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Field article Article de terrain system as well as providing efficient supervision, which will lead to quality of care. A third challenge is how to scale up MAM programmes across the country. Taking charge of malnutrition is an integral part of the axis of nutrition in the food and nutritional security policy document of the government. Addressing MAM will require insertion of a dedicated budget line for purchase of therapeutic inputs and development of social safety nets (with a social safety net ‘cell’ attached to the Prime Minister’s office). Niger depends on UNICEF and WFP for procurement of therapeutic supplies. This is a fragile situation which needs to be changed. The government could significantly reduce its dependence on UN agencies where therapeutic supplies is concerned, by allocating a budget line for procurement of therapeutic supplies to the Ministry of Health Budget and including procurement of therapeutic supplies in the social safety net package that is expanding very quickly in the country. Key lessons There are a number of key lessons from the scale up of CMAM in Niger. CMAM success relies on strong government vision and commitment for strategy, coordination and resource mobilisation. Strong government coordination is vital, especially when many partners are involved. Standardisation of treatment is key to ensure equity in treatment and comparable data. Operational partners prefer to focus on treatment not prevention - there is a need for more preventative programming. Ways forward CMAM is well established in Niger and is being carried out on a very large scale. In addition, quality of care is overall in line with Sphere standards. It is now urgent to maintain the existing capacity for the management of acute malnutrition in the country and to improve quality of care where services are still sub-optimal. In general, the community component of CMAM in Niger is rather weak and work needs to be done at this level to ensure effective involvement of communities. Next steps planned include adoption of the national nutrition plan and development of a national preventative nutrition strategy based on ‘best practices’. In terms of scaling up nutrition more broadly and given the scale of CMAM in Niger, the programme can serve as an entry point for many interventions, including other nutrition programmes, especially those designed with the aim of reducing incidence of all forms of malnutrition in the country. For more information, contact: Dr Guero H Doudou Maimouna, email: dnutniger@gmail.com or mhalidou2002@yahoo.fr Figure 8: Cure rates by region in 2010 Figure 8 : Taux de guéris par région en 2010 90% 80% 70% 60% 70% 60% 50% 40% 30% 20% 10% 0% Sphere Indicator Norme sphère AGADEZ DIFFA DOSSO MARADI NIAMEY TAHOUA TILLABERY ZINDER Region Région Cure rate Taux de Guéris 80% Combined Ensemble recrutement de personnel adéquat dans les établissements de santé et également la mise en place et la mise en œuvre d’un système d’assurance qualité inclusif et d’une supervision efficace, ce qui conduira à une meilleure qualité des soins. Un troisième défi consiste à savoir comment renforcer les programmes de MAM à travers le pays. La prise en charge de la malnutrition fait partie intégrante de l’axe nutritionnel du document relatif à la politique de sécurité alimentaire et nutritionnelle du gouvernement. La lutte contre la MAM exigera l’intégration d’une ligne budgétaire spécifique pour l’achat d’apports thérapeutiques et le développement de dispositifs de protection sociale (avec une "cellule" dédiée à ces derniers rattachée au bureau du Premier ministre). Le Niger dépend des partenaires techniques comme l’UNICEF et le PAM pour l’achat de fournitures thérapeutiques. Il s’agit d’une situation incertaine qui doit changer. Le gouvernement pourrait réduire considérablement sa dépendance envers les agences des Nations-Unies en ce qui concerne les fournitures thérapeutiques en attribuant une ligne budgétaire pour l’achat de fournitures thérapeutiques au budget du ministère de la Santé, et en incluant l’achat de fournitures thérapeutiques au sein du dispositif de protection sociale qui se développe très rapidement dans le pays. Principaux enseignements Plusieurs enseignements clés sont nés du renforcement de la PCMA au Niger. Le succès de la PCMA repose sur une vision forte du gouvernement et sur un engagement en matière de stratégie, de coordination et de mobilisation des ressources. Une coordination gouvernementale solide est vitale, surtout quand de nombreux partenaires sont impliqués. La standardisation du traitement est un élément clé pour assurer l’égalité dans le traitement et la comparabilité des données. Les partenaires opérationnels préfèrent se concentrer sur le traitement plutôt que sur la prévention ; ainsi, des programmes plus axés sur la prévention sont nécessaires. Les voies à suivre La PCMA est bien établie au Niger et elle est mise en œuvre à très grande échelle. En outre, la qualité des soins est globalement conforme aux normes Sphère. À présent, il est urgent de maintenir la capacité existante en matière de prise en charge de la malnutrition aiguë dans le pays et d’améliorer la qualité des soins là où les services laissent encore à désirer. D’une façon générale, la composante communautaire de la PCMA au Niger est plutôt faible et des progrès doivent être réalisés à ce niveau afin d’assurer la participation effective des communautés. Les prochaines étapes prévues incluent l’adoption du plan national de nutrition et le développement d’une stratégie nationale préventive en matière de nutrition fondée sur des "bonnes pratiques". En termes de renforcement de la nutrition de façon plus générale et compte tenu de l’ampleur de la PCMA au Niger, le programme peut servir de point d’entrée pour de nombreuses interventions, y compris d’autres programmes de nutrition, en particulier ceux conçus dans le but de réduire l’incidence de toutes les formes de malnutrition dans le pays. Pour plus d’informations, contacter : Dr Guero H Doudou Maimouna, e-mail : dnutniger@gmail.com ou mhalidou2002@yahoo.fr Figure 9: Defaulter rates by region in 2010 Figure 9 : Taux d’abandon par région en 2010 Figure 10: Death rates by region in 2010 Figure 10 : Taux de décès par région en 2010 16% 14% 12% 10% 8% 6% 4% 2% 0% AGADEZ DIFFA Sphere Indicator Norme sphère DOSSO MARADI NIAMEY TAHOUA TILLABERY ZINDER Region Région Defaulter rate Taux d’abandons 7.1% Combined Ensemble 12% 10% 8% 6% 4% 2% 0% AGADEZ DIFFA Sphere Indicator Norme sphère DOSSO MARADI NIAMEY TAHOUA TILLABERY ZINDER Region Région Defaulter rate Taux de décès 1.7% Combined Ensemble 57
News UNICEF/NYHQ2008-1649/Pirozzi, Eritrea, 2008 Framework for integration of management of SAM into national health systems By Katrien Khoos and Anne Berton-Rafael A Baby's MUAC is leasured in the rural village of Marat, Anseba Region, Eritrea Katrien Ghoos is the Nutrition Specialist on Management of Acute Malnutrition ,Nutrition Information Systems, Emergencies and Disaster Risk Reduction with the UNICEF Eastern and Southern Africa Regional Office (ESARO). She is based in Nairobi, Kenya. Anne Berton-Rafael is the UNICEF ESARO Nutrition consultant for this initiative, based in Nairobi. Both authors have over 15 years of experience on management of acute malnutrition in emergency, post-emergency and development context. Update credit to: The authors wish to thank UNICEF ESARO, UNICEF HQ and USAID/OFDA for the support to this work. Special thanks also go to the several individuals and their organisations that already provided inputs to the initiative. These are UNICEF (colleagues from Kenya Country Offices and from Regional offices in Dakar and Amman), ACF-F, FANTA, Valid, Carlos Navarro-Colorado (CDC) and Mark Myatt. Background In 2010, UNICEF approached VALID International to design and conduct a global mapping review of Community-based Management of Acute Malnutrition (CMAM) with a focus on severe acute malnutrition (SAM) 1 . In addition to this global mapping, regional analyses 2 were conducted and indicated that 13 countries out of 18 3 in Eastern and Southern Africa Region (ESAR) had plans to scale up in 2010/2011. As of May 2010, over half (53%) of CMAM programmes were integrated with Infant and Young Child Feeding (IYCF) and Integrated Management of Childhood Illness (IMCI) programmes. All countries had national coordination mechanisms and in only three countries out of 18, were UNICEF the sole RUTF provider. These findings suggested a certain degree of government ownership and sustainability. However, despite roll out through government services in all countries (except Somalia) at the time of the mapping, most of the inputs to CMAM national programmes were still provided using short term external emergency funding. Also, material and technical support often still came from specialised United Nations (UN) and nongovernmental organisation (NGO) staff. Indeed, in 13 countries, more than 50% of RUTF was provided by UNICEF in 2009, and only one country indicated Ministry of Health (MoH) support for RUTF supplies. Transport of these supplies from national to district level largely happened using a parallel system instead of using the national supply chain. In those cases, UNICEF and implementing partners (e.g. NGO’s) organised transport based on available stocks at national level rather than expressed needs at community level. This description around RUTF supplies is only one example to highlight the lack of a sustainable and systematic approach to scaling up CMAM. Not much has changed since the global mapping exercise. Another consideration is in contexts where prevalence of wasting is relatively low and as in most Southern African countries, closely related to HIV/AIDS. In such scenarios, with little or no dedicated funding available for CMAM, the approach to integrate SAM management into the health system and create or enhance systematic linkages with existing services was thought to be the most cost-effective, and typically the only option, to scale up community based management of SAM. The Framework Given the lack of a systematic approach to CMAM scale up identified in the 2009 global mapping and the need for integration into existing services for a sustainable approach, a framework for institutional integration of management of severe acute malnutrition (IMSAM) into national health systems has been developed and is being piloted by UNICEF (see Box 1). The general objective of the framework is to support countries in assessing gaps, planning priority actions and guide successful and sustainable scaling up of management of severe acute malnutrition through the primary health care system. For reasons explained below, the scope of this initiative is limited deliberately at this stage of development of the IMSAM framework. The six WHO health system (HS) building blocks (governance, financing, human resources, supply, service delivery and health information system) are used as the health system entry points in this proposed framework. A series of field tests were scheduled in order to correct irrelevant elements and finetune promising parts, using different national and sub-national contexts and HS functions of the framework. The proposed framework is relevant also in countries as part of disaster risk reduction (DRR) and/or resilience building approach, where nutrition emergencies are recurrent (e.g. Horn of Africa). As most of these countries have already integrated parts of CMAM into the health system, this proposed framework Box 1: Process of framework development UNICEF ESARO started developing the framework in January 2011, but this had to be interrupted because of Horn of Africa crisis. An extensive literature review already underway continued in October 2011. This review covered successes of processes, strategies and tools used in Health System (HS) strengthening, in standardised development of national programmes to address at scale public health problems such as tuberculosis and malaria, and the roll out of Enlarged Programme of Immunisation (EPI), integrated Community Case Management (iCCM) and Prevention of Mother To Child HIV AIDS Transmission (PMTCT) programmes. The assessment itself is adapted from USAID’s Health Systems Assessment Approach: A How-To Manual 4 . This is based on the WHO’s health systems (HS) framework of the six health system building blocks 5 (WHO 2000, 2007) as well as from the HIS scoring card of the Health Metrics Network 6 (WHO, 2008). Based on these lessons learned, experiences and assessment tools 7 , the framework for Institutional Integration of Management of Acute Malnutrition into national health systems, was suggested. 1 Field Exchange 41 (2011). Global CMAM mapping in UNICEF supported countries. p10. 2 Regional refers to division of UNICEF regions. For example, Eastern and Southern Africa Region (ESAR) includes 21 countries (at the time of global review 20, as South Sudan became independent in July 2011 and joined ESAR at time of independence): Angola, Botswana, Burundi, Comoros, Eritrea, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Somalia, South Africa, Swaziland, Tanzania (+ Zanzibar), Uganda, Zambia, Zimbabwe 3 ESAR countries included in this analysis are all indicated above, except Comoros and South Africa (Angola, Botswana, Burundi, Eritrea, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Somalia, Swaziland, Tanzania (+ Zanzibar), Uganda, Zambia, Zimbabwe). It was not possible to have information from Comoros on time. South Africa only implements the in-patient component of CMAM. In this article, all data used refer to analysis of these 18 countries only. 4 http://www.healthsystems2020.org/content/resource/ detail/528/ 5 http://www.wpro.who.int/entity/health_services/health _systems_framework/en/index.html 6 Available at http://www.who.int/healthmetrics/tools/en/ 7 Among others sources of adaptation are the iCCM Benchmarks and indicators matrix developed by CCM Interagency Task Force available at http://www.ccmcentral .com/?q=indicators_and_benchmarks 8 Also called golden standards by the WHO/Health matrix 58
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