2014 Strategic Plan Annual Results Briefing Joint consultation on Seasonal Malaria Chemoprevention Ouagadougou, Burkina Faso Monday 13 – Wednesday 15 February 2017 Nutrition Integrated delivery approaches: SMC and Nutrition Presented by Joyce Bakka Werner Schultink Associate Director, Nutrition 15 June 2015 | Danny Kaye

UNICEF Procurement support over the Years

Overview of UNICEF’s Engagement in SMC Nature of UNICEF’s support Support for NMCP for the Normative aspects of SMC adoption/reflection in strategic documents Operational costs for SMC delivery Procurement of the medicines Supported countries for procurement Gambia ,Mali, Togo ,Chad ,Niger, Senegal ,Cameroon and Guinea-Bissau

Commonalities: Nutrition and SMC Programs Similar target population- Under 5 year Seasonality −Both malaria and undernutrition are highly seasonal - peaks in rainy seasons High burden for both malnutrition and Malaria In West and Central Africa, one million children under five die from causes related to malnutrition. Malnutrition contributes to 35 per cent of all the child deaths in the region. Malnourished children fall sick more often. High burden of acute malnutrition presents a challenge for SMC treatment Although we have made progress in reducing stunting globally we still have 159 million children affected by Stunting and who will not grow to their full potential We also have 50 million children that are wasted and among those 16 million are severely wasted who have 9 times more chances of dying. Each year, in West and Central Africa, one million children under five die from causes related to malnutrition. Malnutrition contributes to 35 per cent of all the child deaths in the region. Among the 15 countries in the world with the worst under 5 mortality statistics, 10 are in West and Central Africa. Here, at any time one out of four children are underweight, Malnourished children fall sick more often. Chronic malnutrition (stunting) affects 40% of the children – or 26,5  million children in the region Underweight, the indicator used for MDG 1, affects 22% of the children under five –  or 15.4 million children in the region It is estimated that 39 million children live in SMC-eligible areas in Africa; these children experience 33.7 million episodes of malaria and 152,000 childhood deaths from malaria each year

SMC target population = … IYCF Programme Complementary feeding. ( Children 6-23m) Health facility and community levels Micronutrient Programme Supplementation Vitamin A ( Children 6-59m) Health Facilities, campaigns, outreach Zinc (with ORS) Children 0-59m Fortification (MNPs, Low dose LNS) Children 6-23m, Health facilities (for use at HH level) SAM Programme Screening and referrals (Children 6-59m) , Health facility/community Treatment uncomplicated cases (Children 6-59m), Outpatient care ,(HF, Community) Treatment complicated cases (Children 6-59m) Inpatient care Prevention approaches e.g Multi-sectoral approach , Early detection and management of MAM Vitamin A supplementation for children aged 6-59 months which is important for morbidity and mortality risk reduction Zinc supplementation, especially for the treatment of diarrhea and combined with ORS Home fortification with education for diet diversification or provisions of micronutrient powders to sprinkle on foods prepared at home. This can improve the quality of complementary food.

Opportunities for integration Integrate nutrition screening and referral of identified cases of acute malnutrition as part of the SMC outreach Provision of food supplements (e.g., LNS) Provision of MNPs Integration of BCC to mothers to improve rates of early and exclusive breastfeeding

Why Integrated health services? An effort to move towards reduction of missed opportunities and provision of a continuum of preventive and curative services Sustainability aspects- Long term focus Harnesses efficiency and effectiveness of countries preparedness efforts to reduce malaria Where resources are inadequate resources it is important to optimize limited financial and human available by seeking efficiencies and avoid duplication. Vertical programs provide a short-term solution, allowing countries to postpone desperately needed health care system reforms. Integrated health services: “The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system” (WHO) Integration creates a better healthcare experience for the child Integration decreases the cost of healthcare delivery Integration promotes better health outcomes Vertical programs are expensive to run and divert resources and attention from regular basic services. Donors supporting service delivery in developing countries need to show quick results to maintain support for foreign assistance within their constituencies. Unlike horizontal programs,vertical programs are also easier to manage. They can be kept away from the bureaucracy (and in some instances political interference) that comes with implementing programs in

Nutrition & SMC integrated approach- SMaMP study Nigeria Supported by multiple partners CHAI Nutriset UNICEF headquarters and from its country office in Nigeria The Children’s Investment Fund Foundation (CIFF), which provided funding for the pilot program Ministry of Health Nigerian Government LSHTM Surveys covered demographics, anthropometric measurements, coverage, recent fever history, and adherence to interventions among children aged 6-24 months at baseline

SMaMP study in Kano- Nigeria-Results Integrating LNS with SMC did not change SMC coverage and adherence although adherence to LNS lagged behind SMC Nutrition Outcomes: significant decreases in stunting and underweight were observed in both groups between Midline and Endline surveys Malaria outcomes: The addition of LNS to the SMC program may provide an enhanced protective effect against clinical malaria Additional insights Breastfeeding was not adversely affected by the introduction of LNS The increased decline of fevers in the SMC+LNS group indicates possible additional protection from LNS

SMaMP study in Kano- Nigeria- Programmatic Considerations SMC Considerations Bundling SMC with other commodities will not adversely affect SMC with door-to-door distribution; other commodities should be explored SMC may be bundled with LNS to increase protective efficacy against malaria SMC may have a plausible positive impact on nutrition LNS considerations The study did not demonstrate any impact of LNS on nutrition outcomes including stunting, underweight and wasting Although programmatic costs of integration are not high, LNS product cost is significantly more expensive than SPAQ

Programmatic considerations of integrating various programmes with SMC Area Criteria Collaboration Ensure there is good collaboration between the disease programs including a harmonized approach with respect to training, tools, supervision etc. Ensure that there are no funding imbalances, ie ensure that there is co-funding opportunities as early as possible for both interventions Flexibility in financing can mitigate mis-aligned investments MOH prioritization Government advocacy is vital to ensure to areas can work together e.g. dedicated task forces can bring together directorates and ensure joint planning Disease burden should help prioritize interventions to be added to SMC Ensure country-level technical agencies are well briefed and capacitated to ensure advocacy and resources are being dedicated to both programmes in time for the SMC campaigns

Programmatic considerations of integrating various programmes with SMC Area Criteria Referral systems Referral system needs to be set up in case children need to be referred from SMC to addition care (e.g. in the case of SAM or child at risk for TB) CHWs or health facility workers training needs to be able to capture if there are danger signs for both interventions Ensuring there is adequate capacity for appropriate care at the referral sites (for example, needs to be clear where to send children for TB diagnosis ) Supply chain Joint missions are important to drive funding towards integrated systems Division of labor, e.g. some agencies are better and strengthening the national supply chain to deliver, parallel systems for just one disease should be discouraged Monitoring & evaluation Prioritization of an integrated indicator can help drive resources and programming

Sustainable National Supply Chains Supply Chain aspects to consider to achieve long term results Funding & Policies Investments & Infrastructure Systems & Data People & Practices Sustainable National Supply Chains Link SC interventions to Health Systems Strengthening DEFINITION OF NEED BUDGETING & PLANNING PROCUREMENT DELIVERY & CLEARANCE INSPECTION WAREHOUSINGDISTRIBUTION, & REORDER UTILIZATION BY END USER MONITORING & EVALUATION

In conclusion The Sahel region is a region where child malnutrition rates and high seasonal malaria coincide geographically and seasonally. Policies and systems exist to improve efficiency of delivery of life-saving interventions through integration. Let us think together on how and what we can do in our respective countries. Photo Credit: Malnutrition care in Cameroon VOA 2014

Thank you!