1. 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

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

3. 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.

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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?

10. 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

11. 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

12. 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

13. 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

14. Thank you