Yacob Yishak and Regine Kopplow Contributing to Resilience A Model for Nutrition Surge Capacity

Trends in Global Acute Malnutrition 2010 and 2011 nutrition surveys were conducted between April and June. Data from these surveys was used to construct maps

Four Factors 1.Create resilience over the long term 2.Good coordination 3.Strengthen government capacity (e.g. Health System Strengthening) 4.Early scaling up of food, nutrition and livelihood interventions (including water)

Creating Resilience Community involvement and dialogue Switching to drought resistant livestock Promoting diversified livelihoods Rangeland management Conflict mitigation Increasing water availability Early, gradually intensifying emergency interventions in health and nutrition, water, and food security

Nutrition Surge Capacity Strengthen the capacity of government health systems to effectively manage increased caseloads of severe acute malnutrition without undermining on going systems strengthening efforts. The objective is not to reduce malnutrition!

Surge capacity model components 1. Risk analysis 5. Scaling down of surge support 4. Provision of surge support 3. Monitoring against thresholds/ triggering surge support 2. Threshold setting Health system (strengthening where needed)

Health system strengthening Caseload External support Health System Capacity Time *Adapted from P. Hailey and D. Tewoldeberha, ENN, 2010, issue 39 Ongoing health systems strengthening efforts

Health system strengthening Performance analysis Has the health facility achieved the performance indicator? (use checklist) No Yes Determine actual reasons for poor indicators Gap assessment Identified gaps No technical staff/ staff shortage Possible action(s) Lack of reference materials Inadequate supplies Inadequate technical knowledge Inadequate working space at HF Make request for staff allocation Request materials from district Purchase equipments Train staff on knowledge gaps Construct makeshift shelter *On-Job Training Guide for High Impact Nutrition Interventions, Oct. 2011, MOPHS, Kenya Mainly delivered through: -On-the-job training -Joint supportive supervision

What happens to the health system strengthening if an emergency strikes? If and when external support comes: - it is often late - not tailored to needs and existing capacity -if priority is given to treatment of acute malnutrition the delivery of other life-saving services (e.g. treatment of childhood illnesses or vaccination) is compromised Government systems are usually resource constrained and lack the required flexibility Systems often fail to respond when the need and potential public health impact is greatest

Health system strengthening Caseload External support Health System Capacity Time *Adapted from P. Hailey and D. Tewoldeberha, ENN, 2010, issue 39 Strengthen the capacity of government health systems to effectively manage increased caseloads of severe acute malnutrition without undermining on going systems strengthening efforts.

Component 1: Risk analysis Done by staff in Butiye Health Centre, Moyale District, Kenya Analysis of the drivers of increased caseloads and delayed health seeking behaviour Understand what factors have an impact Understand how these factors interlink

Model component 2: Threshold setting (Number of new admissions into nutrition treatment services per month; using the example from Turbi health facility in Chalbi) Emergency Serious Time Caseload Normal Alert How many patients can the health facility cope with? Severe malnutrition Moderate malnutrition >20 >50

3a. Monitoring caseloads against thresholds Butiye Health Centre, Moyale District, Kenya, photos by R.Kopplow Diarrhoea Pneumonia Severe malnutrition (SAM)

Model component 3b: Triggering surge support Health systems strengthening Monitoring of malnutrition and disease caseloads, the health seeking influencing factors and mobilisation activities carried out in the area Caseload reaches threshold Health facility contacts DHMT During DHMT meeting issue is discussed and the scale up of support approved DHMT approaches NGO for additional support where needed Scale up

Model component 4: Provision of surge support Emergency Serious Alert Normal e.g.>25 cases e.g cases e.g cases e.g. <10 cases ThresholdCaseloadSupport provided Mentoring continues plus direct implementation by supporting NGO Mentoring continues plus implementation of short-term solutions to overcome gaps Intensified mentoring focuses on crucial gaps and hot spot facilities Health system strengthening through mentoring approach Make request for staff allocation under MOH AWP Example: shortage of technical staff Follow up request & train non-clinical staff to fill gaps Follow up request & secondment of 1 nurse from another clinic Follow up request & secondment of 1 additional NGO nurse Surge support is: Defined for district Agreed in advance Formalised in MoU Prepared Funded

Model component 5: Scaling down of surge support Health systems strengthening Monitoring of malnutrition and disease caseloads, the health seeking influencing factors and mobilisation activities carried out in the area Caseload reaches threshold Health facility contacts DHMT During DHMT meeting issue is discussed and the scale up of support approved DHMT approaches NGO for additional support (where needed) Caseloads go below pre- defined threshold Health facility contacts DHMT During DHMT meeting issue is discussed and the scale down of support approved DHMT with support of NGO scales down the support Scale up Scale down

Progress so far 1.Technical review around nutrition surge capacity 2.Development of a theoretical nutrition surge capacity model jointly with government and health staff 3.Transformed the theoretical model into a practical operational tool 4.District nutrition teams developed thresholds, activation mechanisms and drafted phased support packages 5.On-going pilot in 14 facilities in Chalbi, Sololo and Moyale

Next steps 1.Amend the MOU with the Ministry to include surge capacity –Agree on the surge support package –Cost the support package 2.Test the scaling up/ down of support 3.Conduct research to proof the concept

Where are the links to livestock? Milk availability for consumption price Animal body condition price for animals & meat Movement of animals: proximity to health facilities workload decision making 1. Livestock impacts on malnutrition prevalence and health seeking behavior 2. Would a similar model be useful to scale up veterinary services to respond to disease outbreaks?

Where are the links to agriculture? 1.Food quantity and diversity impact on nutritional status 2.Workload (of women) influences health seeking, child feeding and caring practices