Maureen Gallagher SAM International conference London, Oct 17, 2013 From vertical to horizontal: Experiences & recommendations in integrating SAM treatment to health systems Maureen Gallagher SAM International conference London, Oct 17, 2013

Presentation Outline Setting the context Background HSS & SAM treatment Experiences – How does it look? Strategic & practical implications Conclusion

Setting the context Universal health care Focus on design and implementation Health systems strengthening (HSS) - -WHO 2007 Integration – ‘institutionalization’ of SAM treatment (GOVERNANCE-LEADERSHIP/ FINANCING / SERVICE DELIVERY/HUMAN WORKFORCE/SUPPLY/INFORMATION SYSTEM) So there are a number of terms that I will be talking about today and I would like to begin this presentation by sharing what definitions these will carry throughout the next 15 minutes Universal health care : Universal health care is not a one-size-fits-all concept; nor does it imply coverage for all people for everything. Universal health care can be determined by three critical dimensions: who is covered, what services are covered, and how much of the cost is covered. In the integration of SAM, it is quite crucial to have free access to health care for children < 5 as part of national policy Health system strengthening – WHO 2007 – a collection of organizations and actors who’s main intent is to promote, restore and maintain health. The framework to support achieving this vision includes six building blocks – Integration – it’s a word used by many in differet context and for this presentation we will be looking at it in terms of mainstreaming/institutionalizing treatment in health systems.

Background Changing landscape of treatment of acute malnutrition with huge advances the last 25 years Coverage still low at between 8-13% globally Need to strengthen treatment of SAM as a disease – linkage Nutrition & Health Learning from experiences of Global Health Initiatives (GHI) shift from disease specific to health systems strengthening Why is it important to speak about this? Changing landscape: Protocols – Inpatient // Outpatient Implementation – Hospital based to community based (often by INGOs) and now mainly hospital and PHC based (integration happens at different levels) Coverage : still low , influenced by limited access (barriers – creating demand and also availability (in terms of quantity and quality – creating supply) Health & nutrition linkage is essential There are some lessons learned from GHIs Adverse effects on the national health systems Weak health systems are a bottleneck to achieving disease specific programming outcomes Shift to health system strengthening by partners call for a cohesive coordinated environment ‘Islands of excellence in seas of underprovision’ Now we will look at a couple of personal experiences that I

Shifting dynamics of HSS Vertical Horizontal (from Wilson, U of Colorado) Here I would just like to summarize on what the shifting/dynamics look like as we move to an increasingly horizontal, health system sensitve/adapted approach Vertical Focused on a specific disease, or health issue Dual reporting structure Usually financed by external donor for limited period of time Specific, measurable outcome objectives within a defined time-frame Activities occur parallel to and in addition to normal primary care activities Often controlled by implementing or supporting agency to do what it takes to achieve the goal Horizontal Focused on providing integrated health care Basic unit for preventive and primary health care of national health system Usually single reporting responsibility to national health system Usually financed by national health system Focused on providing integrated health care for interrelated health problems for entire population WHY is this ALL IMPORTANT FOR SAM TREATMENT? In looking at the history of SAM treatment and the ‘perfect model’, it is very much a vertical implementation process. The opportunity today, with increasing leadership and ownership of government, is to work together to adapt to with partners adapting to their ways of working rather than expecting them to adapt into ‘the perfect model’ (or an adaptation of it) that can result in further burdening and weakening health systems which are needed for other diseases as well.

Shifting dynamics of SAM treatment Vertical Horizontal What does this like for SAM treatment? Explain vertical for SAM – Classic model Explain horizontal for SAM – MUAC screening of every child at consultation, where there are CHWs screening and possibly treatment in communities, RUTF in the pharmacy, etc. The Diagonal approaches reconciles the need to keep some specialized functions while recognizing that programs and their scaling up require stronger health systems. We will look at a couple of case studies today to illustrate why vertical programming cannot immediately shift to horizontal yet got through process to achieve it

NIGERIA Government support Partner support This is how the case studies will be presented: Nigeria Block   Service Delivery SAM treatment is only provided one day a week; passive screening is done on an occasional basis; healthworkers deliver the services with help sometimes from health workers form other health facilities Health Workforce More people are expected to be able to deliver treatment (7-10) thus they either come from neighboring health facilities, or include paid community workers, or involve incentives Information Separate reports from the HMIS system are produced and submitted on a weekly basis to the authority Medical products/Technology RUTF and medicines are stored separately and controlled by the in charge of the clinic; transport of commodities is done on an ad hoc basis based on need and with support of partners Health financing There is some support by health authorities to the transport, yet on an adhoc basis// health workers are well paid on a timely manner ; basic drugs and others not always finance Governance/Leadership SAM treatment is integrated as a basic service in national and state policies which have been approved Authorities are committed to SAM treatment and leave it to partners to support the health system in ensuring that this is provided

DR CONGO Government support Partner support This is how the case studies will be presented: DRC Block   Service Delivery SAM treatment is available 7 days a week at all health facilities in the health zone; MUAC is taken regularly as part of the standard consultation Health Workforce Health workers are not paid regularly by the government and incentives are provided by the partner Information Separate reports from the HMIS system; Reports are produced on a monthly basis and submitted to authorities with support of partner because every information heavy (age groups, etc.) Medical products/Technology There is a regular system for providing orders to the health system in order to ensure timely supply delivery; RUTF and medicines are available in the pharmacy Health financing There is no financing available as part of the health system and all activities are subsidized in order to ensure free health care for children U5 Authorities are committed to SAM treatment and leave it to partners to support the health system in ensuring that this is provided Governance/Leadership No policy of free health care for children U5 SAM treatment is part of national health policy with national guidelines available

Where should we aim to go Partner support Government support This is how the case studies will be presented: AIM Block   Service Delivery SAM treatment is available 7 days a week at all health facilities in the health zone; MUAC is taken regularly as part of the standard consultation; CHWs screen children in communities Health Workforce Health workers are paid regularly and CHW networks are in place and active Information Key SAM treatment indicators are integrated as part of the health information system Medical products/Technology There is a regular system ordering functional supply system; RUTF and medicines are available in the pharmacy; RUTF is included as part of the essential medecines’ list Health financing There is free access to health care for children < 5 years and budget lines for RUTF supply and medecines Governance/Leadership Policy of free health care for children U5 – universal health care SAM treatment is part of national health policy & minimum healht packahge with national guidelines available Is there a good enough model? or is it only 100% (slide 12) is good enough? what building block is more important than the other? what should be priorities to focus on, in case i cant get the 100%? i assume you will say it depends on the context, but maybe a recommendation?

Strategic Implication Bringing nutrition into health & working through the HSS building blocks to achieve sustainable availability & access to SAM treatment Including SAM treatment as part of a minimum health package Shift role of partners from ‘implementer’ to ‘facilitator’ Simplifying CMAM protocols, implementation and follow-up Transitioning from donor financing to MoH financing basic minimum health package of which SAM treatment is part Bring nutrition into health & work through the HSS building blocks to achieve sustainable availability of SAM treatment Need to have them together Including SAM treatment as part of a minimum health package It be seen as one service amongst other health care services Shift role of partners from ‘implementer’ to ‘facilitator’ As technical experts, we know what to do, especially in link with the classic model. Being a facilitator means knowing the technical and jointly finding ways that all essential components of the treatment are available though these may look different from context to context and even from health facility to health facility Simplifying CMAM protocols, impementation and followup For admission promoting MUAC for admission and discharge, for information systems identifying the ‘essential’ information (not what is wanted or interesting, but what is needed to evaluation quality of care) Donor support for longer term funding and acceptance on progressive improvement in quantity and quality of SAM treatment This can be so different . Short term funding will not allow for impact or sustainability. Linkages between emergency on a first response basis and development donors are essential. Acceptance that the treatment may look different on the ground is necessary. Commitment to sustainable treatment

Practical Implications General: Identifying new ways of working from being model oriented to process oriented Coordination of actors in working with one health system Design: Comprehensive assessment of health system Joint planning and implementation Simplification of protocols and systems Implementation: Human resources Supply chain Some que practical implication in making this happen from design to implementation include: General We need to look at working in different ways – this is already being done but with a ‘touch’ of the classic model Coordination of actors in working with one health system – Many actors can also not help the system ift here is no cohesiveness (prime in DRC by 3 partners in one zone) Design: Mainly here we have to take the time and learn all aspects of the health system in link with building block to identify areas for focuaand windows of opportunity Then, to present the essentials that need to be in place and jointly determine the best way to do it in a given system (at state/district and even health facility level this may not look the same) Implementation: Human resources – two dimension – 1) SUPPORT - technical versus capacity building; bringing in know how in order to address all of the building blocks 2) MOH – exploring existing policies and supporting implementation to increase health system workforce Supply chain – key bottleneck for sustainability – cost, availability, transport Other key challenge – long term funding and high burden areas

Next steps Health System Strengthening Task Force ToR developed with support of WHO & UNICEF ACF finalizing the CMAM Integration Guidelines Health System Assessment tool being tested by UNICEF & partners Experiences need to be further tested and documented in relation to quality of care and coverage So there are some things already in the works to support thes processes Health System Strengthening Task Force ToR developed with support of WHO & UNICEF Will support reviewing all lessons learned and identifying ways to best work with health ACF finalizing the CMAM Integration Guidelines to be tested in the field at the end of the year (covers block & tools) Health System Assessment tool being tested by UNICEF & partners // Experiences need to be further designed, tested and documented with a strong scope of improvement in quality of care and coverage over time

Conclusion There lies a significant opportunity ahead in the increasing MoH leadership and commitment in SAM treatment with the evolving role of partners in support of it to ensure that SAM treatment is available as part of regular health services, moving towards quality global coverage. In considering the building block and the contexts that we work in to support increased quality and coverage of SAM treatment, there is no one solution. But there are existing oriented frameworks and new ways of working to support building system for the long run for equity and quality in access and coverage As partners, we also have to be ready to be backstage and give voice to health system key stakeholders to lead the process that we can technicalyl support

Thank you