Download a PDF of this issue - Field Exchange - Emergency ...

News
Integration of the management of severe acute malnutrition
in health systems: ACF Guidance
By Rebecca Brown and Anne-Dominique Israel
Rebecca Brown is Strategic Technical Adviser with ACF Paris
Anne-Dominique is Senior Nutrition Adviser with ACF Paris
The management of severe acute
malnutrition (SAM) has improved
substantially in recent years.
However, despite these improvements
coverage remains shockingly low. There
has been a realisation that treatment can
only be achieved at scale by ensuring the
availability of and access to treatment at all
levels of the health system and community
(task shifting).
In most contexts, and outside of nutritional
emergency situations, a direct
non-governmental organisation (NGO)
intervention approach is no longer feasible
or appropriate. Awareness of the need to
tackle SAM in non-emergency contexts and
to integrate this within existing health services
is increasing. In many countries,
programmes to treat SAM now fall under
the responsibility and leadership of the
Ministry of Health (MoH) and its subnational
authorities. This facilitates the
treatment of SAM within the system as part
of a basic healthcare package.
This new approach implies that stakeholders,
particularly previous direct
implementers such as NGOs, must adapt
their way of working to achieve proper
integration of the management of acute
malnutrition. For NGOs, this has meant a
fundamental shift in approach, from direct
implementation and often running CMAM
programmes in parallel to health
ministries, to supporting the health sector
at every level in managing all aspects of
acute malnutrition. For example, a project
to document Action Contre la Faim (ACF)
International’s programmes found that in
2011, 80% of ACF missions were supporting
the MoH in integrating CMAM. Five
years previous, the exact inverse was the
case with around 80% of CMAM
programmes implemented directly by ACF.
Despite the recognition of the importance
of switching to a more horizontal and
long term approach, implementing agencies
that specialise in acute malnutrition
management are still often struggling to
make this happen. Various adaptations
need to be made to how CMAM
programmes are managed and funded, in
order to move towards programming
embedded in national government
systems. For example, NGOs with a history
of direct intervention in SAM management
now need to review staff skills, i.e. the type
of skills required to take a more ‘hands-off’
approach that focuses on training, capacity
building and supporting health workers
and community-level agents. Good skills in
negotiation, training and mentoring are
now required, as well as a credible medical
or nutritional training and experience in
the management of SAM; skills in service
delivery alone are no longer sufficient.
Moreover, NGO staff are now often physically
located within the health system (at
regional or district MOH offices, for example)
to foster stronger working links and to
ensure MOH ownership and leadership of
the CMAM integration process; these staff
need to have some understanding of how
the health system works. There is still a
serious gap between health professionals
dealing with mother and child health and
those dealing with nutrition issues. In the
past, international NGO (INGO) staff
lacked experience of working within and
trying to strengthen national health
systems. INGOs lacked the institutional
culture and instincts needed for this.
As CMAM is scaled up, full integration
through health system strengthening has
still not taken place. One of the most important
challenges identified in recent months
is the capacity of all the partners to truly
understand and plan integration within
health systems that must first be strengthened.
The need to mitigate potential
adverse effects of CMAM intervention on a
weak health system has so far not being
adequately addressed. Health system
strengthening strategies based on systematic
approaches have not been supported
sufficiently. There is vast room for improvement
in this field. Even at the CMAM
Conference in Addis Ababa, although all
participants claimed that CMAM should
not be implemented as a vertical approach
(and where for the first time, WHO’s six
building blocks of Health Systems (HS)
were mentioned), the challenges faced by
government, UN agencies and international
NGOs to increase access to treatment
were still discussed outside this context.
For example, the delivery of drugs and
RUTF were not considered within the
context of structural recurrent supply chain
problems (one of the HS building blocks)
but rather as a CMAM integration problem.
Locating CMAM scale up within the HS
approach is, we feel, the way to go.
Box 1: Outline of ACF Integration Guidance
The ACF guide consists of 11 chapters. Although the
chapters can be consulted separately as standalone
chapters, they are intended to flow in a logical
manner, following the different stages of the integration
process
Chapter 1: CMAM background and basics
Chapter 2: Scenarios for integrating MSAM into
National Health Systems
Chapter 3: Stakeholder Analysis.
Chapter 4: Health Systems strengthening
Chapter 5: Enabling and Constraining Factors for
integration of SAM management
Chapter 6: The Development of National Strategic
Documents
This chapter makes particular reference to National
Nutrition Policy, nutrition action plans and CMAM
guidelines and examines how a supporting partner
can be involved in this process
Chapter 7: Advocacy for the integration of SAM
management
Chapter 8: Organisation and planning for the
integration of SAM management
Chapter 9: Community aspects of integration of
SAM management.
Chapter 10: Capacity Development and Human
Resources.
This chapter examines definitions of capacity development,
capacity development needs for the integration
of SAM management into government health systems
and the role of INGOs. There is a focus on human
resource needs. The chapter also includes a section on
contingency planning and emergency responses and
the issues to consider to ensure capacity to respond to
increased caseloads of SAM.
Chapter 11: Monitoring, evaluating and reporting
on integrated CMAM programmes
This chapter gives an overview of current national level
health and nutrition data collection and monitoring
systems, and considers the needs in relation to monitoring
and evaluation of the integration of SAM
management process.
In order to underpin this institutional
and cultural shift in approach we believe
that there is a need to develop concrete
operational guidance. The soon to be
published ACF Guidance on integration of the
management of severe acute malnutrition in
health systems 1 (see Box 1) aims to identify
all areas where ACF and other implementing
partners have to develop and further
professionalise. For example, there is one
chapter dedicated to development of advocacy
strategies involving two essential aspects of
CMAM integration strategies: funding mechanisms
and MoH leadership. Long-term funding
for nutrition programmes is vital as short-term
emergency-type funding is no longer appropriate.
Funding must take into account slower
programme set-up, the need for assistance with
policy and protocol development and implementation
and staff capacity building, as well as
community sensitisation and mobilisation in
advance of beginning programme activities. In
order to achieve successful CMAM integration, it
is also essential that the process is owned at all
levels within the MoH. There should be MoH
commitment to a long-term strategy that
includes CMAM as part of pre- and in-service
training.
1
Main authors: Alice Schmidt, Rebecca Brown and Mary
Corbett. Chapter contributions from: Anne-Dominique Israel,
Saul Guerrero and Yvonne Grellety.
62