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MUAC measurement of a child in Jowhar Camp for
displaced people in the city of Jowhar, Somalia
and measuring baseline and tracking progress
on IMSAM at the three HS planning and
implementation levels (national, district and
community level) and for the six HS functions
(governance, financing, human resources,
supply, service delivery and health information
system) for each country, but also per
region and even globally. This will enhance
country level, regional and global analysis,
enable quicker and tailor-made support to
countries, improve documentation of lessons
learned and facilitate advocacy at the different
levels.
In addition, countries will be able to expand
existing HS contacts to include relevant nutrition
services in a systematic manner. For
example, given HIV AIDS is an important
cause of wasting in Zimbabwe, management of
acute malnutrition is ideally linked to
Preventing Mother-to-Child Transmission
(PMTCT) services and promotion of optimal
IYCF practices, as optimal IYCF practices are
known to prevent mother to child transmission.
This integrated approach will increase
coverage of management of acute severe
malnutrition but also improve quality of delivered
PMTCT services overall. Ideally, linkages
should exist at all HS levels and for all HS
functions. These include, for example, that
costed IMSAM action plans are linked with
health sector development plans and Mid
Term Expenditure Framework, indicators for
measuring CMAM are included in the Health
Management Information System, capacity
development for CMAM is part of health
sector HR development plan or policy, and
supply for IMSAM is planned and implemented
through the existing HS supply chain.
Ultimately, the approach can be adapted to
include management of moderate acute
malnutrition, IYCF, micronutrient supplementation
or any other nutrition intervention that
can be delivered through the health system.
Lessons learned so far
The approach is participatory and inclusive.
Through the self-assessment, all partners are
actively involved in sharing of experiences and
information. This is believed to enhance
understanding of importance of IMSAM,
improve overall quality of assessment, reinforce
ownership and encourage further
collaboration.
Despite the long benchmarks list, the
approach is not too ambitious. Depending on
available information, the assessment can be
conducted in one week. By going through the
list, stakeholders realise that more areas can
qualify for integration than considered
initially. In addition, they may discover documents
and policies they were not aware of
prior to the exercise.
The composition of the assessors team is
crucially important. The presence of health
system specialists or health system strengthening
specialists is essential. It is necessary to get
all key stakeholders fully on board. Therefore,
in addition to the initial identification/
mapping of stakeholders, preparation meetings
with these key stakeholders and follow up
discussions are useful.
The appointment of a facilitator and cofacilitator,
familiar with the health system and
context, is essential to correctly adapt the
framework to the local context, to increase
ownership and to translate benchmarks to
local context whenever needed.
Some of the benchmarks at sub-national/
district or community level directly depend on
benchmarks at national level. It may therefore
be helpful to conduct national level assessment
prior to any other level, or a HS function
assessment.
The main limits of the tool are the quality of
the data available and the composition of
groups of assessors, as indicated earlier. Other
aspects to take into account are the different
areas covered by the tool. Indeed, not all
participants are familiar with all components.
In that case, the creation of sub-groups can be
useful. Hierarchical and other links between
the different participants need to be considered
when establishing the groups.
The assessment and planning exercises
should be planned and conducted separately.
Issues being addressed
Terminology
Different terminologies are used by different
actors and usage varies between countries.
Clarification at global level is needed definitions
for terms like coverage, prevalence,
incidence and CMAM, but also for the different
performance indicators
UNICEF/NYHQ2009-0203/Ysenburg, Somalia, 2009
Partnerships
In addition, to UNICEF ESARO, other organisations
are also in the process of developing
approaches and models to facilitate integration
of management of acute malnutrition into the
health system. Linkages between these initiatives
need to be developed and defined in order to
avoid duplication and create complementarity.
HS ‘thinking’
Introduction of the management of acute malnutrition
influences overall performance of the
health system. Therefore, ideally a health
systems thinking approach should be applied in
the proposed approach. However, this raises
questions about the complexity of the tool, how
to assess and address impact on health system
functioning, etc. What level of complexity is
acceptable for a framework that ‘endeavours’ to
facilitate integration by using a fairly easy and
quick approach?
Expand to MAM
In developing the framework it was agreed to
limit the approach to the management of SAM.
Expanding the tool at this initial stage to other
nutrition interventions, and especially management
of MAM, may have delayed the process
and complicated its development. However,
management of MAM must be included in the
framework as soon as possible. This will definitely
require active participation of additional
partners (e.g. WFP and implementing NGO’s).
Next steps
Three major immediate next steps have been
identified: finalise field testing and tools, create a
Technical Advisory Group (TAG) to discuss identified
issues and organisation of a face-to-face
meeting with regional and global stakeholders in
order to reach consensus on aspects of concern
and decide on ways forward, including roll out.
Once tools are finalised and countries introduced
to their use, the same or a similar approach could
be developed for all other nutrition interventions
that need sustained integration into HS and/or
linkages with IMSAM.
A regional and global database could be set
up to capture information on progress on integration
of CMAM into the health system. The
same M&E system would also allow for follow
up on quality and coverage of services.
Conclusions
Although only one test of the framework has
been conducted so far (district level in Kenya),
the approach looks very promising. The results
of this first trial exceeded anticipated outcome,
as the approach and content of the benchmark
were indicated to be relevant and widely
accepted. The test mainly helped in fine-tuning
the process. Additional testing will take place
over the coming months. This will allow testing
the framework in different contexts and using
different components. The framework, including
manuals and operational guidelines, is expected
to be ready for roll out mid-2013.
The authors look forward to continued
exchanges, including a larger group of HS and
CMAM specialists engaging in the process.
For more information or to engage with this
initiative, contact: Katrien Ghoos, email:
kghoos@unicef.org, or Anne Berton-Rafael,
email: abrafael@unicef.org
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