Linking integrated community case management of sick children and nutrition: experiences and meeting report
On 11-12 December 2014, a meeting of a broad range of stakeholders with experience in nutrition and/or integrated community case management (iCCM) was convened to explore linkages between these two domains of health programming. The objectives were to:
- develop a common understanding of the iCCM and nutrition landscape and identify key lessons and experiences to date
- explore options for strengthening linkages between iCCM and nutrition activities, and identify and prioritise opportunities to support their implementation.
This meeting built on two previous meetings: the iCCM Evidence Review Symposium in Ghana (March 2014) and a meeting in London in May 2014 of a small group of stakeholders.
Box 1: iCCM and nutrition
The meeting situated iCCM within the broader framework of community-based infant and child health actions outlined in a three-part package, Caring for newborns and children in the community, developed by WHO and UNICEF. This UNICEF/WHO package includes:
Caring for the sick child in the community (iCCM)
http://www.who.int/maternal_child_adolescent/documents/imci_community_care/en/,
Caring for the newborn at home http://www.who.int/maternal_child_adolescent/documents/caring_for_newborn/en/, and
Caring for the child’s healthy child growth and development
http://www.who.int/maternal_child_adolescent/documents/care_child_development/en/
To date, implementation of the UNICEF/WHO community health worker (CHW) package has focused mainly on iCCM. iCCM is intended to prevent child deaths in settings where there is poor access to care in health facilities. It provides guidance, training materials, and job aids for CHWs to identify, treat, and/or refer children with diarrhoea, pneumonia, and malaria. Screening and referral of severe acute malnutrition (SAM) is also included, and a red mid upper arm circumference (MUAC) reading is one of the key danger signs.
Since iCCM is focused on sick children, the nutrition component in the UNICEF/WHO protocol is limited to: 1) advice on feeding during and after illness and 2) SAM identification and referral. The other two parts of the package, caring for the newborn at home and caring for the child’s healthy growth and development, include counselling and promotion related to optimal infant and young child feeding practices.
Box 1 outlines the iCCM/nutrition framework for the meeting. The meeting proceedings centred on the findings of a detailed review of operational experiences and evidence for linkages/integration of iCCM and nutrition. The review identified a wide range of varied country and programme experiences. Some reflected ‘linked’ programming, e.g. CHW identifies SAM and refers cases for treatment, while others involved a more integrated approach, e.g. the CHW identifies and treats uncomplicated acute malnutrition. There were significant gaps in available evidence on implementation, effectiveness, and cost of linked/integrated iCCM and nutrition.
The review grouped interventions and experiences that linked or integrated iCCM and nutrition into four categories or ‘models’ that describe what currently exists (not necessarily what should or could exist):
Model 1: Advising on “feeding the sick child” within existing services
Model 2: Linkages with Social and Behaviour Change activities on child nutrition
Model 3: Linkages between iCCM activities and acute malnutrition treatment through assessment and referral
Model 4: Treatment of uncomplicated SAM at community level
Models 1-3 are aspects of nutrition that are already included in the UNICEF/WHO package (Caring for newborns and children in the community). Model 4 is an addition, which requires more testing and evidence.
On the principle that iCCM or iCCM/nutrition is part of a larger system for promoting child health and treating illnesses, five key objectives for integrating iCCM and nutrition were proposed and discussed:
- Improve coverage and quality of services for the sick child, thereby exploiting the synergy between the health issues and ideally resulting in greater reductions in mortality.
- Optimise the preventive aspects of iCCM to maximise its contribution to child nutrition.
- Improve implementation of the UNICEF/WHO package.
- Strengthen linkages between community and facility.
- Link health and nutrition at the institutional level.
Participants identified and ranked research priorities to address knowledge gaps. These largely related to implementation challenges. The top five research questions that emerged were:
- Does integrating SAM treatment into iCCM improve the coverage of one or all services?
- What is the additional workload of the CHW and how does that impact on the quality of service delivery?
- What are the outcomes of treating vs. just referring SAM cases?
- When adding on SAM, what impact does it have on the other iCCM interventions and quality of care of both the existing iCCM components and nutrition components (e.g. breastfeeding promotion)?
- How can the OTP protocol be simplified for CHWs, including CHWs with low literacy?
It was recognised that although participants embodied a range of organisations, expertise and knowledge, the list of research questions will need to be examined, refined and vetted by a more representative group before being finalised.
The main challenges to implementing iCCM and nutrition activities identified included: poorly functioning supply chains for ready to use therapeutic food (RUTF), vertical funding streams, lack of standardised nutrition indicators in health information systems and across organisations, inadequate coordination mechanisms for implementation and funding, need for a common agenda/business case/theory of change for integrated iCCM and nutrition, lack of operational guidelines for implementing iCCM and community based management of acute malnutrition (CMAM), lack of an advocacy plan for the integration of iCCM and nutrition, weak health systems, and low utilisation of health services.
Conclusions
There was consensus that the operational linkages between iCCM and community-based nutrition interventions are feasible and necessary, and are likely to provide benefits to both activities. The review of experiences revealed the limited number and types of experiences, as well as the scarcity of available evidence. A number of research questions need to be explored in order to guide the way forward. There is evidence that CHWs can provide high-quality care for childhood illness and for SAM, as well as high-quality advice on nutrition behaviours. The conditions under which these actions can be carried out remain to be defined, as does the best mix of iCCM and nutrition-related actions and the supports needed to carry them out. Participants agreed to identify and set up a governance mechanism for a group that will take forward the work discussed during this meeting, most likely a Nutrition sub-group within the iCCM Task Force.
The meeting report is available at: http://www.coregroup.org/storage/documents/Linking_Integrated_Community_Case_Management__Nutrition_NYC_Meeting_Report.pdf
The review ‘Linking nutrition and (integrated) community case management: a review of operational experiences’ is available at