1. 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

2. UNICEF Procurement support over the Years

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. Thank you!