Severe Acute Malnutrition Guide

124 Pages·2017·1.39 MB·English

UNICEF PROGRAMME GUIDANCE DOCUMENT
MANAGEMENT OF SEVERE ACUTE
MALNUTRITION IN CHILDREN:
WORKING TOWARDS
RESULTS AT SCALE
Copyright: © United Nations Children’s Fund (UNICEF), 2015
Cover photo: © UNICEF/NYHQ2012-0156/Quarmyne
Permission is required to reproduce any part of this publication.
This is a working document. Any comments or corrigenda to this version and requests to reproduce may be sent to [email protected]
UNICEF Programme
Guidance Document
Management of Severe
Acute Malnutrition
in children: Working
towards results at scale
© UNICEF/NYHQ2014-0610/Phelps
FOREWORD
Over 17 million children are affected by severe acute malnutrition (SAM) worldwide. Despite significant
progress in recent years, approximately 2.9 million children accessed treatment in 65 countries in 2013 –
only about 17 percent of the children needing treatment.
Children with SAM are nine times more likely to die than well-nourished children. The management of
severe acute malnutrition (SAM) is critical for child survival and is a key cost-effective component of
the scaling up nutrition framework for addressing undernutrition. Governments face great challenges
in building capacity and providing sufficient resources to prevent and treat acute malnutrition. While
a significant number of acutely malnourished children live in countries where cyclical food insecurity
and protracted crises further exacerbate their vulnerability, many more are in developing countries not
affected by emergencies. The result is significant barriers to sustainable development in these nations.
Climate change and increasing numbers of natural disasters are expected to further challenge efforts to
protect the nutritional status of children and women.
Scaling up access to critical nutrition interventions such as the treatment of SAM is paramount to achieve
the global target, agreed to at the Sixty-Fifth World Health Assembly in 2012 (WHO, A65/11), of reducing
and maintaining childhood wasting to less than 5 per cent. This underscores the urgent need to increase
actions to strengthen country-level capacities to scale-up access to the treatment of SAM alongside
preventive actions to protect the nutritional status of children and women.
This Guidance Document provides practical assistance to Country Offices scaling up programmes to
manage SAM in young children. It outlines a step-by-step process through which countries can analyse
their current situation, identify barriers and bottlenecks through the MoRES approach, and plan action
to scale-up treatment. In particular it addresses the challenge of supporting governments to accelerate
and sustain scale-up, build national capacities and source reliable and sustained supplies and financing
for managing SAM. This document also provides complementary background information, references to
international technical recommendations, resources and tools.
The document is aimed at UNICEF country-level programme managers and their main partners – MoH
technical staff and managers, non-governmental organizations and community-based organizations.
The document was prepared by staff from the Nutrition Section and Supply Division at UNICEF
headquarters. Inputs were provided by regional offices; the Health, HIV and Early Childhood Development
units at headquarters; and selected Country Offices with experience in scaling up management of SAM.
The financial support of USAID Food for Peace in the translation and publication of the document is
gratefully acknowledged.
This is a working document. It draws on a growing body of learning that is being built as programmes to
manage SAM are scaled up. Comments and suggestions are welcome, as are questions and/or requests
for additional information and support on any of the areas covered in this document. Please direct
communications to [email protected].
I hope you find this document helpful in addressing the problem of SAM as we work together so that all
children in every community, especially the most marginalized, realize their right to development.
Ted Chaiban
Director of Programmes
iii
CONTENTS
ACRONYMS AND ABBREVIATIONS..................................vi
1
INTRODUCTION ...........................................1
AIM AND SCOPE ..............................................................................2
AUDIENCE .........................................................................................4
2 PLANNING THE SCALE-UP
OF SAM MANAGEMENT ............................5
STEP 1. ASSESS THE MAGNITUDE
AND DISTRIBUTION OF SAM .........................................................6
Estimate the burden ..................................................................................6
Determine geographical and seasonal distribution ...............................6
STEP 2. MAP, MOBILIZE AND CONSULT .......................................7
Map and Mobilize partners .....................................................................7
Map sources of data .................................................................................8
Consult with stakeholders ........................................................................8
STEP 3. PERFORM BOTTLENECK ANALYSIS ................................8
Carry out determinant analysis ..............................................................10
Collect data and assemble the baseline ................................................10
Identify and carry out causal analyses of bottlenecks .........................10
STEP 4. DEVELOP SCALE-UP PLAN .............................................10
Establish a participatory planning process ...........................................10
Agree on overall objectives, scale-up
modalities, pace and targets ..................................................................11
Incorporate review and learning during scale-up ................................12
Ensure harmonized national guidelines are in place
and supported by all actors ....................................................................13
Decide what to implement and where ..................................................14
Decide who will be involved at each level of implementation ...........15
Develop community mobilization strategies ........................................15
Select capacity development modalities...............................................16
Develop referral modalities between management components ......17
Consider support for the supply chain ..................................................17
Establish links within and outside the health sector............................17
Consider emergencies and contingency planning ...............................20
Address coordination requirements ......................................................21
Determine available resources ...............................................................23
STEP 5. DEVELOP A MONITORING AND EVALUATION PLAN ..24
Identify areas needing monitoring ........................................................24
Assess programme performance indicators.........................................24
Capture and analyse programme outcome data
and provide feedback ..............................................................................25
© UNICEF/NYHQ2012-1871/Noorani Integrate coverage monitoring ..............................................................28
iv
3 GOOD PRACTICES FOR ADDRESSING
BOTTLENECKS IN SCALING UP ...............30
ANNEXES .................................................69
ENABLING ENVIRONMENT ...........................................................30
Politics and policy ...................................................................................30 ANNEX A
Indirectly estimating burden (need),
Resources .................................................................................................31
targets and coverage ........................................................69
Coordination mechanisms......................................................................32
SUPPLIES ........................................................................................33 ANNEX B
Human resources: availability and competencies ................................33 Assessments that feed into
bottleneck analysis ............................................................78
Commodities and logistics .....................................................................35
ANNEX C
DEMAND .........................................................................................37
Fact sheet on direct coverage assessment ...............81
QUALITY ..........................................................................................38
ANNEX D
Protocols and guidance ..........................................................................38
Benchmarks for scale-up of SAM
Supervision ..............................................................................................39 management at national level ......................................89
Developing monitoring and reporting systems ...................................40
ANNEX E
Annotated list of tools for
4 SAM MANAGEMENT: management of SAM .....................................................92
INFORMATION FOR PROGRAMMING .....42
ANNEX F
Management of SAM
BACKGROUND AND CONTEXT ....................................................42 in other groups ................................................................96
SAM and mortality ..................................................................................42
ANNEX G
Management of SAM: A brief history ...................................................44
Information exchange and resource forums ...........103
Global initiatives and the inclusion of
management of SAM ..............................................................................46 ANNEX H
Management of SAM within national structures, Questions, knowledge gaps and
systems and programmes ......................................................................46 research needs in SAM management ......................105
UNICEF POLICY, ROLES AND PARTNERSHIPS ............................48
UNICEF policy on management of SAM ...............................................48
Global and country-level roles ...............................................................49
Partnerships for management of SAM .................................................50 REFERENCES .....................................108
GLOBAL PROGRESS OF SAM MANAGEMENT SCALE-UP ........51
Programming ...........................................................................................52
Supply ......................................................................................................52
Evaluation and lessons learned .............................................................52
REGIONAL AND GLOBAL RESOURCES TO
SUPPORT SCALE-UP ......................................................................53
Training materials ....................................................................................53
Information exchange and resource forums ........................................54
Costs and cost-effectiveness calculations .............................................54
Estimating SAM burden and targets .....................................................56
Advocacy tools ........................................................................................57
Coverage monitoring ..............................................................................58
Programme and progress monitoring...................................................60
Supplies ....................................................................................................60
RUTF supply chain and forecasting .......................................................62
Integration and health systems frameworks and tools .......................64
Resource mobilization ............................................................................66
CONTENTS v
BOXES
Box 1. Guidance point: Data sources .....................................................................6
Box 2. Guidance point: Partners to include in consultations ..................................................7
Box 3. Guidance point: Additional tools to facilitate planning for CMAM scale up ..............................11
Box 4. Guidance point: A phased approach to scale-up ....................................................12
Box 5. Guidance point: Examples of targets for scale-up ...................................................13
Box 6. Guidance point: Dispersed populations and mobile teams ............................................14
Box 7. Guidance point: Successful community mobilization strategies ........................................16
Box 8. Guidance point: Examples of successful programme links ............................................18
Box 9. Good practice: Kenya’s integrated nutrition package .................................................19
Box 10. Guidance point: CCC Preparedness and DRR actions for management of SAM ...........................21
Box 11. Guidance point: Elements of UNICEF coordination support to governments to scale up SAM management. . .22
Box 12. Guidance point: Coordination Mechanisms .............................................................23
Box 13. Guidance point: Criteria for measuring programme performance ..........................................25
Box 14. Guidance point: Sphere performance indicators for SAM management .....................................25
Box 15. Guidance point: Nationally agreed reporting for SAM management ........................................26
Box 16. Guidance point: Coverage and effectiveness ............................................................29
Box 17. Good practice: Bringing management of SAM into the policy agenda .......................................32
Box 18. Good practice: Facilitating resource mobilization ........................................................33
Box 19. Good practice: Planning solutions .....................................................................34
Box 20. Good practice: Supporting health staff at facility and community levels .....................................34
Box 21. Good practice: Addressing training issues ..............................................................35
Box 22. Good practice: Use of RapidSMS technology in Ethiopia ..................................................36
Box 23. Good practice: Protecting shelf life of products ..........................................................37
Box 24. Good practice: Measures to increase focus on demand creation ...........................................38
Box 25. Good practice: Addressing motivation and participation of volunteers and other community agents .............39
Box 26. Good practice: Referral in Uganda ....................................................................39
Box 27. Good practice: Addressing supervision and monitoring challenges .........................................40
Box 28. Definitions: Commonly Used Terms ...................................................................43
Box 29. Definitions: Integrated health services and integrated management of SAM .................................47
Box 30. CCC programme actions for management of SAM .......................................................48
Box 31. Management of SAM within the UNICEF Strategic Plan 2014-2017 .........................................49
Box 32. Definitions: Prevalence of malnutrition .................................................................57
Box 33. Definitions: Coverage ...............................................................................59
Box 34. The global SAM management update tool (Nutridash) ...................................................61
Box 35. Main findings of Horn of Africa supply chain review (Duke University 2009) .................................63
TABLES
Table 1. Key determinants in managing scale-up of SAM management .........................................9
Table 2. Example of monitoring framework ...............................................................24
Table 3. UNICEF and WFP memorandum of understanding (2011): Except from the technical annex for nutrition .....51
Table 4. Cost-effectiveness estimates of community-based management of SAM ...............................55
Table 5. Simplified example of a national CMAM programme ...............................................74
Table 6. Key questions for health system capacity analysis ..................................................79
Table 7. Summary of suggested criteria for admission for SAM used in children five years or older,
adolescents and adults ........................................................................102
vi UNICEF PROGRAMME GUIDANCE DOCUMENT
FIGURES
Figure 1. Components of community-based management of acute malnutrition ...................................4
Figure 2. Process for scaling up management of SAM ........................................................5
Figure 3. New framework for designing management of SAM, illustrating the disaster risk reduction approach .......20
Figure 4. Relationship between effectiveness and coverage ...................................................29
Figure 5. RUTF acquisition from 2000 to 2011, by metric tonnes and number of countries .........................53
Figure 6. Graphic definition of prevalent cases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69
Figure 7. Map of classes of facility-level geographical coverage by region. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
Figure 8. Map showing the spatial distribution of point and period coverage in a CMAM programme
produced using the CSAS method ................................................................83
Figure 9. Barriers to service access and uptake in a CMAM programme reported by carers of non-covered cases
produced using the CSAS method ................................................................83
Figure 10. Relations between factors influencing coverage and effectiveness produced by a SQUEAC assessment .....84
Figure 11. Coverage mapping by risk mapping ..............................................................84
Figure 12. Map of per-district coverage produced by the SLEAC method .........................................85
Figure 13. Using SLEAC and SQUEAC in failing service delivery units ...........................................85
Figure 14. Using SLEAC and SQUEAC in succeeding and failing service delivery units .............................85
Figure 15. Coverage map produced by the S3M method ......................................................86
ACRONYMS AND ABBREVIATIONS
ACF Action Against Hunger / ACF International MAM Moderate acute malnutrition
CCCs Core Commitments for Children in MDG Millennium Development Goal
Humanitarian Action (UNICEF)
MoH Ministry of Health
CMAM Community-based management of acute
MoRES Monitoring Results for Equity System
malnutrition
MSF Médecins Sans Frontières
CO Country Office
M&E Monitoring and evaluation
CSAS Centric Systematic Area Sampling
MUAC Mid-upper-arm circumference
DFID UK Department for International Development
NGO Non-governmental organization
DHSS District Health Systems Strengthening
RUTF Ready-to-use therapeutic food
DIVA Diagnose, intervene, verify, adjust
SAM Severe acute malnutrition
ECD Early childhood development
SCN Standing Committee on Nutrition
ECHO European Community Humanitarian Office
SLEAC Simplified LQAS Evaluation of
ENN Emergency Nutrition Network
Access and Coverage
FANTA Food and Nutrition Technical Assistance
SQUEAC Semi Quantitative Evaluation of
TABLES
GNC Global Nutrition Cluster Access and Coverage
Table 1. Key determinants in managing scale-up of SAM management .........................................9 HIV Human immunodeficiency virus S3M Simple Spatial Survey Method
IMCI Integrated Management of Childhood Illness SUN Scaled-up Nutrition
Table 2. Example of monitoring framework ...............................................................24
ICCM Integrated Community Case Management WFP World Food Programme
Table 3. UNICEF and WFP memorandum of understanding (2011): Except from the technical annex for nutrition .....51
of Childhood Illness
WHO World Health Organization
Table 4. Cost-effectiveness estimates of community-based management of SAM ...............................55
IYCF Infant and young child feeding
Table 5. Simplified example of a national CMAM programme ...............................................74
Table 6. Key questions for health system capacity analysis ..................................................79
Table 7. Summary of suggested criteria for admission for SAM used in children five years or older,
adolescents and adults ........................................................................102
CONTENTS vii
© UNICEF/NYHQ2012-1980/Noorani
viii UNICEF PROGRAMME GUIDANCE DOCUMENT