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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
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