Menu ENN Search

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

View this article as a pdf

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

Location: Global

What we know: Slow progress is being made towards scaling up the integration of severe wasting management into national health systems.

What this article adds: A qualitative synthesis of key informants’ perspectives on the barriers and enablers to scaling up wasting treatment through routine health services was conducted by the Emergency Nutrition Network (ENN) between September 2020 and February 2021. Key informants shared examples of scale-up from pilot studies and case studies, emphasising the need to achieve best practice at scale. Programme coverage remains low and enablers proposed to improve this included an understanding of context-specific bottlenecks and the use of coverage as an indicator of programme success. Participants identified a need to remove the silos between nutrition and health workforce teams and to prioritise the community component of health systems, for example through investment in community health workers. Key informants also identified the need to adapt and simplify nutrition protocols to reduce the requirements and costs of ready-to-use therapeutic food and the need for more local production to shorten supply chains. Other important aspects identified for successful scale up were to minimise parallel reporting systems, ensure adequate technical expertise for data interpretation and translation, the integration of treatment service into existing community platforms and sustained advocacy, funding and political will from governments, donors and implementing agencies.

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

Read more...

More like this

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

Executive summary Introduction Wasting is a critical issue for child survival and development, with therapeutic treatment of severe cases recognised as an essential...

FEX: Severe acute malnutrition: an unfinished agenda in East Asia and the Pacific

By Cecilia De Bustos, Cécile Basquin and Christiane Rudert Lisez cet article en français ici Cecilia De Bustos is a nutrition and public health specialist who...

FEX: One UN for nutrition in Afghanistan - Translating global policy into action: A policy shift to tackle wasting

View this article as a pdf Lisez cet article en français ici Click here to listen to an interview with Dr. Jamil Bawary, Integrated Management of Acute Malnutrition...

FEX: Regional perspectives on simplified approaches for the management of children with acute malnutrition: West and Central Africa

View this article as a pdf Lisez cet article en français ici By Sophie Woodhead, Dolores Rio and Noel Zagre Sophie Woodhead is a Nutrition Specialist with UNICEF in...

FEX: Integration of essential nutrition interventions into primary healthcare in Pakistan to prevent and treat wasting: A story of change

View this article as a pdf Lisez cet article en français ici Click here to listen to an interview with one of the authors on the ENN podcast channel By Dr Baseer Khan...

FEX: Continuum of care for children with wasting in India: Opportunities for an integrated approach

View this article as a pdf Lisez cet article en français ici By Arjan de Wagt, Eleanor Rogers, Praveen Kumar, Abner Daniel, Harriet Torlesse and Saul Guerrero Arjan...

FEX: Editorial perspective on the continuum of care for children with acute malnutrition

View this article as a pdf Lisez cet article en français ici By Jeremy Shoham and Marie McGrath, Field Exchange Co-Editors Rationale for FEX special edition We are...

FEX: Ready-to-use therapeutic food and the WHO list of essential medicines

By Aurélie du Châtelet, Anne-Dominique Israel, Elise Rodriguez, Wisdom Dube, Laetitia Battisti, Magali Garcia, Coline Morin and Natalie Sessions. Aurélie...

FEX: Conference for community-based management of acute malnutrition (CMAM)

View this article as a pdf Concern Worldwide, in partnership with Irish Aid, is hosting a conference for community-based management of acute malnutrition (CMAM) practitioners...

Resource: Ready-to-use Therapeutic Food (RUTF) Scoping Study

This work was conducted by Emily Mates (ENN Technical Director) and Kate Sadler (ENN Consultant). We are grateful to the many individuals and agencies who not only generously...

FEX: South Asia and child wasting – unravelling the conundrum

View this article as a pdf Lisez cet article en français ici By Harriet Torlesse and Minh Tram Le Background Each annual release of the Joint Malnutrition Estimates...

FEX: Accelerating the scale-up of treatment for severe acute malnutrition

News By Saul Guerrero, Erin Boyd, Claire Harbron, Diane Holland, Abi Perry and Sophie Whitney Saul Guerrero is the Director of Nutrition at Action Against Hunger UK (ACF UK)....

FEX: One UN for nutrition in Afghanistan - Translating global policy into action to tackle wasting

This is a summary of a Field Exchange field article that was included in issue 63 - a special edition on child wasting in South Asia. The original article was authored by...

FEX: Community-based management of acute malnutrition (CMAM) Conference 2021

View this article as a pdf Concern Worldwide and Irish Aid hosted a virtual conference on the community-based management of acute malnutrition (CMAM) in March 2021. The...

FEX: Nutritional response in north-eastern Nigeria: Approaches to increase service availability in Borno and Yobe States

View this article as a pdf Lisez cet article en français ici By Sanjay Kumar Das, Dr Sule Meleh, Dr Umar Chiroma, Bulti Assaye and Maureen L Gallagher Sanjay Kumar...

FEX: Editorial

A number of the recommendations in the Grand Bargain reported on in the last issue of Field Exchange speak to the need to forge stronger links between humanitarian and...

NEX: Experiences of the Integrated Management of Acute Malnutrition (IMAM) programme in Nepal: from pilot to scale-up

This is a summary of a Field Exchange field article that was included in issue 63 - a special edition on child wasting in South Asia. The original article was authored by Karan...

FEX: Experiences of the Integrated Management of Acute Malnutrition (IMAM) programme in Nepal: from pilot to scale-up

This is a summary of a Field Exchange field article that was included in issue 63 - a special edition on child wasting in South Asia. The original article was authored by Karan...

FEX: Zambia efforts in prevention, early detection and treatment of wasting during COVID-19

View this article as a pdf By Getinet Babu, Agnes Aongola, Colleen Emary, Phyllis Oyugi, Claire Beck, Chansa Tembo Getinet Babu is a humanitarian nutritionist with over 16...

FEX: Experiences of the Integrated Management of Acute Malnutrition (IMAM) programme in Nepal: from pilot to scale up

View this article as a pdf Lisez cet article en français ici Click here to listen to an interview with one of the authors on the ENN podcast channel By Karan Courtney...

Close

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

(ENN_7083)

Close

Download to a citation manager

The below files can be imported into your preferred reference management tool, most tools will allow you to manually import the RIS file. Endnote may required a specific filter file to be used.