UNICEF global SAM management update (2012)
Summary of report1
Thanks to Saul Guerrero, ACF-UK, for preparing this summary.
What we know: Mapping of global SAM management requires baseline and consistent data.
What this article adds: A web-based data collection and reporting system for SAM management at national level was developed by UNICEF and Valid International to address existing inconsistences in data reporting to strengthen mapping. The 2012 mapping reports on number of countries providing updates, national reporting services, estimated burden of SAM, SAM admissions, quality of SAM treatment, and integration into health services. Recommendations include integration of the UNICEF annual supply forecasting tool into the current online system, and improvement of the quality of performance indicator reporting and trend analysis.
The management of severe acute malnutrition (SAM) is critical for child survival and is a key component of the Scaling Up Nutrition framework for addressing undernutrition. UNICEF is a leading organisation in the scaled-up implementation of community-based management of acute malnutrition (CMAM), providing technical support, capacity building and therapeutic supplies for Ministries of Health and non-governmental organisation (NGO) partners. Monitoring and evaluation of service provision is a significant component of UNICEF’s work.
An initial mapping of countries supported by UNICEF in the area of CMAM was first presented in the ‘Global Mapping Review’ (2010 using 2009 data), followed by the 2011 ‘Global SAM Treatment Update’ in 2011. In order to build on previous efforts to gather baseline data related to SAM management at the national level, in 2012 UNICEF worked with Valid International to gather updated information through a web-based data collection and reporting system.
With a view to address previously noted inconsistencies with data reporting, UNICEF’s Nutrition in Emergencies unit undertook a standardisation process for the three main areas where discrepancies were identified, specifically incidence, burden of SAM and SAM treatment coverage. A range of technical experts, United Nations (UN) agencies, and field staff were consulted and the formulas used for the 2012 update are presented in Box 1. The original questionnaire was also refined based on feedback from previous years. The web-based platform enabled data quality checks at data entry, and guidance for each question was expanded. The main findings of the 2012 update are outlined below:
Number of countries implementing services
- Sixty countries in 2012 reported the provision of SAM treatment services in-country. This is consistent with 2011 (61 countries) and represents an increase from 2009 (53 countries). Not all countries were aiming for countrywide scale up.
- Of these 60 countries, the majority reported implementation of both inpatient and outpatient SAM treatment (56 countries), with a limited number reporting implementation of inpatient SAM treatment only (7 countries). Previous mapping exercises in 2009 and 2011 did not differentiate between inpatient and outpatient service provision.
National reporting rates
- In total, 25 countries were classified with >75% reporting rate (i.e., they received >75% of the required reports within a given reporting period - monthly or quarterly) in comparison with 29 countries in 2011.
- The slight decline in reporting rates reflects the attempts of the 2012 questionnaire to improve data quality by asking for raw numbers of reports expected and received in 2012, in comparison to asking for percentage reporting rates in 2011.
- The proportion of incomplete or absent data indicates the need for continued efforts to improve national reporting systems over time.
Estimated burden of SAM
- The current global figures of SAM burden produced by WHO, UNICEF and the World Bank (2013) estimate that 17.6 million children could be classified with SAM at any point in time. These estimates have their limitations as they do not take into account incidence, nor do they consider oedematous cases of SAM. The 2012 update figures provided national level estimates that help to highlight the need for more precise estimations of the national, regional and global burden.
- A total of 2,662,712 cases of children aged 6 - 59 months with SAM were reported as admitted for treatment of SAM in 2012, compared with an estimated 1.96 million reported in 2011 and 1 million in 2009 (See Table 1).
- As the reporting rate from 2011 to 2012 was largely similar (as opposed to a marked improvement from 2009 to 2011), what can be inferred is that the increase in admissions from 2011 to 2012 is not a due to better reporting, but more truly reflects the increased number of admissions.
- Most admissions for community SAM treatment are located in East/Southern and Central/Eastern Africa. Given the high burden of SAM in South Asia, it is evident that SAM scale up in South Asia could result in significant progress towards meeting the global burden of SAM cases.
|Table 1: Reported annual admissions for SAM treatment by UNICEF region (2009-2012)|
EASRO Eastern and Southern Africa Regional Office, WCARO West and Central Africa Office, ROSA South Asia Regional Office, MENA Middle East and Northern Africa Regional Office, TACRO Americas and Caribbean Regional Office EAPRO East Asia and the Pacific Regional Office
Quality of SAM treatment
The three globally agreed performance indicators (recovered, defaulted and died) are routinely collected at a decentralised level to assess quality of SAM treatment. In order to give a more accurate picture of performance indicator rates in 2012, countries were asked to provide raw numbers for death, defaulting and recovery which were then used to calculate performance statistics, as opposed to reporting percentages as in previous rounds of data collection. With a focus on recovery and defaulting:
- 30 countries in 2012 achieved a minimum recovered rate of ≥75% (Sphere standard for recovered), representing an increase from 21 countries in 2011.
- 25 countries in 2012 achieved a defaulter rate of <15% (Sphere standard for defaulted), representing an increase from 20 countries in 2011.
Challenges were presented with reporting data as raw numbers, with over 42% of the countries (25 countries) unable to report either defaulter or reporting figures. Efforts are required to support countries in the collection/ collation of these performance indicators.
Integration into Health Services
Integration of SAM management into national health systems has expanded the geographical coverage of SAM treatment as some ministries of health have adopted SAM management as part of the essential health package (not all countries are aiming for nationwide scale-up).
Some aspects of integration of SAM treatment into health systems were found to be strong with many countries reporting:
- management of SAM incorporated into Maternal and Child Health and Nutrition (MCHN) policies,
- at least one SAM indicator in HMIS, and
- incorporation of SAM into the MCHN service package
At the same time, many countries reported areas where there was less integration, such as:
- no allocation of funds for SAM in the annual health sector plan
- no national curricula for management of SAM
- Ready to Use Therapeutic Food (RUTF) not on the essential supplies list
The analysis found no obvious correlation between integration indicators and the levels of treatment or geographic coverage or number of admissions attained by countries. Nevertheless, it is clear that more needs to be done to advocate for an enhanced commitment by governments to SAM management.
Integration of the UNICEF annual supply forecasting tool into the current online system.
Whilst harmonised in terms of timing, the supply forecasting exercise and 2012 Global SAM Update are currently two separate data collection processes.
Improvement of the quality of performance indicator reporting and trend analysis.
UNICEF and partners are continuing to work with countries to improve SAM reporting using a variety of techniques (national web-based platforms, SMS systems, HMIS integrated reporting etc).
Integration of coverage survey data.
UNICEF will work with partners to strengthen capacity of some countries to undertake coverage surveys.
Development of additional modules for micronutrients and infant and young child feeding.
Creating additional data modules is crucial to building UNICEF’s global data management system from a harmonised perspective and lessening the burden of multiple information requests to countries at different times.
Box 1: Key definitions
Incidence of SAM
An estimate of the incidence of SAM can be calculated as follows:
Incidence = Prevalence/average duration of disease
A common estimate of the average duration of an untreated SAM episode is 7.5 months (Garenne et al. 2009). Using this to estimate incidence over one year (i.e., 12 months) yields:
Incidence = Prevalence × 12/7.5 = Prevalence × 1.6
1.6 is therefore the incidence correction factor for the calculation of incidence from a given prevalence.
Burden of malnutrition
The burden of SAM is defined as an estimation of the total number of SAM cases in a population over a specific period (i.e. prevalent cases + incident cases in the year).
Burden = Population 6-59m x [Prevalence + (Prevalence x 1.6)]
Or simplified to: Burden = Population 6-59m x Prevalence x 2.6
To clarify further:
- Prevalent cases = prevalent SAM x population 6-59m
- Incident cases = prevalent SAM X population 6-59m x 1.6 (where 1.6 is a correction factor which gives incidence as factor of prevalence)
SAM treatment coverage is defined as the proportion of children with SAM who receive therapeutic care. For UNICEF’s 2012 data, this was calculated as follows:
SAM Treatment coverage = Admissions / Population 6-59m x [Prevalence + (Prevalence x 1.6)]
The working definition for geographical coverage used by UNICEF in its 2012 Global SAM Management Update is as follows:
SAM Geographical Coverage = Healthcare facilities delivering treatment for SAM/ total number of healthcare facilities
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Reference this page
Saul Guerrero (2014). UNICEF global SAM management update (2012). Field Exchange 47, April 2014. p52. www.ennonline.net/fex/47/unicef