed outside this context. For example, the delivery of drugs and RUTF were not considered within the context of structural recurrent supply chain problems (one of the HS building blocks) but rather as a CMAM integration problem. Locating CMAM scale up within the HS approach is, we feel, the way to go.

In order to underpin this institutional and cultural shift in approach we believe that there is a need to develop concrete operational guidance. The soon to be published ACF Guidance on integration of the management of severe acute malnutrition in health systems¹ (see Box 1) aims to identify all areas where ACF and other implementing partners have to develop and further professionalise. For example, there is one chapter dedicated to development of advocacy strategies involving two essential aspects of CMAM integration strategies: funding mechanisms and MoH leadership. Long-term funding for nutrition programmes is vital as short-term emergency-type funding is no longer appropriate. Funding must take into account slower programme set-up, the need for assistance with policy and protocol development and implementation and staff capacity building, as well as community sensitisation and mobilisation in advance of beginning programme activities. In order to achieve successful CMAM integration, it is also essential that the process is owned at all levels within the MoH. There should be MoH commitment to a long-term strategy that includes CMAM as part of pre- and in-service training.

¹Main authors: Alice Schmidt, Rebecca Brown and Mary Corbett. Chapter contributions from: Anne-Dominique Israel, Saul Guerrero and Yvonne Grellety.