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Scale-up of severe wasting management within the health system: A stakeholder perspective on current progress

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Summary of report¹

This summary was prepared by Brenda Akwanyi who undertook the review together with Philip James, Natascha Lelijveld and Emily Mates on behalf of ENN

Background

There has been considerable progress towards integrating severe wasting management into national health systems in countries with high burdens of wasting. However, scale-up remains slow. This report offers a qualitative synthesis of key informants’ perspectives on the barriers and enablers to scaling up wasting treatment through routine health services, conducted between September 2020 and February 2021. A total of 25 in-depth interviews were conducted with key informants from a range of national and regional government institutions, non-governmental organisations (NGOs), United Nations (UN) agencies and academic institutions. Interviews were guided by a semi-structured questionnaire based around the six pillars of the World Health Organisation (WHO) health system strengthening framework.

Service delivery

While there has been progress towards scale up of severe wasting services, programme coverage remains low. Key enablers to improve coverage include understanding the importance of coverage as an indicator of treatment success and context-specific bottlenecks.  

Several initiatives have aimed to identify the drivers of wasting to inform responsive programming over the last decade. While successful activities, including community outreach for severe wasting management and building demand for services, should now be implemented at scale, severe wasting has dropped off the agenda in some countries. Maximising the core entry points for child health service delivery at facility and community level was identified as a key enabler to ensuring that severe wasting is included in investments into routine community outreach services. The role of community health workers (CHWs) and family members in the early detection of severe wasting is also central to reaching children at risk. Various adaptations for case detection such as the ‘Family mid-upper-arm circumference (MUAC)’ approach have been developed to facilitate this and innovation, experience sharing and the scale-up of programme adaptations by health systems are needed. Key informants also felt that successful examples of using surge capacity to manage infectious diseases such as cholera, Ebola and COVID-19 could be utilised to improve the scale-up of severe wasting services. This would require recognising severe wasting as an urgent health condition.

Health workforce

The integration of severe wasting treatment within the health workforce was felt to require a dual approach of training health staff and ensuring their accountability to severe wasting outcomes and training nutrition staff in the principles of health system strengthening. This would diminish siloed teams and better empower primary health teams to plan and implement severe wasting treatment.

The community component of health systems was identified by key informants as the most neglected in terms of funding and institutionalisation. Lobbying is needed to increase investment for CHWs at subnational and national levels and to put in place appropriate legal regulation, certification and remuneration and simplified referral systems to support the work of CHWs.

Supplies

The costs of ready-to-use therapeutic food (RUTF) remain a stubborn barrier to the scale-up of severe wasting management and challenges to sustainable supplies of RUTF hamper the continuity of care and quality of services. Product adaptations and simplified nutrition protocols offer promising opportunities to decrease the amount of RUTF required, for example through adapted dosage regimes for severe wasting treatment, reducing logistics costs through local production, controlling misuse or ‘leakage’, improving supply chain efficiencies and/or developing new, cheaper formulations. As these protocols undergo further piloting and review, the existing supply chains of national health systems need to be further reinforced. To date, 43 country governments have included RUTF in their essential medicine lists and are moving towards a more secure national supply chain. However, the COVID-19 pandemic added further strain on the global supply chain and highlighted the need for more local production of RUTF to shorten and potentially simplify the supply chain.

Health information systems

Key enablers to effective health information systems include minimising parallel reporting systems and ensuring the availability of technical expertise to interpret data on severe wasting so that this can be translated into programmatic action. Identified bottlenecks also need to be tackled within the District Health Information System 2 (DHIS2) which is already used in 73 countries so as to maximise its potential to support health workers to better anticipate and manage fluctuations in demand for severe wasting services. The intentional embedding of technical expertise in nutrition information systems within maternal and child health information and/or monitoring and evaluation departments could also improve the analysis and use of nutrition data. For example, key informants described how governments with established e-health platforms could feasibly integrate nutrition data into existing infrastructure at scale and pilot programmes have been successful in using digital platforms to integrate severe wasting data. Engaging with scalable e-health platforms and leveraging them to scale up e-nutrition digital investment is now needed.

Financing

Full and accurate budgeting is required to implement severe wasting treatment at scale, yet the allocations for severe wasting treatment in some national and subnational budgets is insufficient. The ongoing costing exercise for country action plans that target wasting (Global Action Plan for wasting outcome 4) offer an opportunity to ensure realistic national and subnational costing and budgeting for severe wasting. Involving health systems specialists in these budgeting activities could further improve financial projections.

Currently, most severe wasting treatment services are largely funded through international humanitarian or emergency financing mechanisms which can be unpredictable and inefficient.  They also tend to use parallel systems that do not build national capacity. Securing adequate and sustainable longer-term funding streams for wasting costs requires innovative funding mechanisms and the informants proposed many possible opportunities. These included expanding innovative regional multilateral development finance initiatives, such as the Global Financing Facility, and exploring regional government procurement services to reduce the costs of essential supplies.

Leadership and governance

The ongoing national and global discussions on universal health coverage (UHC) offer a huge opportunity to ensure the health consequences of severe wasting are prioritised, especially for high burden countries. The Tokyo Nutrition for Growth (N4G) working group on nutrition has laid down some priority commitments that can be leveraged for these discussions. There are many examples of health services that achieve impressive coverage, such as the community integrated management of childhood illnesses (C-IMCI) and the expanded programme on immunisation (EPI). These provide platforms into which severe wasting services should be integrated to maximise coverage. Key informants also suggested that support infrastructure from agencies needs to be maintained alongside government prioritisation of wasting and that this should involve consistent messaging on the importance of scaling up severe wasting management from all stakeholders who influence government policy and funding.

Conclusion

Many successful examples of scaling up severe wasting management from pilot studies and case studies exist but the need to achieve best practice at scale remains. During this qualitative synthesis, key informants highlighted the need for sustained advocacy and funding and political will from governments, donors and implementing agencies to continue progress and to maximise opportunities including the current efforts towards achieving UHC.

For more information, please contact Brenda Akwanyi at brenda@ennonline.net

Reference this page

Brenda Akwanyi (). Scale-up of severe wasting management within the health system: A stakeholder perspective on current progress. Field Exchange 65, May 2021. p84. www.ennonline.net/fex/65/cmambarriersfacilitators

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