Linking Nutrition & (integrated) Community Case Management

Transcription

1 02 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Linking Nutrition & (integrated) Community Case Management A REVIEW OF OPERATIONAL EXPERIENCES Lynette Friedman & Cathy Wofheim December 2014

2 02 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 A c k n o w e d g e m e n t s The authors woud ike to thank a the individuas and organisations that made this review possibe. In particuar, the authors woud ike to thank the members of the Steering Committee overseeing this review; Samira Aboubaker (WHO), Sau Guerrero (Action Against Hunger UK), Diane Hoand (UNICEF), Emiy Keane (Save the Chidren UK), Katie MacDonad (PSI) and Casie Tesfai (Internationa Rescue Committee). Specia thanks to Lauren Browne, Sonam Hitendre and Emiy Hockenhu for their assistance with data coation and management during this review. Proposed Citation: Friedman, L.& Wofheim, C.(2014) Linking Nutrition and (integrated) Community Case Management (iccm/ccm): A Review of Operationa Experiences (London, 2014) This review was made possibe thanks to the financia contribution of:

3 03 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 C O N T E N T S ABBREVIATIONS AND ACRONYMS 04 EXECUTIVE SUMMARY 05 INTRODUCTION & BACKGROUND 08 About the Review 10 Methodoogy 10 Limitations 12 REVIEW FINDINGS 13 Typoogy 1: Advising on feeding the sick chid within existing iccm services 14 Typoogy 2: Linkages with Socia and Behaviour Change activities on chid nutrition 16 Typoogy 3: Linkages between iccm activities and acute manutrition treatment through assessment and referra 19 Typoogy 4: Treatment at community eve of uncompicated Severe Acute Manutrition 25 DISCUSSION 35 Typoogy 1 Discussion 37 Typoogy 2 Discussion 38 Typoogy 3 Discussion 39 Typoogy 4 Discussion 39 Knowedge Gaps 42 LESSONS & CONCLUSIONS EMERGING FROM THE REVIEW 43 ANNEXES 45 Typoogy 1: Key Informant Organisations 45 Typoogy 2: Community-eve Nutrition Actions Identified 47 Typoogy 3: CHWs Providing Treatment for SAM: CHW and Programme Profies 49 Typoogy 4: Operations Research Underway or Panned 50 Typoogy 5: Documents Reviewed 54

4 04 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 A B B R E V I A T I O N S & A C R O N Y M S ACF A&T ANC APE ASC CBD CBN CBNP CCM CDD CHA CHW CMAM CNW CSB CTC DALY DRC GAIN GAM HDA HEW HIV HMIS HSA iccm IFPRI IIP JHU IMCI IMNCI IRC ITN IYCF MAM MOH MUAC NGO ORS OTP RaCE RDT RUSF RUTF SAM SBC SFP SMART TB UNICEF USAID WFH WHO Action Contre a Faim/Action Against Hunger Aive and Thrive Antenata Care Agente Poivaente Eementar Agent de Santé Communautaire Community-Based Distributor Community-Based Nutrition Community-Based Nutrition Programme Community Case Management Community Drug Distributor Community Heath Activist Community Heath Worker Community-based Management of Acute Manutrition Community Nutrition Worker Corn Soy Bend Community Therapeutic Centre Disabiity-Adjusted Life Year Democratic Repubic of the Congo Goba Aiance for Improved Nutrition Goba Acute Manutrition Heath Deveopment Army Heath Extension Worker Human Immunodeficiency Virus Heath Management Information System Heath Surveiance Assistant integrated Community Case Management Internationa Food Poicy Research Institute Institute for Internationa Programs at Johns Hopkins University Integrated Management of Chidhood Iness Integrated Management of Neonata and Chidhood Iness Internationa Rescue Committee Insecticide Treated Net Infant and Young Chid Feeding Moderate Acute Manutrition Ministry of Heath Mid Upper Arm Circumference Non-Governmenta Organisation Ora Rehydration Sats Outpatient Therapeutic Programme Rapid Access Expansion Programme Rapid Diagnostic Test Ready-To-Use Suppementary Food Ready-To-Use Therapeutic Food Severe Acute Manutrition Socia and Behaviour Change Suppementary Feeding Programme Standardized Monitoring and Assessment of Reief and Transition Tubercuosis United Nations Chidren Fund United States Agency for Internationa Deveopment Weight-for-Height Word Heath Organization

5 05 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 E X E C U T I V E S U M M A R Y Nutrition is crucia to both individua and nationa deveopment. Recent estimates suggest that improving access and coverage of specific nutrition interventions coud save hundreds of thousands of ives every year. In spite of this potentia, the reach of many of these interventions remains imited. Integrated Community Case Management (iccm) of chidhood inesses may be a ogica patform, perhaps currenty a missed opportunity, for increasing the reach and coverage of treating manourished chidren, and potentiay for preventing manutrition. The objective of this review is to map out and describe operationa experiences in inking nutrition and Community Case Management/integrated Community Case Management interventions, with the goa of identifying emerging essons and identifying gaps in knowedge. The decision to undertake this review was an outcome of a meeting hed in London in May 2014 to examine potentia inkages between iccm, Community Heath Workers (CHW), and manutrition. That meeting concuded with an agreement to work towards buiding and sharing the evidence base for effective service deivery in different contexts. This review utiized two principa methods of data coection: desk review and key informant interviews. Documents reviewed incuded peer-reviewed journa artices, programme reports, goba and nationa CCM/iCCM and nutrition guideines, programme proposas and study designs. Four countries were seected for more in-depth review: Bangadesh, Ethiopia, Niger and South Sudan. To suppement and enhance programmatic and impementation-reated information gathered during the desk review, 22 key informant interviews were carried out with individuas from seven Non-Governmenta Organisations (NGOs), three donor agencies, WHO headquarters staff representing expertise in iccm and in nutrition, and UNICEF staff at headquarters, regiona, and country eves. Anaysis of impementation experiences brought to ight four categories of approaches to integrating or inking iccm and nutrition. In this review, these categories are referred to as typoogies. The typoogies provide an organizing framework for describing, exporing and comparing existing experiences and evidence, anaysing advantages and disadvantages, and defining knowedge gaps. The construct of the four typoogies is usefu for examining current and past experiences, however it is ikey that the way forward may be through a combination of typoogies, or through the addition of new aternative approaches to inkage or integration. Typoogy 1 Typoogy 2 Typoogy 3 Typoogy 4 Advising on feeding the sick chid within existing iccm services Linkages with Socia & Behaviour Change activities on chid nutrition Linkages between iccm activities and acute manutrition treatment through assessment and referra Treatment at community eve of uncompicated Severe Acute Manutrition

6 06 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 1 Typoogy 1 focuses on providing advice to the caregiver of the sick chid during the sick chid consutation. According to the UNICEF/WHO iccm protoco, the iccm worker advises the caregiver as part of home care. The task is imited to advising (providing information on the recommended behaviour) concerning home treatment of iness (how to give ORS, zinc, antibiotics, antimaarias), and when to return to the CHW or seek medica care. Athough every CHW impementing iccm is supposed to advise the caregiver of a sick chid to continue feeding and fuids, the review found itte data about the quaity or quantity of feeding-reated advice. No data was found on the effect of this advice on the heath status of the chid. Athough the review found no data on cost for this typoogy, it is assumed that costs of strengthening the messaging woud be reativey ow, requiring the review and revision of goba and nationa iccm training manuas and recording forms to ensure that continued feeding of the sick chid is emphasized and made more expicit. Typoogy 1 is probaby the simpest of the four identified typoogies to carry out or strengthen. Typoogy 2, inkages with socia and behaviour change activities on chid nutrition, provides a strong patform for reaching a wide popuation with preventive messages. Many nutrition programmes focus on improving infant and young chid feeding practices through a range of approaches from deivering heath education messages to impementing socia and behaviour change (SBC) activities. Most of the socia and behaviour change experiences reviewed are resource-intensive and require home visits compemented by socia mobiization and mass communication activities. In the UNICEF/WHO iccm materias, information on disease prevention is imited to key advice reated to home care incuding advising caregivers to give more fuids and continue feeding, to seep under bednets in maaria areas, and to ensure fu vaccination. Because messages are tighty context-specific, the impementation of Typoogy 2 impies the avaiabiity off skied personne, as we as adequate finances to carry out the needed formative research and message deveopment. It aso suggests an additiona oad on the iccm CHW to carry out the home visits, athough this coud be avoided this by using different cadres. The evidence identified came from sma to medium size interventions. Typoogy 2 Typoogy 3 Typoogy 3, inkages between iccm activities and acute manutrition treatment through assessment and referra, is aready part of the standard UNICEF/WHO protoco. According to the protoco, iccm workers measure every sick chid over six months of age with a MUAC strap and assess for biatera pitting oedema. An important variation on this typoogy is the use of active screening or active case detection through home visits or at growth monitoring group activities. This aows measurement of every chid, sick or we, and may be the standard in many countries or projects. Despite the incusion of assessment and referra for acute manutrition in the UNICEF/ WHO iccm standard protocos, itte hard evidence was found concerning how we or even whether this action was carried out during a sick chid consutation, the quaity of the assessment, whether the referra advice was foowed, and utimatey whether it resuted in adequate treatment. This typoogy requires a strong programme in pace to treat cases of acute manutrition at heath faciities and a functioning referra system, in addition to a we-trained, extensive network of CHWs. It aso needs the appropriate nationa poicies, protocos, and data systems for both iness management and nutrition, and a supervisory structure to ensure the adequate use of MUAC. Athough there is some indication that active case-finding increases coverage of treatment for chidhood iness, no data was found showing whether the same is true for acute manutrition. Typoogy 4, treatment at community eve of uncompicated Severe Acute Manutrition, has been impemented by severa NGOs and governments adapting CMAM protocos. These experiences fa into two categories: 1) the assessment, cassification and treatment for acute manutrition were added onto the existing responsibiities of the iccm worker, and; 2) the iccm worker was inked to or connected with a second community-based cadre with responsibiities and skis for addressing acute manutrition. The contexts for the various experiences differ widey, ranging from deveopment to emergency in severa different countries. With the exception of Ethiopia, most experiences to date have been (or wi be) conducted at a sma scae with strong supervision. Avaiabe evidence is thus restricted to a smaer number of experiences but provides insight into a arger number of topic areas. In contrast to the previous three typoogies, the review found data on a number of additiona factors incuding time spent by the CHW, cost Typoogy 4

7 07 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 of impementation, and poicy impications. Typoogy 4 is arguaby the most compex of the four identified typoogies. Impications for impementation cover training time, training compexity, quaity of care, supervision, poicy, suppy, costs, and issues of protoco adaptations. In discussing which approaches key informants woud or woud not recommend, community-based treatment of uncompicated severe acute manutrition eicited strong reactions on both sides of the argument. In addition to identifying what was known about integrating nutrition and iccm/ccm, this review sought to identify remaining gaps in knowedge in order to hep focus future impementation and research directions. In contrast to the abundant evidence supporting the need to integrate or ink, and the equay abundant evidence for each of the two domains separatey, the paucity of hard evidence of how inkages coud be done confirms the imited experience. Future work wi need to examine the best combination of actions probaby crossing over the proposed typoogies -- to ensure better coverage of interventions that identify and ensure treatment and prevention of chidhood iness and acute manutrition. The ist of questions put forward in this review is vast but a subset is incuded in the main body of the report. Much of what is not known reates to arge-scae impementation, feasibiity, and the transferabiity of experience from one context to another. One frequent theme arising throughout the review process, in both the desk review and the key informant interviews, is the primordia importance of context; what works in one country or part of a country may not be appropriate for another. There are a number of other common essons that arose from this review: a. The profie of the CHW is decisive. The gamut runs from a paid, iterate CHW with a reativey sma catchment area and a substantia amount of training, to a vounteer, iiterate CHW with a arge number of househods to cover and one week of training. b. The organisation of work and current responsibiities of CHWs hep determine the best approach, for exampe whether the integration of nutrition activities shoud buid on a heath education patform or on a treatment patform. c. A division of responsibiities whereby the CHW who does treatment is compemented by others who do active case-finding, home visits, and/or IYCF messaging has the potentia of increasing coverage whie not overoading one particuar cadre. d. iccm is ony one deivery patform; nutrition coud be added to others, incuding the Expanded Programme on Immunization and antenata care activities. e. The poitica context is aso decisive. In paces with a high prevaence of acute manutrition, ow access to treatment and poor heath infrastructure, for exampe South Sudan, there is a stronger argument for community-eve treatment. At the same time there is more opportunity for the CHW to see acutey manourished chidren and thus to practice and retain the reevant skis. The same argument may appy to areas in emergency situations. f. There is a papabe tension between the nutrition and heath sectors. This tension reates to avaiabe funding (donor attention), funding streams, and management structures. This coud be ikened to a simiar tension often found in iccm between vertica maaria programmes and more horizonta chid heath programmes in countries. The advantages to both sectors of inking shoud be ceary articuated, using terminoogy acceptabe by a concerned. g. Other sectors and concerns must be taken into consideration. Exampes incude gender issues (men are famiy decision-makers), socia protection schemes, and food security. h. Key informants agreed that it was reasonabe to expect a iccm CHWs to assess, refer and counse acutey manourished chidren. There was agreement amongst a number of respondents that iccm coud be an effective patform for reinforcing IYCF messages, strengthening feeding practices during iness, and foowing up acutey manourished chidren. i. Respondents brought up the chaenges of integrating nutrition and heath at the nationa eve, reated to coordination across MOH directorates, funding streams, and the chaenge of ensuring that usefu nutrition indicators were incuded in the Heath Management Information System (HMIS).

8 08 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 I N T R O D U C T I O N & B A C K G R O U N D According to The Lancet Materna and Chid Nutrition Series, 20131, the goba prevaence of chid stunting is sowy decreasing, but in 2011 sti affected at east 165 miion chidren under five years of age. Wasting affected at east 52 miion chidren. Undernutrition, incuding foeta growth restriction, suboptimum breastfeeding, stunting, wasting, and deficiencies of vitamin A and zinc, cause 45% of a chid deaths, some three miion per year. The same series estimates that 90% coverage of eary and excusive breastfeeding pus appropriate compementary feeding coud save as many as 221,000 ives per year; the same coverage of the management of moderate acute manutrition woud save 435,000 ives, and of Severe Acute Manutrition woud save between 285,000 and 482,000 ives. Nutrition is crucia to both individua and nationa deveopment. The evidence in [the Lancet] Series furthers the evidence base that good nutrition is a fundamenta driver of a wide range of deveopment goas. The post-2015 sustainabe deveopment agenda must put addressing a forms of manutrition at the top of its goas. (The Lancet Materna and Chid Nutrition Series, 2013, Executive Summary) Despite the widespread need, ony about 15% of chidren who suffer from Severe Acute Manutrition receive adequate treatment. Even in countries where Community-based Management of Acute Manutrition (CMAM) exists, coverage remains ow with many subnationa services reaching ess than 50% of a cases 2. Chaenge: There is a ong way to go to meet the needed 90% rate of coverage postuated in The Lancet series. Integrated Community Case Management (iccm) of chidhood iness is a strategy to identify and treat the major diseases affecting mortaity in chidren under five years of age. It is based on an interaction during a sick chid encounter. In parae with the approach of Integrated Management of Chidhood Iness (IMCI) at the heath faciity eve, iccm takes a hoistic approach, reviewing a danger signs and providing needed treatment, prevention and foow-up for the chid s condition(s). In most countries, the iccm protoco (foowing the UNICEF/WHO package Caring for the Sick Chid in the Community 3 ) incudes the identification of acute manutrition by measuring Mid Upper Arm Circumference (MUAC) and biatera pitting oedema, and the immediate referra of chidren with Severe Acute Manutrition (SAM). It aso incudes advice on continued feeding of any sick chid treated at home, as we as advice on seeping under bednets and ensuring the correct vaccination status. iccm may be a ogica patform, perhaps currenty a missed opportunity, for increasing the reach and coverage of treating manourished chidren, and potentiay for preventing manutrition. The hypothetica advantages to inking iccm and nutrition services are manifod, given the considerabe overap between disease and manutrition. Interventions to prevent or decrease manutrition or infectious disease are expected to decrease chid mortaity, and interventions that accompish both wi have the greatest effect 4. In many countries, Community Heath Worker (CHW) programmes are in pace. It is cautioned at the outset of this review that shifting tasks and responsibiities to CHWs is sometimes considered by governments and partners as a cost-saving approach to increasing access to care. As wi be described ater, the impementation of effective CHW programmes requires soid support in the form of supervision, training, suppy and ogistics, and functiona referra systems. To ensure that this support is in pace, CHW programmes need to be firmy situated in a process of overa heath systems strengthening. 1 The Lancet Materna and Chid Nutrition Series Executive Summary, 6 June UNICEF/Coverage Monitoring Network/ACF Internationa (2012) The State of Goba SAM Management Coverage 2012 (New York & London, August 2012) 3 This package, pubished in 2011, was designated as the god standard for iccm training by the Steering Committee of the iccm Taskforce 4 Peetier DL et a. Epidemioogic evidence for a potentiating effect of manutrition on chid mortaity. Am J Pubic Heath Aug;83(8):

9 09 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Advantages for the chid and community of inking nutrition and iccm incude: Ensuring more hoistic and comprehensive management of the sick and we chid; Increasing access to acute manutrition services; Increasing efficiency of screening, by using sick chid visits to identify and foow up acutey manourished chidren; Providing a singe point of care for different heath and nutrition services for the caregiver; Earier identification of manutrition, eading to faster recovery times, ower mortaity, reduced need for inpatient care, and ess costy treatment; Providing the CHW an opportunity to communicate the inkages between disease and manutrition. In addition, there are potentia programmatic advantages to inking nutrition and iccm: Integrated services can be more cost-effective. Motivation of the CHW may be improved: since Ready- To-Use Therapeutic Food (RUTF) provides quick, visibe improvements in chidren, job satisfaction and community appreciation for the CHW who treats acute manutrition can increase. It is more ikey that chid nutrition, both curative and preventive, is given adequate attention in chid heath programming, toos and interventions. Merging funding from CMAM-specific and iccm-specific streams may ensure more sustainabe support. Athough it may be interpreted that most of the advantages isted above are seen from the nutrition perspective (what s in it for nutrition programmes?), there are aso firm arguments from the iccm perspective. The chidren most ikey to die from diarrhoea, pneumonia or maaria are those who are ma / undernourished, with manutrition underying one-third of a chid deaths. There is aso substantia evidence that chidren respond better to treatment (e.g. for maaria) if their nutritiona status is addressed. Reducing manutrition shoud aso reduce morbidity (thus reduce caseoad) and reduce the duration of iness. The effort being made to treat Severe Acute Manutrition in Niger is tremendous, and this needs to be supported. The probem in 2012 was that a massive pan for treating Severe Acute Manutrition was prepared and impemented, but it excuded other heath needs, in particuar maaria prevention and immunisations. The response was taiored to the manutrition crisis, and faied to take account of the fact that even if you provide chidren with appropriate nutrition, you can sti ose them to maaria or a respiratory infection which coud have been prevented by a pneumococca vaccination. There is a need for an integrated response, rather than for pushing one response to the excusion of others, which can have a detrimenta effect on the surviva of chidren. Addressing the underying vunerabiity of the chid is ikey to increase the effectiveness of iccm as we. Nutritiona screening activities provide significant opportunities for identifying cases of diarrhoea, pneumonia and maaria and thus increasing coverage of treatment. There are aso significant and obvious disadvantages to inking nutrition with iccm. These cover, most notaby, concerns of overworked, often underpaid (or vounteer) CHW and the famiiar reated issues of sustainabe quaity of the care provided, retention, motivation, supervision, suppy, referra systems, and imited resources. José Antonio Bastos MSF Spain president Apri 2013

10 10 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 About the Review There are mutipe converging and competing points of view on whether and how best to ink iccm and nutrition interventions. The objective of the current review is to map out and describe operationa experiences in inking nutrition and Community Case Management/ integrated Community Case Management interventions, with the goa of identifying emerging essons and identifying gaps in knowedge. The decision to undertake this review was an outcome of a meeting hed in London in May 2014 to examine potentia inkages between iccm, CHWs, and manutrition. That meeting concuded with a statement of intent that nutrition shoud be effectivey integrated into iccm, and an agreement to work towards buiding and sharing the evidence base for effective service deivery in different contexts. Moreover, curiosity about the current status of impementing inked activities had been stimuated at the iccm Evidence Symposium in Ghana in March 2014, with the presentation of a cross-sectiona survey conducted by UNICEF to expore iccm poicy and impementation in sub Saharan Africa. Methodoogy The iterature on iccm and on chid nutrition is vast. Because the present review was carried out with the aim of describing experiences and consoidating avaiabe evidence of programmes or projects that ink iccm and nutrition interventions, the anaysis was restricted as much as possibe to experiences that refect this. This review utiized two principa methods of data coection: desk review and key informant interviews. The desk review aimed to map and describe operationa experiences and existing evidence about inking nutrition and CCM/iCCM interventions. Documents reviewed incuded peerreviewed journa artices, programme reports, goba and nationa CCM/iCCM and nutrition guideines, programme proposas and study designs. Documents were soicited through the review Steering Group 5, CORE Group istserve, iccm Task Force istserve, and goba and regiona offices of WHO and UNICEF. The reviewers sought additiona materias through web searches and individua organisationa contacts. The USAID Materna and Chid Surviva Project conducted a secondary anaysis on data from the UNICEF cross-sectiona survey to determine if any additiona information was avaiabe on nutrition interventions reported in conjunction with iccm. Four countries were seected for more in-depth review: Bangadesh, Ethiopia, Niger and South Sudan. The reviewers sought extensive information on each of these countries from documentation and from key informants. Experiences were reviewed for detais reated to context, interventions impemented, costs, and evidence base. The experiences are: Bangadesh: Save the Chidren project in South Bangadesh (with the Feinstein Internationa Center at Tufts University) Ethiopia: Nationa Heath Extension Programme Niger: Internationa Federation of Red Cross and Red Crescent Societies, French Red Cross, Niger Red Cross South Sudan: Maaria Consortium, Internationa Rescue Committee, Popuation Services Internationa, Save the Chidren 5 Action Against Hunger, UNICEF, WHO, Save the Chidren, Internationa Rescue Committee and Popuation Services Internationa

11 11 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 The focus on a sma number of seected countries was intended to baance the goba scope of the review with a more in-depth and detaied examination of specific programmatic experiences. Countries were identified by the Steering Group, based on prior exporation of programmes with documented operationa experiences inking iccm and nutrition interventions. To suppement and enhance programmatic and impementation-reated information gathered during the desk review, the reviewers carried out 22 key informant interviews. Interviews were conducted using pre-defined questionnaires. The key informants incuded individuas from seven Non-Governmenta Organisations (NGOs), three donor agencies, WHO headquarters staff representing expertise in iccm and in nutrition, and UNICEF offices at headquarters, regiona, and country eves. The origina ist of key informants was provided by the Steering Group, and augmented based on recommendations. Every effort was made to reach a variety of organisations and incude representation of both nutrition and iccm expertise within organisations. A ist of organisations interviewed can be found as Annex 1. For the purpose of this review the foowing definitions were used: Nutrition interventions This term covers a range of actions, incuding one or more of the foowing ist: Identification, referra and/or foow up of acute manutrition cases (severe and/or moderate) Treatment of acute manutrition cases (severe and/or moderate) at faciity Treatment of acute manutrition cases (severe and/or moderate) at home (or in the community cose to home) Deworming Micronutrient suppementation Advising on feeding of the sick chid Advising /counseing on Infant and Young Chid Feeding (IYCF) (incuding eary and excusive breastfeeding and compementary feeding) Community Heath Worker (CHW) Various terms used incude community heath workers, community-owned resource persons, heath surveiance assistants, fied or extension workers, ady heath workers, community drug distributors. Generaizations about the profie of CHWs are difficut, however the main focus of the term in this review is on CHWs as ay (non-medica) heath workers. In various programmes, they may be men or women, young or od, iterate or iiterate, paid or unpaid. iccm vs CCM (integrated community case management vs community case management) The difference is subte. CCM can be case management of any condition, at the community eve. iccm is integrated, not singe-disease, and not combined (e.g. not: first ook for and treat pneumonia, then ook for and treat diarrhoea). It is in many ways a simpified version of IMCI. It has aso, by design, been imited to those conditions that can be fata for chidren and that can be treated reativey easiy: pneumonia, diarrhoea, maaria, pus the identification of acute manutrition. It shoud be emphasized that iccm is not intended to stand aone in its impementation. It is part of a arger set of actions that cover caring for the newborn at home and caring for the chid s heathy growth and deveopment (see box in Discussion section). Linkage/integration These are different ways to describe the connection between iccm and nutrition interventions. iccm in its generic form incudes the identification of acute manutrition using MUAC and oedema of both feet, and referra of the chid to a feeding programme or rehabiitation centre. In this case, the two programmes or types of actions are inked but are not integrated. On the other end of the spectrum is the identification and treatment of acute manutrition by the CHW. This coud be considered integration.

12 12 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Limitations The review examined numerous and assorted documents, ranging from goba poicies and protocos to reports of time-bound or sma-scae projects. The methodoogy and scope of this review present a certain number of important imitations: There is amost no hard data avaiabe on the impact or effect of inking or integrating iccm and nutrition; most of what is avaiabe concerns ony one set of interventions or the other. A reevant data found has been presented in the section on Findings. The nutrition universe is diverse, and there are many expectations on what inkages between iccm and nutrition shoud be or shoud accompish. This increased the chaenge of grouping the key informant interviews into ike statements, and the numerous interviews generated as many questions as they answered. It is aso noted that key informants were argey representatives of agencies; no nationa impementation partners or staff of ministries of heath were incuded. This coud be usefu for a foow-on exercise. The broad definition of nutrition interventions made comparison and generaization across experiences chaenging. Few countries impement iccm at nationa scae, and ony Ethiopia and Rwanda have nutrition integrated at that eve. Neary a information gathered focused on countries in Africa, with the South Bangadesh project as the notabe exception. Some information was aso reviewed from Afghanistan and the Phiippines but this was mosty focused on iccm. There is some indication that Maawi may aso have nutrition integrated at a nationa eve but the reviewers found no documentation to support this. Despite the enthusiastic support of mutiatera organisations and NGOs to request materias through regiona and country networks, the response was ess than anticipated. This may be an indication of the sma amount of written materia avaiabe.

13 13 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 R E V I E W F I N D I N G S The review identified numerous experiences that demonstrate inkages or integration between nutrition actions and iccm. Annex 2, Community-eve nutrition actions identified, shows the breadth and variety of nutrition-reated actions across countries and experiences. The tabe is incuded to demonstrate the eusive quaity of defining nutrition interventions and inkage with iccm. Many actions are imited to identifying and referring acute manutrition; others incude reguar deworming and vitamin A distribution; others cover acute manutrition treatment. Some are stricty IYCF and preventive messaging. In addition, some actions identified are outside the scope of iccm and may or may not be inked programmaticay. Anaysis of impementation experiences brought to ight four categories of approaches to integrating or inking iccm and nutrition. In this review, these categories are referred to as typoogies. These typoogies are not mutuay excusive, and many impementation experiences incude a combination of severa among the four. Typoogy 1 Advising on feeding the sick chid within existing iccm services Typoogy 3 Linkages between iccm activities and acute manutrition treatment through assessment and referra Typoogy 2 Linkages with Socia & Behaviour Change activities on chid nutrition Typoogy 4 Treatment at community eve of uncompicated Severe Acute Manutrition Findings from the desk review are organized according to these typoogies. Under each typoogy there is a description, exampes of impementation experiences, and supporting evidence identified. Key informant views on the types of typoogies or interventions to recommend or not, based on their experience, are summarized in the Discussion section of findings.

14 14 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 1 Description In this typoogy, advice on feeding during iness is provided to the caregiver of the sick chid during the sick chid consutation. The interactions between iness and manutrition in chidren are direct and we documented 6,7. Optima feeding practices support heathy immune function, rapid and sustained recovery, and growth. Optima feeding, during and after iness, is critica not ony for recovery from the current iness but necessary to reduce susceptibiity to future iness and manutrition 8. According to the UNICEF/WHO iccm protoco, the iccm worker advises the caregiver as part of home care. The task is imited to advising (providing information on the recommended behaviour). It does not invove counseing, which impies istening, refecting back and using a probem-soving process. The standard materias recommend that the CHW discuss four main points with the caregiver of any sick chid treated at home (see Figure 1, extracted from the Sick Chid Recording Form ). In principe, this advising is done in any country that impements iccm. Advising on feeding the sick chid within existing iccm services 6 Back RE et a and the Materna and Chid Nutrition Study Group. Materna and chid undernutrition and overweight in ow-income and midde-income countries. Lance 2013; pubished onine June UNICEF. Pneumonia and diarrhoea: Tacking the deadiest diseases for the word s poorest chidren. (2012) 8 LINKAGES. Facts for Feeding. Feeding Infants and Young Chidren During and After Iness Washington DC. USAID. Academy for Educationa Deveopment.

15 15 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Exampes of impementation A iccm protocos and materias considered in this review incude some form of home care advice. An earier review of iccm training materias in ten African countries 9 reveaed that much of the home care advice concerns information on when the chid shoud seek medica care (or return to the CHW), and on the correct use of bed nets. Nutritiona advice for the sick chid in Democratic Repubic of the Congo (DRC), Ethiopia, Liberia, Rwanda, South Sudan and Zambia, covers feeding and fuids for a sick chidren, whie in Madagascar, Mai and Senega this advice is imited to cases of diarrhoea. The training materias reviewed from Guinea incude a separate section on nutrition counseing for the manourished chid; however, advice on continuing feeding and fuids for chidren consuting for diarrhoea, pneumonia or fever is not evident. Supporting evidence identified A study on the quaity of care provided by iccm-trained Heath Surveiance Assistants (HSAs) in Maawi 10 shows that these workers counseed caregivers about the dose, frequency and duration of treatment for over haf of chidren provided ORS, antibiotics or antimaarias (61%), and 81% of caregivers described correcty how to give these treatments. Just over haf (55%) of caregivers of chidren with diarrhoea were advised to give extra fuids and to continue feeding the chid during the iness episode. In the project in South Bangadesh, caregivers were advised on fuids and continued feeding during a sick chid consutation for cases of diarrhoea 11. The project evauation showed that this was done correcty by 81% of iccm-ony CHWs, and 68% of CHWs trained to do iccm and treat acute manutrition, for an overa performance of 73%. The same CHWs provided counseing and feeding information during routine househod visits, which may or may not be considered part of iccm services. In a concept paper to identify effective approaches to reinforce nutritiona counseing within iccm impementation, Save the Chidren states: Research and programme evidence suggest that caregiver and heath worker support of nutrition during and after iness is frequenty suboptima Unequivocay in many contexts, recommended feeding practices are poor, with responsive and active feeding not being practiced. Heath workers sometimes share and reinforce (inappropriate) beiefs, though more frequenty they do not activey provide nutritiona counseing as a part of treatment and foow-up 13. The evidence from Maawi and South Bangadesh is from studies pubished in peer-review journas. Maawi is impemented as a nationwide scae-up; the study cited covers six districts and 131 HSAs. The South Bangadesh experience is a sma-scae tria covering one intervention and one contro Upazia (see Typoogy 4). The information from the ten-country review is descriptive and hypothetica, based on the contents of training materias and panning documents. It is noted that a of the evidence found concerns process: whether and how we certain activities were carried out. No evidence of effect or impact was identified. 9 Review of Integrated Community Case Management Training and Supervision Materias in Ten African Countries, MCHIP Giroy K et a Quaity of sick chid care deivered by Heath Surveiance Assistants in Maawi. Heath Poicy Pan. (2013) 28 (6): doi: /heapo/czs Puett C et a. Does greater workoad ead to reduced quaity of preventive and curative care among community heath workers in Bangadesh? Food and Nutrition Buetin, 33(4), The United Nations University 12 Piwoz E. Improving Feeding Practices During Chidhood Iness and Convaescence. Lessons Learned in Africa Washington, DC, USAID Academy for Educationa Deveopment, SARA project. 13 Persona communication, Save the Chidren

16 16 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 2 Linkages with Socia & Behaviour Change activities on chid nutrition Description Recent anayses of chid growth patterns iustrate that growth fatering (growth rates beow those appropriate for a chid s age and sex, by height and/or weight) in eary chidhood is greater than suggested by previous anayses and starts earier 14. Growth fatering in chidren happens mosty from three to months of age, justifying the scaeup of the promotion of a optima IYCF practices, incuding during iness and recovery. Many nutrition programmes focus on improving infant and young chid feeding practices through a range of approaches from deivering heath education messages to impementing Socia and Behaviour Change (SBC) activities 15. The inkages between these approaches and iccm appear to fit into severa categories: The CHW providing iccm is part of a arger team that incudes vounteers focusing on heath education and prevention. The same programme that manages iccm aso operates socia and behaviour change programmes focused on a arger popuation. Heath education messages, incuding nutrition, are incuded in the curricuum and responsibiities for the iccm CHW. In some cases this situation exists when the iccm responsibiities are added on to a CHW cadre originay focused on heath education. Exampes of impementation There is an overwheming number of SBC experiences that promote improved nutrition practices in countries. This review describes a imited seection that seemed to be inked at some eve to iccm. Bangadesh, Ethiopia & Viet Nam Aive & Thrive The Aive & Thrive programme was impemented on a reativey arge scae in Bangadesh, Ethiopia and Viet Nam (VN). Activities incuded counseing during home visits (Bangadesh, Ethiopia) and at heath faciities (VN), group sessions, mass media and oca media. In Bangadesh, approximatey 1.7 miion mothers of chidren under two received counseing on IYCF by a BRAC frontine worker. The Viet Nam experience is in 15 provinces. In Ethiopia the programme is caed strong and smart famiies and is promoted through the Heath Extension Workers (HEWs) and the Heath Deveopment Army in the four most popuous regions of the country. The eve of inkage with iccm services is not specified in the documents avaiabe, but because iccm is impemented in Bangadesh in the projects described (Essentia Heath Care and Materna Newborn Chid Heath programmes), and in Ethiopia through HEWs, the inkage has been inferred in these two countries. 14 Victora CG et a. Wordwide timing of growth fatering : revisiting impications for interventions. Pediatrics ;125(3). 15 An SBC approach is a strategic, interactive process that aims to change not ony individua behaviours but aso socia conditions. It requires understanding the situation, designing a focused strategy, deveoping interventions and materias, impementing, monitoring, evauating, and adjusting. Source: MCHIP, Chid Surviva Chid Heath Grants Program Technica Reference Materias, Socia and Behavior Change, 2014

17 17 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Nationa iccm Materias in Ten African Countries The ten-country review of iccm training materias found that six countries (Democratic Repubic of the Congo, Guinea, Liberia, Madagascar, Mai, and Senega) provided significant training time focused on disease prevention. Prevention messaging incuding hand washing, excusive breastfeeding, avoiding exposure to indoor air poution, instructions for re-dipping bed nets, and indoor spraying. This prevention advice is generay incuded with the training chapters and agorithms for each specific iness. The materias reviewed for South Sudan aso cover causation and prevention by disease, but specificay state that this information shoud ony be discussed with the caregiver in situations where the chid wi be treated at home. When there is need for urgent referra, prevention shoud not be discussed. In Guinea, the iccm training materias and job aids incude a modue on nutrition, with recommendations defined in six-month age bocks. It is important to note that the origina roe of the CHWs in Guinea was promotive and iccm was ater added on. Source: Review of Integrated Community Case Management Training and Supervision Materias in Ten African Countries, MCHIP 2013 Rwanda experience Word Reief Word Reief is impementing an Innovation Chid Surviva Project ( ) with USAID funding in southern Rwanda. In support of the Ministry of Heath s the Ministry of Heath s Community-Based Nutrition Programme (CBNP) protoco, Word Reief is focusing on addressing the weaknesses in the current behaviour change communication approaches and testing an approach caed Nutrition Weeks to repace the standard cooking demonstrations and nutrition taks. Nutrition Weeks are schedued three times a year at a time when women are ess busy in the fieds. They target pregnant women and a househods with chidren under the age of two (mothers, husbands and grandmothers are encouraged to participate) in order to prevent manutrition. During Nutrition Weeks, participants spend two hours per day for five days in a sma group of up to ten women, focused on earning about the nutrient vaue of oca foods and buiding the reevant skis to incorporate their use into a nutritious diet. Patterned after Positive Deviance/Hearth, the women work together to prepare and feed their chidren age-appropriate, nutrient-dense meas using ocay-avaiabe foods provided by participants. They earn about and practice responsive feeding aong with other behaviours associated with the prevention of manutrition. CHWs reinforce key nutrition messages during home visits. The Word Reief project aso supports CHWs providing iccm services; these same CHWs are among the vounteers running the Nutrition Weeks intervention. Source: Persona communication; MCHIP, Summary of Operations Research within the USAID Chid Surviva Grants Program

18 18 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Supporting evidence identified The review identified the foowing evidence for this typoogy: Word Reief is in the process of conducting operations research on the Nutrition Weeks intervention in Rwanda. Resuts from their third annua report indicate that Nutrition Weeks are effective in promoting behaviour change for better chidren s diet: resuts in the intervention area were 55% higher than in the comparison area for Minimum Acceptabe Diet, a composite indicator that incudes dietary diversity and mea frequency. Responsive feeding remained high at 97% (7% baseine (BL), 96% year 2) in Kaduha (intervention area), and 95% (13% BL, 92% year 2) in Kigeme (comparison). Ageappropriate introduction of semi-soid foods remained consistent at 79% (52% BL, 81% year 2) in Kaduha (intervention) and 75% (58%BL, 79% year 2) in Kigeme (comparison) 16. A process evauation conducted in Bangadesh and Viet Nam by the Internationa Food Poicy Research Institute (IFPRI) in 2013 found sizabe improvements in feeding practices in Aive & Thrive (A&T) programme areas between 2010 and Changes in excusive breastfeeding in intervention areas in Bangadesh were amost 25 percentage points higher than in comparison areas. The percentage of chidren who had minimum dietary diversity amost doubed, from about one-third to two-thirds of chidren in programme areas. No changes were seen in comparison areas. In Viet Nam, excusive breastfeeding rates rose from ess than 20% to more than 60% in A&T areas 17. Evidence from a three countries above was extracted from programme reports and presentations, and represent sma-to-medium-scae experiences. 16 Word Reief Innovation Chid Surviva Project Rwanda, Third Annua Report Menon et a, presentation entited Eary impact assessment of a arge-scae initiative to improve infant and young chid feeding (IYCF) in Bangadesh and Vietnam suggests improvements in IYCF practices and highights importance of potentia to benefit. Internationa Food Poicy Research Institute, 2014

19 19 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 3 Linkages between iccm activities and acute manutrition treatment through assessment and referra Description According to the standard UNICEF/WHO protoco, the iccm worker measures every sick chid over six months of age with a MUAC strap and assesses for biatera pitting oedema. Red MUAC and biatera pitting oedema are danger signs, and the CHW refers the chid to a heath centre for immediate care. There is space on the referra sip to note this. This process is consistent with CMAM recommendations. The treatment protoco for a yeow reading on MUAC is ess we-defined. The CHW shoud refer the chid to a feeding programme if one exists nearby; if this is not possibe, the recommended action is counseing on compementary feeding. An important variation on Typoogy 3 is the use of active screening or active case detection through home visits or at growth monitoring programme group activities. This aows measurement of every chid, sick or we, and may be the standard in many countries or projects. Exampes of impementation According to the ten-country review of iccm materias, it is the poicy in a countries with the exception of Senega to use MUAC to identify manourished chidren within iccm. (Note that the iccm CHW does not have responsibiity for nutrition work in Senega). A countries except Senega and Liberia use a red MUAC reading as a danger sign, thus sending the chid for immediate referra. The potentia ist of exampes is arge. Of the 45 countries in the UNICEF cross-sectiona survey, 31 reported incuding CCM of manutrition. This was defined as screening and referra by CHWs of severe manutrition Rasanathan K et a Community case management of chidhood iness in sub Saharan Africa findings from a cross sectiona survey on poicy and impementation. J Goba Heath, 2014 (in press) The use of active screening or active case detection through home visits or at growth monitoring programme group activities...may be the standard in many countries or projects

20 20 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 South Sudan Maaria Consortium Maaria Consortium worked in two counties in Northern Bahr e Ghaza starting in 2010 focusing on integrating iccm and CMAM. Maaria Consortium worked with two cadres of community vounteers: a iterate Community Nutrition Worker (CNW) trained to provide community-based treatment for acute manutrition (Typoogy 4) and an iiterate Community Drug Distributor (CDD) who was trained to conduct assessment and referra for SAM in addition to providing iccm services. CDDs were provided with a six-day training on diagnosis and management of chidhood inesses, incuding performing and interpreting the MUAC and oedema assessment for undernourished chidren. The CDD gives the caregiver of a chid fitting the cut-off criteria for admission into the Outpatient Therapeutic Programme (OTP) a manutrition referra triange. The referra triange is a aminated picture of the reason for referra (in the case of SAM, the picture is of a chid with a MUAC tape). The chid is referred to the Community Nutrition Worker (CNW) at the nearest OTP for diagnosis and admission into the OTP. Chidren requiring referra under the iccm programme (suffering from a severe case of maaria, pneumonia or diarrhoea and/or presenting with danger signs) are given a referra triange according to their diagnosis (aminated triange with a picture of a case of diarrhoea, pneumonia, or maaria) and referred to the nearest faciity. Additionay, the CNW at either the referra site (OTP) or in the community, screens chidren for manutrition, using the same criteria (MUAC, assessment of oedema). The CNW shoud aso assess the chid for compications of manutrition. If the chid is found to have SAM with compications (unabe to pass an appetite test or presenting with other medica conditions) the chid is referred to the nearest stabiization centre. As the CNW are iterate, they are abe to compete referra forms that are given to the caregiver to present to the nurse at the stabiization centre. The CDDs are responsibe for foowing up referred cases under the iccm component of the programme and the CNWs foow those referred under the OTP component. Source: Persona communication & Keene, E., Learning Paper: Integrating severe acute manutrition into the management of chidhood diseases at community eve in South Sudan, 2013