UNICEF Global reporting update: SAM treatment in UNICEF supported countries

A child being screened for malnutrition in a UNICEF supported programme

By UNICEF Nutrition in Emergencies Unit and Valid International

Following the CMAM mapping exercises of 2009 and 2011, UNICEF and Valid International are working together through a UNICEF-supported Project Cooperation Agreement (PCA). Thanks to Erin Boyd (UNICEF), Nicky Dent (Valid International),James Hedges (UNICEF HQ), Gideon Jones (Valid International), and Rachel Lozano for contributing to this article.

UNICEF is one of the principal organisations supporting the implementation and scale up of the community-based management of acute malnutrition (CMAM¹) approach with respect to managing severe acute malnutrition (SAM). UNICEF is the main provider of Ready to Use Therapeutic Food (RUTF), therapeutic milk (F-75, F100) and other essential supplies in treating SAM. UNICEF also provides technical guidance and supports capacity building efforts of Ministries of Health (MoHs) and non-governmental organisations (NGOs) to improve both the quality and access of SAM treatment.

A key component of UNICEF’s work is monitoring and evaluation (M&E) to demonstrate impact. The need to have a standardised method to compile, collate and compare information on impact and increase accountability related to the management of SAM has been evident for some time. A Global Mapping Review in UNICEF-supported countries was conducted in 2010, based on 2009 data, to determine the current situation of CMAM programming with a focus on SAM treatment, and the findings were shared in March 2011². A major finding of this CMAM Mapping Review was the need to improve the quality and frequency of SAM treatment performance reporting and one specific recommendation was to develop a Global SAM reporting system. One step in addressing this has been the development of an annual summary, referred to as the ‘Global SAM Treatment Update’ to report on the status of SAM treatment for 2011 in UNICEF-supported countries. The purpose of this article is to summarise some of the key information from the 2011 SAM Treatment Update, including some comparison with the 2009 data, and outline the way forward on global SAM treatment reporting.

Overview of the 2011 Global SAM Treatment Update

Building on the 2010 Global Mapping Review, the data capture methodology for 2011 was amended with the aim to improve the quality of responses. The original questionnaire³, based on the World Health Organisation (WHO) health systems framework, was modified to increase the specificity of both the qualitative information (general CMAM programme background/ context, country objective, bottlenecks) and quantitative information (caseloads, prevalence, access and coverage, performance indicators) being requested.

The questionnaire was sent out in December 2011 to 61⁴ UNICEF County Offices (COs), selected on the basis of previous orders for therapeutic supplies⁵. Fifty-seven UNICEF COs responded (93 per cent response rate). This exercise has provided significant learning on how to achieve a strengthened reporting system for the future and has yielded important SAM treatment information, allowing for some comparison of the progress in the quality and scale-up of CMAM programming over the last few years.

Main findings of the UNICEF Global SAM Treatment Update, 2011

Number of countries reporting services

At the end of 2009, 53⁶ UNICEF country offices reported community-based services for the management of SAM⁷ and by the end of 2011 this had risen to 61⁸. In the 2011 questionnaire, countries were asked about their stage or objective to scale up of services for management of SAM. While the definition of classifying countries requires strengthening to ensure countries providing inpatient services only are also captured, Figure 1 gives some indication of country objectives with regard to scale up.

Annual total admissions of children with SAM 6-59 months

In total, 1,961,772 reported cases of children aged 6-59 months with SAM were admitted for treatment during 2011, compared with just over 1 million reported during 2009. While this large increase in reported admissions reflects overall improved reporting at national level, it is also indicative of the ongoing scaling up of treatment of SAM. The total reported admissions still represents between 10-15 per cent of the ~20 million expected SAM cases annually.

National reporting rates

Twenty-nine countries (48%) reported that they had >75% reporting rate (i.e. they received >75% of the required monthly reports) compared with eight countries (15 per cent) in 2009. The reporting rate demonstrated a large improvement in data collection at the national level. However, given there is no standardised system of national reporting, intra-country comparisons should be made with caution. Each country collects data differently, with the reporting rate sometimes reflecting the percentage of reports received from health facilities with functional services for SAM, and sometimes the percentage received from implementing partners.

Performance Indicators

Cure rate: Twenty-two countries (31.4%) achieved a minimum recovered rate of >75% (SPHERE standard for recovered) (47.1% response rate) (see Figure 2). Collection of this specific information was particularly challenging given wide variance in performance indicator calculation methods, often as different denominators were used. Further guidance in this area is crucial for strengthening the quality of this information.

Defaulter rate: Twenty countries (30%) achieved a defaulter rate of <15% (SPHERE standards - defaulted rate) where adequate reports were available (50.2% of countries) (see Figure 3). Again, there is a need to support countries in collecting and collating these performance data. A benefit of this would be that default rates could be used to identify which countries might benefit in receiving more technical assistance or investigation, for example through community enquiries or specialised coverage surveys.

Geographical and treatment coverage

Despite the current absence of a standardised international way of illustrating geographical coverage for management of SAM, the data gathered from 2011 showed a marked increase in countries’ ability to track geographic coverage. Attempting to strengthen the data from 2009, which yielded very varied responses, for 2011 a more precise question was posed, asking for "number of health facilities integrating the management of SAM in country/total number of health facilities in country." Encouragingly 28 countries (46 per cent) were able to respond to questions pertaining to geographic coverage based on the existence of services at heath facility level. Nevertheless, reporting challenges were still apparent, illustrating continuing difficulties in measuring geographical coverage and the range of methodologies used. For treatment coverage, while admissions data were strong, further clarity on the denominator is evidently needed: the overall range of responses - from 0.004 per cent to 150 per cent - was too wide (and sometimes questionable) to allow a meaningful comparison.

Integration into Health Services

Integration of management of SAM into the health system is a strategy gaining momentum as some MoHs adopt management of SAM as part of the essential health package (note, not all countries are aiming for nationwide scale up, as management of SAM is not always a country health priority). Questions for the 2011 Global SAM Treatment Update were posed differently in the 2010 mapping so direct comparison cannot be made, apart from a slight increase in the number of countries incorporating SAM indicators in the Health Management Information System/HMIS (16 countries in 2011 compared with 14 in 2009) and a greater increase in including community-based management of SAM in pre-service training (15 countries in 2011 compared with 9 in 2009).

Procurement of RUTF

In 2011, UNICEF procured 27,000 MT - some 80 per cent of the global supply. UNICEF continues to support the local production of RUTFs and has diversified its own supplier base to include manufacturers in Dominican Republic, Ethiopia, France, Haiti, India, Kenya, Madagascar, Malawi, Mozambique, Niger, Norway, Sierra Leone, South Africa, Sudan, Tanzania and USA.

Data limitations

The different understanding of respondents was evident in the data collection process, with mixed responses received for certain questions. It is evident that UNICEF staff have varying understanding and experience of terminology and standardisation of this understanding will be crucial for strengthening future data collection efforts. For the 2011 exercise, responses have not been ‘eliminated’ if they appeared out of range, apart from obviously incomplete responses for the geographical coverage question. COs were not requested to clarify or correct responses or add missing data, limiting the reliability and completeness of the data set. Another limitation was the sending out of questionnaires only to countries ordering SAM-related supplies, this measure led to some countries being missed in the initial sending of the data collection tool. In addition, the status of some countries said to be "planning" CMAM programmes from the mapping exercise is not known and a comprehensive view of countries with inpatient management of SAM services is not available.

Ways forward

Through 2012, UNICEF and Valid International have been working together to develop a webbased data collection and analysis mechanism to capture key information related to the management of SAM at country level for synthesis at global and regional level. Currently, the automated Global SAM Treatment Update mechanism is nearing the piloting phase, but work is still being done to improve the tool to ensure greater clarity and utility. This includes the incorporation of quality checks and balances in the system to minimise inappropriate data submissions.

Much of the information to be inserted within the SAM Treatment Update tool is already collected by countries currently, but the regular and systematic collation across countries and regions at the global level has exciting potential. Through the SAM Treatment Update, key data can be produced for the general health and nutrition community, fulfilling a need at the global level for big picture information on the current situation of scale up of and management of SAM. Over time, this should enable the tracking of trends and changes from year to year and country to country. This, in turn, will support the identification of gaps and guiding of advocacy efforts, decision-making, and resource mobilisation. The more detailed raw data will be utilised by UNICEF for in-depth analysis to inform its support to countries, strategic decision-making and fundraising efforts, as well as supply forecasting and programme planning.

In terms of the immediate way forward on this initiative to strengthen SAM treatment related information for improving and expanding access to SAM treatment, there are certain key actions to be undertaken:

• Finalize outputs of Global SAM Treatment Update: The major variable outputs of a web-based data capture tool need to be finalised, as these will be reported on an annual basis for distribution internally to UNICEF management, field staff and externally to stakeholders involved in the management of SAM (other UN agencies (WHO, WFP, FAO, UNHCR), donors, NGOs, technical bodies). Information will likely include the number of countries carrying out services for management of SAM, country caseload, admissions data and so on.
• Refine data capture tools and process: Based on learning from past data capture exercises, further work is needed in terms of how best to define and request specific information required at global and regional levels including linking with the supply aspect. Further work will also be needed on how to ensure that information from all countries with services for SAM is captured, including those with inpatient services only. In addition, continued development of the web-based system for data entry with greater guidance on how to minimise errors and missing data will be undertaken.
• Develop standardised definitions and methodology and refine content: as part of the tools development, efforts are needed to further refine definitions and methods to provide a common language and methodology to measure geographical and treatment coverage, and to define the classification/ stage of SAM services with international experts, stakeholders and health/nutrition technical bodies. To this end, the development of regional webinars is being planned for UNICEF staff to develop common definitions and to strengthen country capacities to improve their existing information systems. Indicators designed to effectively capture information on the integration of SAM into national systems is being piloted with UNICEF East Africa regional office as part of the development of a framework to support integration of SAM management in national health systems.⁹
• Ongoing support: The weaker data from previous global capture exercises will be used to prioritize countries and identify areas that require additional support, to be linked to competency frameworks and capacity building strategies.

Conclusions

The progress on SAM-treatment reporting over the last few years has been significant and has played an important role in highlighting the global achievements to date and the challenges remaining. This information is increasingly being utilised to inform a range of actions in support of improving and expanding treatment of SAM treatment at country level. This has led to amendment of programmatic strategies and actions and provides an evidence base for strategic decision-making, resource mobilisation and advocacy. UNICEF remains committed to the nutritional well-being of children and mothers and it is envisaged that this mandate will be increasingly strengthened through improved data reporting. The Global SAM Treatment Update initiative constitutes another important step towards this.

For further information, contact: Ilka Esquivel, Senior Adviser, Nutrition in Emergencies, iesquivel@unicef.org

¹Also known as Integrated Management of Acute Malnutrition (IMAM) or Community-based Therapeutic Care (CTC)

²Global Mapping Review of community based management of acute malnutrition with a focus on SAM. March 2011. Valid International, UNICEF HQ Nutrition (long report with individual country/regional data: internal circulation only; summary report: external circulation)

³For any additional documents pertaining to the review, please contact UNICEF New York Nutrition in Emergencies office.

⁴Questionnaires were sent out to Guinea Conakry and Namibia later than the other country offices.

⁵See data limitations section.

⁶Fifty-five countries by mid 2010, with Ghana and Honduras starting services.

⁷Note: not all countries with inpatient services only may have been captured by the questionnaire. No definition of community-based management of SAM was provided and the existence of programming is from CO reports.

⁸Cambodia, Comoros, Ghana, Guinea Bissau, Honduras, Lao PDR, Vietnam and Zanzibar reported starting communitybased programmes subsequent to the 2009/2010 mapping exercise. Mainland Tanzania and Zanzibar counted sepa rately due to the different nature of the SAM treatment programmes.

⁹See news piece in this issue of Field Exchange.