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A view of NACS in Kenya from 60,000 feet
Nutrition and HIV Program – Kenya
Brian Njoroge
1
Outline
Concept –Continuum of
care
Approaches
Facility-community
Way Forward
Opportunities
2
Understanding the Issues
Integrating nutrition assessment, education and counseling as a universal service
Positioning of nutrition assessment as a vital sign
Positioning nutrition assessment & education as a life skill
Integrating FBP as a targeted (referral) service to those with clinical nutritional deficiency diseases
Standardized treatment protocols
Understanding nutritional risk and their relative importance to progression of malnutrition –
Biomarkers : slow progressors vs rapid progressors
3
Severely undernourished
(5 – 11%)
Moderately undernourished
(20 -25%)
Normal
(60 – 80%)
Epidemiology of malnutrition in adult PLHIV
Population of PLHA
Over nourished ( ~ ?)
4
Defining the NACS Package of services
Category (inferred from anthropometric assessment)
Package of services (What, Where and by who? )
Assessments Interventions (IEC materials at all levels)
Normal Anthropometric , dietary and lifestyle
BCC, Group counseling, Referrals
Moderatelyundernourished(wasted)
Anthropometric , dietary and lifestyle assessments, (refer to other diagnostic services)
BCC, Group counseling, Individualized counseling, FBP and Referrals
Severelyundernourished(acute wasting)
Anthropometric , function, dietary and lifestyle (refer to other diagnostic services).
BCC, Referrals , Group counseling daily observed feeding (DOF), individualized counseling
Overnutrition /obesity, overloads
As above primary relevant to this discussion Nutritional diseases
BCC, individualized counseling, participation group therapy, referral
5
NUTRITION SERVICES
FOOD
SECURITY
HEALTH
CARE
CONTINUUM OF NUTRITION, HEALTH & FOOD SECURITY SERVICES
6
Concept –Continuum of
care
Approaches
Facility-community
Way Forward
Opportunities
7
System Approach for NACSAgenda Setting – Alignment with existing policies ,
statutes etc
Leadership at national and sub-national levels & Managerial capacity
Resource Needs (Inputs) – HRH, Equipment, Infrastructure, Financing & Social Capital
Service Package – single intervention vs multiple interventions
Delivery channels – vertical vs integrated
Identify novel approaches – private sector delivery channels vs public sector
Identify synergies & partners and persuade
Secure Political Commitment; Leadership Planning & Implementation; Resources
8
Dispensaries
Health Centers
Sub-District Hospitals
District Hospitals
Provincial Hospitals
National ReferralHospitals
Dispensaries
Lower-LevelHospitals
HealthCenters
Higher-Level Hospitals
Faith-Based/Non Governmental
Organization Hierarchy
CommunityMedicalCentre
Clinic
Lower-LevelHospitals
Nursing Homes
Maternity Homes
Higher-Level Hospitals
Private Sector Hierarchy
Key: Central sites Satellite sites except Nairobi
Health System: NACS Service Delivery in Kenya
MOH/ Other Public Hierarchy
USG I PartnersUSAIDCDCWFPGlobal FundUNICEFMSFWHOOthers
Partner coordination and collaboration
Agriculture & other Sectors
9
Pilot Phase -2006 Transition/Adaptation Phase - 2008
Scale-up Phase -2009
Scale-up Phase -2010/12
Nutrition Service Register; LMIS ToolsMaturation Phase –
Post 2013
MoH, FBO
INSTA INSTA NHP
NHPINSTA
MoH, FBO
SCM
MoH, FBOINSTA NHP
NHP
MoH, FBO,Private Sector
KEMSA
SCM
partners
OTHER
INSTA
MoH, FBO
Moving From Pilot to Scale (Creating a critical mass) …..
10
5,618
30,293
36,432
40,473
49,474 51,202
7
57 57
105
130
158
-
20
40
60
80
100
120
140
160
180
-
10,000
20,000
30,000
40,000
50,000
60,000
2006 2007 2008 2009 2010 2011
No
. o
f C
entr
al
Sit
es
No
. o
f N
ew P
ati
ents
en
roll
ed
YEAR
Growing NACS – health facility perspective
No. of New patients enrolled
No of FBP Central Sites
11
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
180.0
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000 Ja
nu
ary
Feb
ruar
y
Mar
ch
Ap
ril
May
Jun
e
July
Au
gust
Sep
tem
ber
Oct
ob
er
No
vem
ber
De
cem
be
r
Jan
uar
y
Feb
ruar
y
Mar
ch
Ap
ril
May
Jun
e
July
Au
gust
Sep
tem
ber
Oct
ob
er
No
vem
ber
De
cem
be
r
Jan
uar
y
Feb
ruar
y
Mar
ch
Ap
ril
May
Jun
e
July
Au
gust
Sep
tem
ber
Oct
ob
er
No
vem
ber
De
cem
be
r
Y1-Q4 Y2-Q1 Y2-Q2 Y2-Q3 Y2-Q4 Y3-Q1 Y3-Q2 Y3-Q3 Y3-Q4 Y4-Q1 Y4-Q2 Y4-Q3
2009 2010 2011
Met
ric
Ton
ne
s
Nu
mb
er
of
Clie
nts
Reporting Period
New Clients Revisits FBF Delivered
Trends in Uptake of NACS/FBP and Flow of Food Commodities
12
Growing NACS – community perspective
0
200
400
600
800
1000
1200
1400
1600
1800
2000
0
2000
4000
6000
8000
10000
12000
14000
Jul-Sep Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec
3 1 5 7 8
Nu
trit
ion
al S
tatu
s -
No
Clie
ntsN
o A
sse
sed
No CBO's, Reporting YearNo Assessed SAM MAM
4 New CBO's onboard
(Nyanza, Western)
Retraining for DQI
Train new CHW [FAIR]
13
5,618
30,293
36,432
40,473
49,474
51,202
60,000
7
57 61 130
158200
250
280
300
-
200
400
600
800
1,000
1,200
1,400
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
No
of
Site
s
No
. of
Clie
nts
Years
Clients Central Sites Total Sites (Central + Satellites)
Asymptote
?
??
?
Model for Growing NACS/FBP Services
14
Concept –Continuum
of care
Approaches
Facility-community
Way Forward
Opportunities
15
Beyond HIV – Opportunities for optimizing NACS
• Trend of non communicable diseases in developing countries– Type II diabetes, hypertension, end stage renal
disease (as complications), cancers
• Filter of NACS allows (index of suspicion) for early identification of chronic diseases
• Using NACS to stimulate actions towards realization of MDGs
• Increased service uptake, adherence to treatment and Quality Improvement
16
Beyond the health sectors - NACS informing Agriculture & Industry, education & Disaster preparedness
Agriculture Value Chain – Productivity, commercialization and competitiveness
Information dissemination - - Policy Regulation/ Standards/ Food safety/ production/ value addition
Private sector investment and participation
Food security and livelihood support initiatives & Food fortification programs
Social marketing of specially formulated foods for better access and sustainability.
Education
Basic and higher level education curriculum – Life skills
Disaster preparedness
17
Concept –Continuum of
care
Approaches
Facility-community
Way Forward
Opportunities
18
Going ForwardAccelerate scale-up of NACS as part of the community
strategyHarmonize protocols for SAM and advanced MAM
management e.g. use of combination therapy and Scale up QI
Demystify FBP by expanding NACS+FBP for management of mild and early moderate malnutrition at community level –targeting those with overt risks (6-24 mo), adolescent mums and geriatrics
Strengthen advocacy and lobby for policy review to promote improved access – quota system, review taxes & tariffs on minerals & vitamins pre-mixes and therapeutic foods as public goods
R&D of more efficacious formulations and strengthening capacity of local food industry
19
Most vulnerable = NACS + (Specialized services)
Low risk
Moderate risk
High risk
Triage point
Thank You
20
Wondering
What is the meeting point between GHI and FtF – in the Kenyan context and others?
How can we amplify NACS agenda using Radio Frequency at 60,000 and net work at ground level?
How feasible is it to navigate regional approaches e.g. at East African Community –given the economic sense?
21