Scale-up of severe wasting management within the health system: A stakeholder perspective on current progress

Introduction

Wasting is a critical issue for child survival and development, with therapeutic treatment of severe cases recognised as an essential intervention for achieving global wasting and mortality targets. There have been many efforts to scale up severe wasting treatment over the past 10 years with the ultimate aim of achieving national and international coverage of a sustainable, quality service provided as an integral part of the health system and supported by a strong community base. However, progress is slow and only up to 25% of children who need treatment are currently accessing it.

After completing a comprehensive scoping study on ready-to-use therapeutic food (RUTF) in 2020 and in preparation for the ‘CMAM 20 Years On’ conference, Emergency Nutrition Network (ENN) considered that the time was right to synthesise reflections on the past decade of experiences of scaling up severe wasting treatment into routine primary health services. This report summarises key informant perspectives, supported by a literature review, to highlight the current state of the scale-up of severe wasting services while drawing out some of the key barriers and enablers of this process. This report does not aim to describe ENN’s perspective, but rather it offers a qualitative synthesis of the perspectives of key informants to provide an up-to-date snapshot of how people are thinking and acting on the topic of severe wasting treatment scale-up.

Methodology

ENN conducted the research for this report between September 2020 and February 2021, completing 25 in-depth key informant interviews, to obtain perspectives on the progress of the scale-up of severe wasting treatment within national health systems. Key informants were drawn from a range of national and regional government institutions, non-governmental organisations (NGOs), United Nations (UN) agencies and academia. A semi-structured questionnaire guided the interviews with questions based around the six pillars of the World Health Organisation (WHO) health system strengthening framework. While the prevention and treatment of all forms of malnutrition are critical, we restricted the scope of this report to the treatment of severe wasting. We also conducted a narrative literature review to supplement the findings.

Findings: Key barriers and enablers to scaling up severe wasting treatment

A wide range of potential enablers and barriers were identified for influencing progress for the scale-up of severe wasting services within national health systems. Findings were categorised according to the six pillars of WHO’s health system strengthening framework.

Service delivery

Key informants focused on four main themes within service delivery: the importance of severe wasting programme coverage, understanding barriers to coverage, the role of community health platforms and anticipating caseload through the year.

While there has been progress on increasing the geographic coverage of severe wasting services, actual programme coverage remains low. Key enablers centre around understanding the importance of programme coverage as a critical indicator of severe wasting treatment success, alongside a commitment to understanding context-specific bottlenecks around limited programme coverage. Prioritising community outreach remains an integral part of severe wasting management along with creating demand for services yet, in some countries, severe wasting has dropped off the agenda of routine community healthcare activities. It is therefore vital to maximise opportunities to utilise existing healthcare entry points wherever possible and to examine why severe wasting has often been omitted from the community healthcare agenda.

Key informants emphasised the role of community health workers (CHWs) and family members in the early detection of children with severe wasting and provided examples of various adaptations for the detection of cases and service delivery that have been developed to facilitate this such as the ‘Family MUAC’ (mid-upper arm circumference) approach. The health sector now needs to drive innovation, experience sharing and the scale-up of successful pilots of such programme adaptations.

Better use of nutrition surveillance data is required to anticipate and accommodate seasonal fluctuations in severe wasting incidence. The ability of the health system to surge capacity in times of increased demand has been demonstrated in the response to diseases such as cholera, Ebola and COVID-19. Key informants felt there was an opportunity to consider successful examples of surge capacity within infectious disease management and to apply some of the lessons learnt about planning and resourcing to improve the scale-up of severe wasting services. An important component of this involves the recognition of severe wasting as an urgent health condition.

Health workforce

To integrate severe wasting treatment within the health workforce, key informants felt that a dual approach is needed: a) training health staff on severe wasting programming and b) ensuring all staff working on severe wasting programmes know how best to support the health system integration process. To support this process there needs to be strong collaboration between academic and healthcare institutions to provide up-to-date, evidence-based nutrition training at all levels - for pre-service, in-service and as part of continuing professional development. Innovative training initiatives, such as open-source e-learning courses, can be helpful in both improving knowledge and enabling the regular revision of teaching content. Such digital learning platforms are particularly important for frontline workers placed in remote or insecure areas without easy access to up-to-date information.

The community aspect of health systems was identified by key informants as the most neglected component in terms of both funding and institutionalisation. CHWs were identified as an essential component of the health workforce to invest in if severe wasting treatment is to be delivered at scale. This requires active government budgeting of CHW networks, securing the required finances and CHWs being adequately remunerated for their work. Alongside this is a need to simplify CHW work schedules where possible, strengthen the training of CHWs on how to identify households at highest risk and ensure that the work of the CHWs is supported with strong referral systems.

Supplies

Challenges to a sustainable supply of RUTF hamper the continuity of care and quality of services. There are barriers associated with the formulation, production, regulation, cost and supply of RUTF. While progress has been made in including RUTF as part of essential medical supplies, allowing it to be better integrated into health system supply chains, many countries still have parallel supply chains managed by UN and non-government partners. The COVID-19 pandemic has added further strain on the global supply chain, highlighting the continued need for the development of more local RUTF production, to shorten and potentially simplify the supply chain.

RUTF costs remain a stubborn barrier to severe wasting scale-up but can potentially be reduced by a number of adaptations, for example, adaptation of dosage regimes for treating severe wasting, reducing logistics costs through local production, controlling misuse or ‘leakage’, improving supply chain efficiencies and/or developing new, cheaper formulations.

Health information systems

Key enablers under this pillar include ensuring that parallel severe wasting reporting systems can be avoided and making sure sufficient technical expertise is available to interpret the data on severe wasting and translate this into programmatic action. Severe wasting data needs to be regularly reported as part of routine health information, for example in the District Health Information System 2 (DHIS2). Strengthening the DHIS2 system with a nutrition lens can support health workers to better anticipate and manage fluctuations in demand for severe wasting services. Another enabler is to ensure there is sufficient technical expertise in the interpretation of severe wasting data within strategic national and regional government institutional departments.
Key informants described how governments with established e-health platforms could feasibly integrate nutrition data at scale using existing infrastructure. Investment in digital data collection by CHWs provides a key opportunity for feeding timely nutrition information into the health information system. Indeed, there have been successful pilots of using digital platforms to integrate severe wasting data. Digital initiatives within health need to fully integrate nutrition information and thus facilitate health system ownership and ensure meaningful scale-up.

Financing

Full and accurate budgeting at the national and subnational level is required for severe wasting treatment to be implemented at scale. Yet the allocations for severe wasting treatment in some national and subnational budgets is insufficient to ensure funding is secured and managed within robust government systems. A helpful strategy to address this has been to ensure full involvement of health specialists in national costing exercises.

Currently, most severe wasting treatment services are largely funded through international humanitarian or emergency financing mechanisms which can be unpredictable and inefficient and tend to use parallel systems that do not build national capacity. Achieving, and then sustaining, the services for severe wasting at scale requires the ability to access longer-term funding streams. Potential solutions include expanding innovative regional multilateral development finance initiatives, such as the Global Financing Facility, and exploring pooled procurement services at the regional level to reduce costs of essential supplies.

Leadership/Governance

Continued efforts are required to ensure severe wasting treatment at scale remains a priority on international and national health agendas, for example through harnessing the momentum to achieve universal health coverage (UHC). There are many examples of health services that achieve impressive coverage, such as the community integrated management of childhood illnesses (C-IMCI) and expanded programme on immunisation (EPI), within which components of severe wasting services should be integrated to maximise coverage. Key informants suggested that it is not just governments’ prioritisation of wasting that needs to be maintained but also the supporting infrastructure from other agencies. This involves consistent messaging about the importance of severe wasting scale-up from all stakeholders who influence government policy and funding.

Conclusion

At the 20th anniversary of the first community-based management of acute malnutrition (CMAM) pilot study, we take stock of the many successes in the global scale-up of severe wasting treatment, yet also acknowledge that there is still a long way to go. Key informants affirmed that there had indeed been considerable global progress towards the integration of severe wasting management into national health systems. However, there was consensus that this remains a slow and difficult task, especially in the many countries with persistently high caseloads of wasted children and overburdened health systems. Many successful examples from pilot studies and case studies exist but the need to achieve these best practices at scale remains. Sustained advocacy, funding and political will is required from governments, donors and implementing agencies to continue the progress, including maximising opportunities that present themselves such as current efforts towards UHC.

Using the interview findings, we conclude the report with 28 recommendations from key informants directed to policy makers, practitioners, researchers and donors for enhancing the scale-up of severe wasting services. These may not all be universally agreed upon but they represent current issues that still need to be addressed to maintain and further accelerate progress on the scale-up of severe wasting treatment. They cover all six of the WHO pillars of health system strengthening and we trust they serve as an informative guide to help sustain and build upon the momentum that has been generated on this important topic.