UNICEF/NYHQ2008-1649/Pirozzi, Eritrea, 2008 News Framework for integration of management of SAM into national health systems By Katrien Khoos and Anne Berton-Rafael Katrien Ghoos is the Nutrition Specialist on Management of Acute Malnutrition ,Nutrition Information Systems, Emergencies and Disaster Risk Reduction with the UNICEF Eastern and Southern Africa Regional Office (ESARO) She is based in Nairobi, Kenya Anne Berton-Rafael is the UNICEF ESARO Nutrition consultant for this initiative, based in Nairobi Both authors have over 15 years of experience on management of acute malnutrition in emergency, post-emergency and development context A Baby's MUAC is leasured in the rural village of Marat, Anseba Region, Eritrea Background In 2010, UNICEF approached VALID International to design and conduct a global mapping review of Community-based Management of Acute Malnutrition (CMAM) with a focus on severe acute malnutrition (SAM)1 In addition to this global mapping, regional analyses2 were conducted and indicated that 13 countries out of 183 in Eastern and Southern Africa Region (ESAR) had plans to scale up in 2010/2011 As of May 2010, over half (53%) of CMAM programmes were integrated with Infant and Young Child Feeding (IYCF) and Integrated Management of Childhood Illness (IMCI) programmes All countries had national coordination mechanisms and in only three countries out of 18, were UNICEF the sole RUTF provider These findings suggested a certain degree of government ownership and sustainability However, despite roll out through government services in all countries (except Somalia) at the time of the mapping, most of the inputs to CMAM national programmes were still provided using short term external emergency funding Also, material and technical support often still came from specialised United Nations (UN) and nongovernmental organisation (NGO) staff Indeed, in 13 countries, more than 50% of RUTF was provided by UNICEF in 2009, and only one country indicated Ministry of Health (MoH) support for RUTF supplies Transport of these supplies from national to district level largely happened using a parallel system instead of using the national supply chain In those cases, UNICEF and implementing partners (e.g NGO’s) organised transport based on available stocks at national level rather than expressed needs at community level This description around RUTF supplies is only one example to highlight the lack of a sustainable and systematic approach to scaling up CMAM Not much has changed since the global mapping exercise Another consideration is in contexts where prevalence of wasting is relatively low and as in most Southern African countries, closely Update credit to: The authors wish to thank UNICEF ESARO, UNICEF HQ and USAID/OFDA for the support to this work Special thanks also go to the several individuals and their organisations that already provided inputs to the initiative These are UNICEF (colleagues from Kenya Country Offices and from Regional offices in Dakar and Amman), ACF-F, FANTA, Valid, Carlos Navarro-Colorado (CDC) and Mark Myatt related to HIV/AIDS In such scenarios, with little or no dedicated funding available for CMAM, the approach to integrate SAM management into the health system and create or enhance systematic linkages with existing services was thought to be the most cost-effective, and typically the only option, to scale up community based management of SAM Box 1: Process of framework development UNICEF ESARO started developing the framework in January 2011, but this had to be interrupted because of Horn of Africa crisis An extensive literature review already underway continued in October 2011 This review covered successes of processes, strategies and tools used in Health System (HS) strengthening, in standardised development of national programmes to address at scale public health problems such as tuberculosis and malaria, and the roll out of Enlarged Programme of Immunisation (EPI), integrated Community Case Management (iCCM) and Prevention of Mother To Child HIV AIDS Transmission (PMTCT) programmes The assessment itself is adapted from USAID’s Health Systems Assessment Approach: A How-To Manual4 This is based on the WHO’s health systems (HS) framework of the six health system building blocks5 (WHO 2000, 2007) as well as from the HIS scoring card of the Health Metrics Network6 (WHO, 2008) Based on these lessons learned, experiences and assessment tools7, the framework for Institutional Integration of Management of Acute Malnutrition into national health systems, was suggested The Framework Given the lack of a systematic approach to CMAM scale up identified in the 2009 global mapping and the need for integration into existing services for a sustainable approach, a framework for institutional integration of management of severe acute malnutrition (IMSAM) into national health systems has been developed and is being piloted by UNICEF (see Box 1) The general objective of the framework is to support countries in assessing gaps, planning priority actions and guide successful and sustainable scaling up of management of severe acute malnutrition through the primary health care system For reasons explained below, the scope of this initiative is limited deliberately at this stage of development of the IMSAM framework The six WHO health system (HS) building blocks (governance, financing, human resources, supply, service delivery and health information system) are used as the health system entry points in this proposed framework A series of field tests were scheduled in order to correct irrelevant elements and finetune promising parts, using different national and sub-national contexts and HS functions of the framework The proposed framework is relevant also in countries as part of disaster risk reduction (DRR) and/or resilience building approach, where nutrition emergencies are recurrent (e.g Horn of Africa) As most of these countries have already integrated parts of CMAM into the health system, this proposed framework Field Exchange 41 (2011) Global CMAM mapping in UNICEF supported countries p10 Regional refers to division of UNICEF regions For example, Eastern and Southern Africa Region (ESAR) includes 21 countries (at the time of global review 20, as South Sudan became independent in July 2011 and joined ESAR at time of independence): Angola, Botswana, Burundi, Comoros, Eritrea, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Somalia, South Africa, Swaziland, Tanzania (+ Zanzibar), Uganda, Zambia, Zimbabwe ESAR countries included in this analysis are all indicated above, except Comoros and South Africa (Angola, Botswana, Burundi, Eritrea, Ethiopia, Kenya, Lesotho, Madagascar, Malawi, Mozambique, Namibia, Rwanda, Somalia, Swaziland, Tanzania (+ Zanzibar), Uganda, Zambia, Zimbabwe) It was not possible to have information from Comoros on time South Africa only implements the in-patient component of CMAM In this article, all data used refer to analysis of these 18 countries only http://www.healthsystems2020.org/content/resource/ detail/528/ http://www.wpro.who.int/entity/health_services/health _systems_framework/en/index.html Available at http://www.who.int/healthmetrics/tools/en/ Among others sources of adaptation are the iCCM Benchmarks and indicators matrix developed by CCM Interagency Task Force available at http://www.ccmcentral com/?q=indicators_and_benchmarks Also called golden standards by the WHO/Health matrix 58 News Table 1: Number of benchmarks per Health System (HS) function (horizontal) for the three levels of implementation (vertical) and total HS functions National District Community Total A Governance 44 40 36 120 Information/Assessment Capacity 4 11 Policy Formulation and Planning 16 15 11 42 Social Participation and System Responsiveness 10 10 29 Accountability 10 9 28 Regulation 3 10 B Financing 13 16 14 43 Pooling and Allocation of Financial Resources 10 24 Joint financing 5 16 Purchasing and Provider Payments 1 C HR 33 35 33 101 Planning 15 10 Policies 5 14 11 Performance Management 4 13 12 Training and education 11 12 12 35 13 In-service training or IMSAM/MNCH* integrated training 6 18 14 Pre-service training IMSAM /MNCH integrated 2 18 17 44 15 Pharmaceutical Policy, Laws, and Regulations 12 13 30 16 Joint supply management** 3 17 Selection of Pharmaceuticals 1 23 31 29 83 18 Availability and continuity of care 2 19 Access and coverage of IMSAM services 3 10 20 Utilisation 6 17 21 Organisation: Integrated package 4 11 22 Quality assurance 13 29 11 13 16 36 24 IMSAM integrated in HIS 10 13 29 25 M&E 3 144 155 128 427 D Supply E Service delivery 23 Community Participation in Service Delivery F HIS TOTAL *Maternal, newborn and child health ** RUTF supply falls under this catergory intends to further guide the identification and coverage of gaps in sustained integration of CMAM Components of framework The framework is composed of three parts: • benchmark matrix to facilitate assessment • a tool (visual) to help summarise main assessment findings • a planning, monitoring and evaluation tool to facilitate yearly and multiyear planning, monitoring and evaluation The benchmarks matrix suggests for each of the six HS components, a series of conditions, referred to as benchmarks8, that should be in place in order to help attain a sustainable level of IMSAM into the health system (see Table for an overview) Programme staff must take these into account when planning, implementing, monitoring, and evaluating IMSAM The benchmarks matrix has three levels as planning, implementing, monitoring, and evaluating are approached differently at national, sub-national/district or community level The benchmark matrix can be used vertically by one of the three implementation levels (national, sub-national/ district, and community) or horizontally by HS function, expressed under the six building blocks (governance, financing, human resources, supply, service delivery and health information system) The way the benchmark matrix is used depends on national or local priorities, identified by all relevant stakeholders, especially by government services responsible and/or closely involved in CMAM This flexible use should support CMAM programme managers in defining IMSAM technical and financial inputs in health sector audits, programmatic and financial reviews and sectoral reforms For example, if stakeholders agree that the objective is to assess human resources (HR) for IMSAM, because investment in HRs for the health sector is planned, the assessors can single out the benchmarks for the HR component (see Figure for an example) Meanwhile the community component can be looked at, for example, in preparation for community health policy development discussions or just for regular yearly, or multi-year, planning or evaluation purposes Framework in practice At this stage of development of the approach, the benchmarks are grouped per level and per HS function on excel sheets (as reflected in Figure 1) Each level of planning and implement ation (national, sub-national/district, community) corresponds to one excel sheet On each sheet, the first column corresponds to a HS function and its sub-division (see Figure 2) The second column gives the benchmarks/conditions list followed by a column on guidance, if any Different assessors can assess each benchmark/condition separately according to a range of provided possible scenarios (expressed in columns: highly adequate, adequate, present but not adequate, not adequate at all) This allows for objective and quantitative rating compared to the benchmark/ condition for integration A column for comments is included, so assessors can add qualitative comments in addition to the rating, explaining why/how/when The next column will capture the data sources, followed by the score from interviewees and their names The last column will indicate the average score, reflected in the visual tool (see Figure 3) As obvious from this description, the final results depend entirely on the opinion of assessors It is therefore essential to include all relevant stakeholders Ideally, these are HS Also called golden standards by the WHO/Health matrix Figure 1: district benchmark assessment work sheet for planning part of Human Resources (HR) HS function Functions Benchmarks Guidance Highly adequate Adequate Present but not Not adequate Rationale/ Data adequate at all Comments: NA or If source not adequate, why? HR Planning 9.1 Health care professionals distribution in urban and rural areas balanced YES, highly adequate 9.2 Human resources data system set up 9.3 Comprehensive human-resource strategy for MNCHN initiated YES, adequate YES, partially adequate YES, the system YES, the system exists YES the system exists and is used but is seldom used exists but it is regularly never used including a HR YES, the strategy planning exists, it's system comprehensive and implemented YES, the strategy exists and implemented but not comprehensive NO, not adequate NO, no system YES, the strategy NO, no HR exists, it's compre- strategy hensive but not implemented 9.4 Facilities have adequate numbers of At least 90% staff and it exists scale up and down of staff of staff are in according to the season and livelihood zones place NO, no adequate staff 9.5 Special budget dedicated to HR YES, it exists with YES, it exists but adequate without adequate resources resources YES, it exists but not used NO, no special budget 9.6 Job classification system created 59 YES, Staff is in YES, staff are in place YES, the position place and scale but scale up & down exist but is not up & down exists are rare filled YES, the system exists and is functional YES, the system exists YES, the system and is functional but exists but is not partially functional NO, no system Response from interviewees Average Name Name Name specialists, CMAM programme managers, M&E specialists, technical and financial partners, etc Given the importance of including the right people in the assessment, a mapping of actors prior to the assessment is advised (see below) This will limit the risk of biased results Using results of the assessment, the feasibility of addressing the identified gaps can be analysed using the planning tool This planning tool can be used to facilitate comparison of the target result, also present in the benchmarks matrix as the benchmark or condition, with the existing situation, or identified gap (See Figure for an example) Weaknesses, barriers to change and opportunities are identified, interventions proposed and budget and timelines defined Once this analysis is completed, proposed actions, timeline, cost, etc can be put together in a yearly or multiyear action plan Progress on implementation of the action plan can then be monitored on a regular basis UNICEF/NYHQ2009-0204/Ysenburg, Somalia, 2009 News Suggested process for use of the framework At this stage of development of the tool, four steps are suggested They are composed of: Step 1: Pre-assessment As indicated, the framework needs to fit context specific needs During the pre-assessment step, all country specific details will be agreed These include: a) identification/ mapping of all relevant stakeholders to be invited to support assessment (government services, donors, CMAM partners, etc.), b) agreement of the scope, time frame, budget and dates of the assessment, c) identification of IMSAM and health systems data sources and documents, listing of identified gaps as well as health system strengthening interventions, etc Step 2: Assessment using benchmark matrix This step starts with a literature review of all relevant documents These can be HR policies, M&E tools used, data collected from facilities, facility registers, quality supervision reports, administrative and budget documents, supply registration lists, review of training curricula, client exit interviews reports, etc The benchmark matrix is then filled out by different stakeholders or assessors It is important to note that this is a self-assessment (important for stakeholders, especially MoH, ownership) undertaken by a group of experts It is advised to organise group work in a way that the assessors only assess the benchmarks, or conditions, they are expert on This also helps keep duration of assessment to a minimum, as different groups can work simultaneously After the group work, the different results will be brought together and discussed as explained in Step When available information is insufficient, key informant interviews, e.g health system users, can be organised in order to complete the assessment In addition, site visits are highly A woman feeds a child a ready-to-use food as part of a UNICEF-supported nutrition programme in Jowhar Camp, Somalia Figure 3: Example of visualisation tool with summary of results: IMSAM Human Resources – District level assessment results Results Rating Level Adequacy achieved IMSAM Human Resources – District A HR- mean* 1.4 46% HR – mean HR planning 1.2 40% 3.0 HR policy 100% 2.0 In-services HR planning Performance management 2.3 76% 1.0 Training & education 1.3 43% 0.0 In-services 0.7 23% Training & Legend HR policy education Rating Level Adequacy achieved Performance Highly adequate 2.25 - 75 -100% management Adequate 1.50 – 2.24 50 – 74% Present, but not adequate 0.75 – 1.49 25 – 49% Not adequate at all – 0.74 – 24% *Average for all HR section results recommended as they allow direct observation of most of the service delivery components (e.g facility registers, daily availability of services, stock-out, reports….) and therefore reduce the bias in the scoring Step 3: Analysis and validation During the consensus building meeting, the average rating for each condition is given, visualised and results are reviewed The presentations and final assessment report should include rating and summary of comments, as rating alone cannot capture all aspects of the conditions For example, the condition could be present but supported 100% by NGOs and therefore not sustainable Steps to are closely linked and implemented during the same exercise, while Step can be organised at a different moment after analysis of assessment results Step 4: Development of multi-year and yearly action plan Starting from the identified gaps (conditions that are not fulfilled, benchmarks not reached), the stakeholders will analyse which gaps they want to address, how these gaps will be addressed and within which time frame using the planning tool (shared earlier in Figure 4) This will be captured in the corresponding action plan From this exercise, yearly and multi-year action plans can be defined, including a corresponding monitoring and evaluation approach Stakeholders can decide to repeat all steps or parts on a yearly or multi-year basis as part of monitoring, evaluation and planning of national CMAM programmes Expected results The process is expected to facilitate national ownership, commitment and sustained adequate investment in the management of acute severe malnutrition and to provide a standardised approach for identification of bottlenecks in scaling up of IMSAM across countries Even, if the approach is meant to be standardised, countries should adapt the framework to their context This approach will allow for development of yearly and multi-year costed actions plans Figure 4: Example of Planning tool: HR function at community level Level HS function Target Weakness Threat/ Result current Barriers to (benchmark) result changing result Community HR Clear written ToR for CHW Oral ToR Staff turnover Opportunities Objective Proposed for change/ /expected intervention to enabling results address change factors National guideline exist Lack of literate staff TOR: Terms of reference CHW: Community Health Workers JD: Job description 100% of CHWs have signed a JD Impact on other Feasibility Timeline/ Human Cost MNCH implementation Resources programme & speed needed HS Performance - CHW supervisor - Standardisation yes to write ToR among CHWs - DMO to standardise ToR according to national guideline DMO: District Medical Officer Year - Integration with iCCM HR performance - 90% CHWs position staffed Budget: xx USD iCCM: Intergrated Community Case Management 60 News Partnerships In addition, to UNICEF ESARO, other organisations are also in the process of developing approaches and models to facilitate integration of management of acute malnutrition into the health system Linkages between these initiatives need to be developed and defined in order to avoid duplication and create complementarity UNICEF/NYHQ2009-0203/Ysenburg, Somalia, 2009 HS ‘thinking’ MUAC measurement of a child in Jowhar Camp for displaced people in the city of Jowhar, Somalia and measuring baseline and tracking progress on IMSAM at the three HS planning and implementation levels (national, district and community level) and for the six HS functions (governance, financing, human resources, supply, service delivery and health information system) for each country, but also per region and even globally This will enhance country level, regional and global analysis, enable quicker and tailor-made support to countries, improve documentation of lessons learned and facilitate advocacy at the different levels In addition, countries will be able to expand existing HS contacts to include relevant nutrition services in a systematic manner For example, given HIV AIDS is an important cause of wasting in Zimbabwe, management of acute malnutrition is ideally linked to Preventing Mother-to-Child Transmission (PMTCT) services and promotion of optimal IYCF practices, as optimal IYCF practices are known to prevent mother to child transmission This integrated approach will increase coverage of management of acute severe malnutrition but also improve quality of delivered PMTCT services overall Ideally, linkages should exist at all HS levels and for all HS functions These include, for example, that costed IMSAM action plans are linked with health sector development plans and Mid Term Expenditure Framework, indicators for measuring CMAM are included in the Health Management Information System, capacity development for CMAM is part of health sector HR development plan or policy, and supply for IMSAM is planned and implemented through the existing HS supply chain Ultimately, the approach can be adapted to include management of moderate acute malnutrition, IYCF, micronutrient supplementation or any other nutrition intervention that can be delivered through the health system Lessons learned so far The approach is participatory and inclusive Through the self-assessment, all partners are actively involved in sharing of experiences and information This is believed to enhance understanding of importance of IMSAM, improve overall quality of assessment, reinforce ownership and encourage further collaboration 61 Despite the long benchmarks list, the approach is not too ambitious Depending on available information, the assessment can be conducted in one week By going through the list, stakeholders realise that more areas can qualify for integration than considered initially In addition, they may discover documents and policies they were not aware of prior to the exercise Introduction of the management of acute malnutrition influences overall performance of the health system Therefore, ideally a health systems thinking approach should be applied in the proposed approach However, this raises questions about the complexity of the tool, how to assess and address impact on health system functioning, etc What level of complexity is acceptable for a framework that ‘endeavours’ to facilitate integration by using a fairly easy and quick approach? Expand to MAM In developing the framework it was agreed to limit the approach to the management of SAM Expanding the tool at this initial stage to other nutrition interventions, and especially management of MAM, may have delayed the process and complicated its development However, management of MAM must be included in the framework as soon as possible This will definitely require active participation of additional partners (e.g WFP and implementing NGO’s) The composition of the assessors team is crucially important The presence of health system specialists or health system strengthening specialists is essential It is necessary to get all key stakeholders fully on board Therefore, in addition to the initial identification/ mapping of stakeholders, preparation meetings with these key stakeholders and follow up discussions are useful Next steps The appointment of a facilitator and cofacilitator, familiar with the health system and context, is essential to correctly adapt the framework to the local context, to increase ownership and to translate benchmarks to local context whenever needed Once tools are finalised and countries introduced to their use, the same or a similar approach could be developed for all other nutrition interventions that need sustained integration into HS and/or linkages with IMSAM Some of the benchmarks at sub-national/ district or community level directly depend on benchmarks at national level It may therefore be helpful to conduct national level assessment prior to any other level, or a HS function assessment The main limits of the tool are the quality of the data available and the composition of groups of assessors, as indicated earlier Other aspects to take into account are the different areas covered by the tool Indeed, not all participants are familiar with all components In that case, the creation of sub-groups can be useful Hierarchical and other links between the different participants need to be considered when establishing the groups The assessment and planning exercises should be planned and conducted separately Issues being addressed Terminology Different terminologies are used by different actors and usage varies between countries Clarification at global level is needed definitions for terms like coverage, prevalence, incidence and CMAM, but also for the different performance indicators Three major immediate next steps have been identified: finalise field testing and tools, create a Technical Advisory Group (TAG) to discuss identified issues and organisation of a face-to-face meeting with regional and global stakeholders in order to reach consensus on aspects of concern and decide on ways forward, including roll out A regional and global database could be set up to capture information on progress on integration of CMAM into the health system The same M&E system would also allow for follow up on quality and coverage of services Conclusions Although only one test of the framework has been conducted so far (district level in Kenya), the approach looks very promising The results of this first trial exceeded anticipated outcome, as the approach and content of the benchmark were indicated to be relevant and widely accepted The test mainly helped in fine-tuning the process Additional testing will take place over the coming months This will allow testing the framework in different contexts and using different components The framework, including manuals and operational guidelines, is expected to be ready for roll out mid-2013 The authors look forward to continued exchanges, including a larger group of HS and CMAM specialists engaging in the process For more information or to engage with this initiative, contact: Katrien Ghoos, email: kghoos@unicef.org, or Anne Berton-Rafael, email: abrafael@unicef.org 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 T he 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 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 systems1 (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 advo- 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 cacy 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 Main authors: Alice Schmidt, Rebecca Brown and Mary Corbett Chapter contributions from: Anne-Dominique Israel, Saul Guerrero and Yvonne Grellety 62 News En-net update, March-May 2012 MAMI-2 research prioritization – call for collaborators By Tamsin Walters, en-net moderator Thirty-six questions were posted on en-net in the three months March to May inclusive, eliciting 176 replies In addition 25 job vacancies were posted Recent discussions have included: Mid Upper Arm Circumference (MUAC) changes in pregnancy and ongoing research into what are the most appropriate thresholds to use for pregnant and lactating mothers in programmes to treat acute malnutrition and how they correlate with adverse outcomes, dilemmas of whether to use weight-forheight or MUAC to diagnose acute malnutrition and the potential biases of the two measures in different population groups, the challenges inherent in attempting causal analyses of acute malnutrition, and considerations of how to continue to promote breastfeeding in community-based management of acute malnutrition (CMAM) programmes An interesting discussion arose from a situation in Somalia where reports came in of mothers “starving” their children in order to benefit from nutritional treatment and a protection ration being provided alongside programmes to treat acute malnutrition This is not an unfamiliar scenario and has been reported in several countries, with greater or less emphasis, in many programmes implemented in crisis situations The Nutrition Cluster in Somalia is trying to gather further evidence to establish how significant and widespread the problem is Meanwhile, performance monitoring data from one programme in Somalia has shown an increase in relapses in the last three months from 8% to 17%, which could be linked to the same issue Suggestions and solutions were sought on how to address this situation Discussants advised enhancing community mobilisation and counselling for both mothers and fathers, as well as engaging other influential community leaders Contributors cited successful examples of both individual counselling as well as group discussions in programmes in Uganda, South Sudan, Ethiopia, Niger, Haiti and Bangladesh Despite these examples of successful approaches to address the immediate issues, it was agreed that ‘starving’ of children was most likely symptomatic of a much greater underlying problem of food insecurity “These are usually decisions made under conditions of real stress which aid workers, agencies, donors and planners have never personally faced and often to not consider”1 A situation where people are taking such desperate measures to access basic commodities suggests a large unmet need in terms of general rations and basic household food needs It is a survival strategy for the family Excerpts from a letter from Nelson Mandela on World Food Day, September 2004, was quoted to bring home the real issues people are facing and the decisions they are making in such situations: "Hunger is an aberration of the civilized world Families are torn asunder by the question of who will eat As global citizens, we must free children from the nightmare of poverty and abuse and deprivation We must protect parents from the horrifying dilemma of choosing who will live.2" The discussion concluded with a consensus that mothers should never be shamed or punished in nutrition programmes, but efforts should be made to understand and help them Mothers not harm their children unthinkingly; they are facing desperate life and death decisions for their families Our work is to try to understand and respect the reality of their day to day lives and adjust our programmes accordingly to meet their needs To view the full discussion, go to http://www.en-net.org.uk/question/717.aspx To join any discussion on en-net, share your experience or post a question, visit www.en-net.org.uk I n January 2010, the report of ‘The Management of Acute Malnutrition in Infants aged