Linking Nutrition and iCCM: A Review of Operational Experiences

Lynette Friedman Cathy Wolfheim

Objective of the review

Map out and describe operational experiences and supporting evidence in linking nutrition and iCCM to --Identify emerging lessons --Identify questions needing

investigation

Methodology • Desk review (120 + documents) • Key informant interviews (22) • In-depth analysis of selected country experiences:

– South Bangladesh – Ethiopia – Niger – South Sudan

Focused on: Context, interventions implemented, costs, and evidence of coverage and performance

Experiences grouped into four typologies

• Non-mutually exclusive • Useful to examine experiences; the way

forward may be through a combination of typologies or the addition of new approaches

Experiences grouped into four typologies

• # 1: Advising on “feeding the sick child” within existing iCCM services

• # 2: Linkages with Social and Behavior Change activities on child nutrition

• # 3: Linkages between iCCM activities and acute malnutrition treatment through assessment and referral

• # 4: Treatment at community level of uncomplicated severe acute malnutrition

# 1: Advising on “feeding the sick child” within existing iCCM services

For ALL children treated at home, advise on home care

--Advise caregiver to give more fluids and continue feeding --Advise on when to return. Go to nearest health facility immediately, or if not possible, return to CHW if child

Cannot drink or feed Becomes sicker Has blood in the stool

--Advise caregiver on sleeping under a bed net (ITN) --Follow up child in 3 days

Supporting evidence identified

• Feeding and fluids advice for sick child included in most iCCM materials reviewed

• Caregiver and health worker support of nutrition during and after illness is frequently suboptimal

• In many contexts, recommended feeding practices are poor, with responsive and active feeding not being practiced

• Sources: – 10 country review of national iCCM training materials – Malawi quality of care study – South Bangladesh counselling data

Implications of Typology 1

• Simplest of the four models to implement • Minimal cost • Coverage only for the sick child visit • Little data on quality or quantity of feeding-

related counseling • No data on effect of the advice on health

status of the child

#2: Linkages with Social and Behavior Change (SBC) activities on child nutrition

Sub categories: 1. iCCM CHW is part of larger

team; different cadre of volunteers provides health education

2. Same programme has iCCM and SBC interventions

3. Health education messages included in iCCM CHWs responsibilities

Supporting evidence identified

• Nutrition Weeks in Rwanda were found to be effective in promoting behavior change for better children’s diet: Ex. Minimum Acceptable Diet 55% higher in intervention area

• Process evaluation in Bangladesh and Viet Nam found sizable improvements in feeding practices in Alive & Thrive programme areas between 2010 and 2013

Implications of Typology 2

• Potential reach/coverage is vast • Evidence exists for potential effect and impact • SBC efforts can be resource intensive and

require good formative research and design • Which cadres carry out SBC and how close does

the link need to be with iCCM?

# 3: Assessment and referral

• Gold standard iCCM: Red MUAC and bilateral pitting oedema are danger signs for immediate referral

• Typology 3 may also include

active screening or active case detection through home visits or GMP activities

Typology 3 Examples

• South Sudan, Malaria Consortium: CDDs trained to assess and refer

• Rwanda, Concern Worldwide, IRC and World Relief: Active and passive case finding for MAM and SAM using MUAC and WFH; referral

• Niger Red Cross: monthly weighing sessions and active screening with MUAC

• Pakistan LHWs screen during house-to-house visits and other opportunities

• Global iCCM policy is to screen all sick children using MUAC and bilateral oedema

Supporting evidence identified

• Potential issues related to correct use of MUAC • Little hard evidence on:

– How well CHWs provide assessment and referral – Whether referral advice is followed – Whether children are admitted and receive adequate

treatment • Some indication that active case finding increases

coverage of treatment for childhood illness; no data showing whether the same is true for acute malnutrition

• Variable policies for yellow MUAC reading

Implications of Typology 3

• Requires a strong programme in place at health facilities to treat acute malnutrition

• Requires a functioning referral and counter-referral system

• No data to indicate whether coverage is increased

# 4: Treatment at community level of uncomplicated SAM

• Two principal types of implementation – added onto existing responsibilities of the

iCCM worker (South Bangladesh, Ethiopia HEW)

– iCCM worker linked to or connected with a second community-based cadre (Malaria Consortium S. Sudan)

Supporting evidence identified (1)

• Numbers of children treated for SAM increased (South Bangladesh, Niger)

• Quality of SAM treatment and iCCM remained high (S Bangladesh, Ethiopia, S Sudan)

• High cure rate (S Bangladesh)

Supporting evidence identified (2)

• Workload increased significantly (South Bangladesh)

• Difficulty classifying SAM (Ethiopia) • Costs of community treatment of SAM are on

same level as other interventions (South Bangladesh)

Implications of Typology 4

• Training time: likely to exceed one week

• Training complexity: requires judgment

• Quality of care: some indication that this is not problematic

• Supervision: increasingly complex

Implications of Typology 4

• Policy: Permission for CHWs to use and dispense additional medications

• Supply: Potentially difficult logistics, RUTF bulky

• Costs: RUTF most significant line item • Protocol adaptations: appetite test, RUTF

dosages, admission and discharge criteria

Conclusions (1)

• The profile of the CHW is decisive • The organization of work and current

responsibilities help determine the best approach • iCCM is only one delivery platform • The political context is also decisive • There is a palpable tension between the

“nutrition” and “health” sectors • Other sectors and concerns must be taken into

consideration

Conclusions (2)

Context, Context, Context.