Experiences of the Integrated Management of Acute Malnutrition (IMAM) programme in Nepal: from pilot to scale-up
This is a summary of a Field Exchange field article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Karan Courtney-Haag, Anirudra Sharma, Kedar Raj Parajuli and Anju Adhikari.
Karan Courtney-Haag is Chief of Nutrition for UNICEF Nepal Country Office.
Anirudra Sharma is a Nutrition Specialist for UNICEF Nepal Country Office.
Kedar Raj Parajuli is Chief of the Nutrition Section, Family Welfare Division, Department of Health Services, Ministry of Health and Population Nepal.
Anju Adhikari is a UNICEF Nutrition Consultant, Nutrition Section, Family Welfare Division, Department of Health Services, Ministry of Health and Population Nepal.
Background
Improving the nutritional status of children under five years of age is a major challenge in Nepal where an estimated 12% of children are wasted and 3% severely wasted. Malnutrition in Nepal is a result of complex and interrelated causes such as household socio-economic status, sub-optimal breastfeeding and complementary feeding practices, recurrent childhood illnesses and poor sanitation and environmental conditions. These issues are exacerbated by severe and recurrent humanitarian crises.
Prior to the introduction of community-based management of acute malnutrition (CMAM)1 in Nepal, treatment of acute malnutrition was primarily provided in Nutrition Rehabilitation Homes (NRHs). In this model, severely wasted children were treated as inpatients at the NRH resulting in high default rates. The limited number and low capacity of NRHs also made it impossible to address severe wasting on a large scale.
In March 2007, the joint global statement in support of CMAM by the WHO, the World Food Programme (WFP), the Standing Committee on Nutrition (SCN) and UNICEF provided impetus for the Government of Nepal to implement CMAM programming.
Building the evidence for CMAM in Nepal
A pilot CMAM programme was approved for implementation by the Government of Nepal in 2008 to evaluate integration within the existing government health system. Five districts from the three agro-ecological zones of the country were selected for the pilot due to their high prevalence of wasting (>10%), widespread poverty, hospital infrastructure and existing capacity for community-based integrated management of childhood illness (CBIMCI). A baseline nutrition survey was carried out by Action Contre la Faim (ACF) and Concern Worldwide (Concern) in all pilot districts and three different operational models for severe wasting treatment were then tested. In model one, Concern provided technical and financial assistance to government health personnel to implement the CMAM programme in one district. In model two, UNICEF provided direct financial support and technical assistance to the central government who, in turn, allocated funds to two districts for CMAM implementation. In model three, a local non-governmental organisation (NGO), with remote technical assistance from UNICEF and the Ministry of Health and Population (MoHP), supported the capacity development of district and provincial health officers.
By the end of the pilot, 75 outpatient therapeutic centres (OTCs) had been established in the five pilot districts in primary health centres (PHCs), hospitals, health posts (HPs) or, in a few cases, sub-health posts (SHPs). OTCs were staffed by existing government health workers trained in the CMAM protocol. Ready to use therapeutic food (RUTF), sourced by development partners and managed through the government health supply chain, was used to treat severely wasted children without complications. A 2011 UNICEF supported MoHP evaluation demonstrated good performance against Sphere indicators in all five pilots. Overall, out of 5,609 discharged children, 86% recovered, 0.2% died and 9% defaulted. The average length of stay was 49 days and the average weight gain was 4.8g/kg/day. Model two was identified as the most cost-efficient and the model that fostered the strongest government ownership.
Integration of CMAM into Primary Health Care Services
Policy framework
Following the pilot’s success, the CMAM programme was introduced in six out of seven of Nepal’s provinces. Termed ‘Integrated Management of Acute Malnutrition (IMAM)’, the programme aimed to further integrate facility and community-based approaches, as well as prevention and treatment services. In 2013, national IMAM guidelines were developed by the MoHP and the programme was included in the country’s first Multi-sectoral Nutrition Plan (MSNP) as well as in the second MSNP approved in 2018. The MoHP leads IMAM programming and is accountable to the High-Level Nutrition and Food Security Steering Committee within the National Planning Commission.
Funding
The IMAM programme was initially funded by development partners, including UNICEF. However, the MoHP now funds 90% of the programme with UK Foreign, Commonwealth and Development Office (FCDO)2 funding and the World Bank supporting the remaining 10%. Government funds cover staffing, training and information management as well as the procurement and management of therapeutic food and milks. UNICEF, the United States Agency for International Development (USAID) and ACF provide ad hoc support for capacity development activities on request from the MoPH. The MoHP are currently developing a five-year costed action plan for nutrition which will include the IMAM programme.
CMAM implementation modality
IMAM forms part of a comprehensive set of nutrition interventions delivered through an integrated health service package by the government health system. At municipal level, IMAM is delivered at health facilities alongside other child health and nutrition programmes, including routine growth monitoring, infant and young child nutrition counselling and the integrated management of childhood illnesses (IMCI). Female community health volunteers (FCHVs) also screen children using mid-upper arm circumference (MUAC) during biannual vitamin A campaigns, distribution of micronutrient powders, village-level mothers’ groups and nutrition education activities.
Performance indicators
The IMAM programme is now implemented in 38 out of 77 districts through 500 OTCs located in health posts and 21 NRHs located within hospitals. Social mobilisation efforts and media campaigns have also promoted IMAM services and the capacity of health workers has been increased to identify and treat severely wasted children. Between 2009 and 2018, OTCs have performed well against Sphere standards with an average recovery rate of 83%, a low death rate of 0.26% and a defaulter rate of 10.9%.
Barriers and bottlenecks
Despite successful scale-up of the IMAM programme in Nepal, limited active case finding acts as a barrier to coverage and quality of services. Caregiver recognition of wasting and the associated risks is also very low, limiting early detection and health seeking for treatment. The MoHP are therefore set to revise national guidelines to include ‘family MUAC’ or ‘mother-led MUAC’3 and facilitate screening for wasting by caregivers.
Weaknesses in the government supply chain management system act as a barrier to treatment with frequent stock-outs and stock losses of RUTF or therapeutic milks occurring at facility level. These supply chain issues are systemic and will require increased financial and human resource investment by MoHP to resolve.
The continued high prevalence of wasting and the lack of treatment for children with moderate wasting in Nepal indicate the need for an understanding of wasting prevention and earlier treatment protocols. Currently, caregivers of moderately wasted children are counselled on feeding, hand washing, sanitation and hygiene practices. However, the MoHP is considering the inclusion of a treatment option for moderately wasted children into the national IMAM guidelines, e.g., through the provision of supplementary food and/or a change to a simplified wasting management protocol. This would help to reduce the number of children who develop severe wasting.
Lessons learnt implementing IMAM in Nepal
Many factors have been identified as contributors to the success of IMAM implementation in Nepal while some require greater attention. For example, inclusion of IMAM within a national policy framework has established it as a priority programme with a costed action plan for implementation and management. There are also well-established nutrition governance architecture and financing platforms which ensured that the IMAM programme received the funding required to evolve. Similarly, there has been commitment from all tiers of government to annual work plans and budget allocation for essential nutrition services, including IMAM.
While UNICEF continues to provide technical assistance, the Government of Nepal has allocated domestic resources for the procurement of RUTF, capacity development of healthcare providers and sustainable continuity of the programme. However, while the MoHP has gradually assumed responsibility for procuring RUTF and therapeutic milks, the allocated budget cannot meet the needs of all severely wasted children in Nepal. As a result, the MoHP hopes to include RUTF in the Essential Medicine list in Nepal which may increase allocated funds.
Technical and financial assistance provided by UNICEF, the European Union, UK FCDO, ACF and Concern has helped to guide and steer the evolution of the IMAM programme. These partners continue to support the MoHP in training, capacity development, supply chain management and programme monitoring and review as well as the revision of national IMAM guidelines.
The well-established community health system has been essential in facilitating and strengthening referral linkages for IMAM between villages and health facilities. This includes community-level mothers’ groups and FCHVs in communities and health worker capacity at health facilities. However, treatment coverage remains low (approximately 15%) and an increase in active case finding and referral of severely wasted children is needed.
Conclusions
The IMAM programme in Nepal has been scaled up to improve coverage of wasting treatment using a government-led approach. Success has been achieved through the integration of the programme within the national health system using a strong policy framework, national and decentralised governance structures and financial commitment. IMAM is now delivered at scale by skilled government health workers in 38 districts across the country. While continuing to develop existing services, the MoHP must now explore the management of moderately wasted children and invest in wasting prevention.
For more information, please contact Anirudra Sharma.
1 CMAM is an approach to the treatment of child wasting that involves the management of medically uncomplicated cases in the community.
2 formerly the UK Department for International Development (DFID)
3 Family-MUAC (or mother-led MUAC) is an approach through which caregivers screen their own children for wasting for referral for treatment services using MUAC tapes.