Linking Nutrition & (integrated) Community Case Management

Transcription

1 02 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Linking Nutrition & (integrated) Community Case Management A REVIEW OF OPERATIONAL EXPERIENCES Lynette Friedman & Cathy Wofheim December 2014

2 02 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 A c k n o w e d g e m e n t s The authors woud ike to thank a the individuas and organisations that made this review possibe. In particuar, the authors woud ike to thank the members of the Steering Committee overseeing this review; Samira Aboubaker (WHO), Sau Guerrero (Action Against Hunger UK), Diane Hoand (UNICEF), Emiy Keane (Save the Chidren UK), Katie MacDonad (PSI) and Casie Tesfai (Internationa Rescue Committee). Specia thanks to Lauren Browne, Sonam Hitendre and Emiy Hockenhu for their assistance with data coation and management during this review. Proposed Citation: Friedman, L.& Wofheim, C.(2014) Linking Nutrition and (integrated) Community Case Management (iccm/ccm): A Review of Operationa Experiences (London, 2014) This review was made possibe thanks to the financia contribution of:

3 03 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 C O N T E N T S ABBREVIATIONS AND ACRONYMS 04 EXECUTIVE SUMMARY 05 INTRODUCTION & BACKGROUND 08 About the Review 10 Methodoogy 10 Limitations 12 REVIEW FINDINGS 13 Typoogy 1: Advising on feeding the sick chid within existing iccm services 14 Typoogy 2: Linkages with Socia and Behaviour Change activities on chid nutrition 16 Typoogy 3: Linkages between iccm activities and acute manutrition treatment through assessment and referra 19 Typoogy 4: Treatment at community eve of uncompicated Severe Acute Manutrition 25 DISCUSSION 35 Typoogy 1 Discussion 37 Typoogy 2 Discussion 38 Typoogy 3 Discussion 39 Typoogy 4 Discussion 39 Knowedge Gaps 42 LESSONS & CONCLUSIONS EMERGING FROM THE REVIEW 43 ANNEXES 45 Typoogy 1: Key Informant Organisations 45 Typoogy 2: Community-eve Nutrition Actions Identified 47 Typoogy 3: CHWs Providing Treatment for SAM: CHW and Programme Profies 49 Typoogy 4: Operations Research Underway or Panned 50 Typoogy 5: Documents Reviewed 54

4 04 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 A B B R E V I A T I O N S & A C R O N Y M S ACF A&T ANC APE ASC CBD CBN CBNP CCM CDD CHA CHW CMAM CNW CSB CTC DALY DRC GAIN GAM HDA HEW HIV HMIS HSA iccm IFPRI IIP JHU IMCI IMNCI IRC ITN IYCF MAM MOH MUAC NGO ORS OTP RaCE RDT RUSF RUTF SAM SBC SFP SMART TB UNICEF USAID WFH WHO Action Contre a Faim/Action Against Hunger Aive and Thrive Antenata Care Agente Poivaente Eementar Agent de Santé Communautaire Community-Based Distributor Community-Based Nutrition Community-Based Nutrition Programme Community Case Management Community Drug Distributor Community Heath Activist Community Heath Worker Community-based Management of Acute Manutrition Community Nutrition Worker Corn Soy Bend Community Therapeutic Centre Disabiity-Adjusted Life Year Democratic Repubic of the Congo Goba Aiance for Improved Nutrition Goba Acute Manutrition Heath Deveopment Army Heath Extension Worker Human Immunodeficiency Virus Heath Management Information System Heath Surveiance Assistant integrated Community Case Management Internationa Food Poicy Research Institute Institute for Internationa Programs at Johns Hopkins University Integrated Management of Chidhood Iness Integrated Management of Neonata and Chidhood Iness Internationa Rescue Committee Insecticide Treated Net Infant and Young Chid Feeding Moderate Acute Manutrition Ministry of Heath Mid Upper Arm Circumference Non-Governmenta Organisation Ora Rehydration Sats Outpatient Therapeutic Programme Rapid Access Expansion Programme Rapid Diagnostic Test Ready-To-Use Suppementary Food Ready-To-Use Therapeutic Food Severe Acute Manutrition Socia and Behaviour Change Suppementary Feeding Programme Standardized Monitoring and Assessment of Reief and Transition Tubercuosis United Nations Chidren Fund United States Agency for Internationa Deveopment Weight-for-Height Word Heath Organization

5 05 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 E X E C U T I V E S U M M A R Y Nutrition is crucia to both individua and nationa deveopment. Recent estimates suggest that improving access and coverage of specific nutrition interventions coud save hundreds of thousands of ives every year. In spite of this potentia, the reach of many of these interventions remains imited. Integrated Community Case Management (iccm) of chidhood inesses may be a ogica patform, perhaps currenty a missed opportunity, for increasing the reach and coverage of treating manourished chidren, and potentiay for preventing manutrition. The objective of this review is to map out and describe operationa experiences in inking nutrition and Community Case Management/integrated Community Case Management interventions, with the goa of identifying emerging essons and identifying gaps in knowedge. The decision to undertake this review was an outcome of a meeting hed in London in May 2014 to examine potentia inkages between iccm, Community Heath Workers (CHW), and manutrition. That meeting concuded with an agreement to work towards buiding and sharing the evidence base for effective service deivery in different contexts. This review utiized two principa methods of data coection: desk review and key informant interviews. Documents reviewed incuded peer-reviewed journa artices, programme reports, goba and nationa CCM/iCCM and nutrition guideines, programme proposas and study designs. Four countries were seected for more in-depth review: Bangadesh, Ethiopia, Niger and South Sudan. To suppement and enhance programmatic and impementation-reated information gathered during the desk review, 22 key informant interviews were carried out with individuas from seven Non-Governmenta Organisations (NGOs), three donor agencies, WHO headquarters staff representing expertise in iccm and in nutrition, and UNICEF staff at headquarters, regiona, and country eves. Anaysis of impementation experiences brought to ight four categories of approaches to integrating or inking iccm and nutrition. In this review, these categories are referred to as typoogies. The typoogies provide an organizing framework for describing, exporing and comparing existing experiences and evidence, anaysing advantages and disadvantages, and defining knowedge gaps. The construct of the four typoogies is usefu for examining current and past experiences, however it is ikey that the way forward may be through a combination of typoogies, or through the addition of new aternative approaches to inkage or integration. Typoogy 1 Typoogy 2 Typoogy 3 Typoogy 4 Advising on feeding the sick chid within existing iccm services Linkages with Socia & Behaviour Change activities on chid nutrition Linkages between iccm activities and acute manutrition treatment through assessment and referra Treatment at community eve of uncompicated Severe Acute Manutrition

6 06 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 1 Typoogy 1 focuses on providing advice to the caregiver of the sick chid during the sick chid consutation. According to the UNICEF/WHO iccm protoco, the iccm worker advises the caregiver as part of home care. The task is imited to advising (providing information on the recommended behaviour) concerning home treatment of iness (how to give ORS, zinc, antibiotics, antimaarias), and when to return to the CHW or seek medica care. Athough every CHW impementing iccm is supposed to advise the caregiver of a sick chid to continue feeding and fuids, the review found itte data about the quaity or quantity of feeding-reated advice. No data was found on the effect of this advice on the heath status of the chid. Athough the review found no data on cost for this typoogy, it is assumed that costs of strengthening the messaging woud be reativey ow, requiring the review and revision of goba and nationa iccm training manuas and recording forms to ensure that continued feeding of the sick chid is emphasized and made more expicit. Typoogy 1 is probaby the simpest of the four identified typoogies to carry out or strengthen. Typoogy 2, inkages with socia and behaviour change activities on chid nutrition, provides a strong patform for reaching a wide popuation with preventive messages. Many nutrition programmes focus on improving infant and young chid feeding practices through a range of approaches from deivering heath education messages to impementing socia and behaviour change (SBC) activities. Most of the socia and behaviour change experiences reviewed are resource-intensive and require home visits compemented by socia mobiization and mass communication activities. In the UNICEF/WHO iccm materias, information on disease prevention is imited to key advice reated to home care incuding advising caregivers to give more fuids and continue feeding, to seep under bednets in maaria areas, and to ensure fu vaccination. Because messages are tighty context-specific, the impementation of Typoogy 2 impies the avaiabiity off skied personne, as we as adequate finances to carry out the needed formative research and message deveopment. It aso suggests an additiona oad on the iccm CHW to carry out the home visits, athough this coud be avoided this by using different cadres. The evidence identified came from sma to medium size interventions. Typoogy 2 Typoogy 3 Typoogy 3, inkages between iccm activities and acute manutrition treatment through assessment and referra, is aready part of the standard UNICEF/WHO protoco. According to the protoco, iccm workers measure every sick chid over six months of age with a MUAC strap and assess for biatera pitting oedema. An important variation on this typoogy is the use of active screening or active case detection through home visits or at growth monitoring group activities. This aows measurement of every chid, sick or we, and may be the standard in many countries or projects. Despite the incusion of assessment and referra for acute manutrition in the UNICEF/ WHO iccm standard protocos, itte hard evidence was found concerning how we or even whether this action was carried out during a sick chid consutation, the quaity of the assessment, whether the referra advice was foowed, and utimatey whether it resuted in adequate treatment. This typoogy requires a strong programme in pace to treat cases of acute manutrition at heath faciities and a functioning referra system, in addition to a we-trained, extensive network of CHWs. It aso needs the appropriate nationa poicies, protocos, and data systems for both iness management and nutrition, and a supervisory structure to ensure the adequate use of MUAC. Athough there is some indication that active case-finding increases coverage of treatment for chidhood iness, no data was found showing whether the same is true for acute manutrition. Typoogy 4, treatment at community eve of uncompicated Severe Acute Manutrition, has been impemented by severa NGOs and governments adapting CMAM protocos. These experiences fa into two categories: 1) the assessment, cassification and treatment for acute manutrition were added onto the existing responsibiities of the iccm worker, and; 2) the iccm worker was inked to or connected with a second community-based cadre with responsibiities and skis for addressing acute manutrition. The contexts for the various experiences differ widey, ranging from deveopment to emergency in severa different countries. With the exception of Ethiopia, most experiences to date have been (or wi be) conducted at a sma scae with strong supervision. Avaiabe evidence is thus restricted to a smaer number of experiences but provides insight into a arger number of topic areas. In contrast to the previous three typoogies, the review found data on a number of additiona factors incuding time spent by the CHW, cost Typoogy 4

7 07 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 of impementation, and poicy impications. Typoogy 4 is arguaby the most compex of the four identified typoogies. Impications for impementation cover training time, training compexity, quaity of care, supervision, poicy, suppy, costs, and issues of protoco adaptations. In discussing which approaches key informants woud or woud not recommend, community-based treatment of uncompicated severe acute manutrition eicited strong reactions on both sides of the argument. In addition to identifying what was known about integrating nutrition and iccm/ccm, this review sought to identify remaining gaps in knowedge in order to hep focus future impementation and research directions. In contrast to the abundant evidence supporting the need to integrate or ink, and the equay abundant evidence for each of the two domains separatey, the paucity of hard evidence of how inkages coud be done confirms the imited experience. Future work wi need to examine the best combination of actions probaby crossing over the proposed typoogies -- to ensure better coverage of interventions that identify and ensure treatment and prevention of chidhood iness and acute manutrition. The ist of questions put forward in this review is vast but a subset is incuded in the main body of the report. Much of what is not known reates to arge-scae impementation, feasibiity, and the transferabiity of experience from one context to another. One frequent theme arising throughout the review process, in both the desk review and the key informant interviews, is the primordia importance of context; what works in one country or part of a country may not be appropriate for another. There are a number of other common essons that arose from this review: a. The profie of the CHW is decisive. The gamut runs from a paid, iterate CHW with a reativey sma catchment area and a substantia amount of training, to a vounteer, iiterate CHW with a arge number of househods to cover and one week of training. b. The organisation of work and current responsibiities of CHWs hep determine the best approach, for exampe whether the integration of nutrition activities shoud buid on a heath education patform or on a treatment patform. c. A division of responsibiities whereby the CHW who does treatment is compemented by others who do active case-finding, home visits, and/or IYCF messaging has the potentia of increasing coverage whie not overoading one particuar cadre. d. iccm is ony one deivery patform; nutrition coud be added to others, incuding the Expanded Programme on Immunization and antenata care activities. e. The poitica context is aso decisive. In paces with a high prevaence of acute manutrition, ow access to treatment and poor heath infrastructure, for exampe South Sudan, there is a stronger argument for community-eve treatment. At the same time there is more opportunity for the CHW to see acutey manourished chidren and thus to practice and retain the reevant skis. The same argument may appy to areas in emergency situations. f. There is a papabe tension between the nutrition and heath sectors. This tension reates to avaiabe funding (donor attention), funding streams, and management structures. This coud be ikened to a simiar tension often found in iccm between vertica maaria programmes and more horizonta chid heath programmes in countries. The advantages to both sectors of inking shoud be ceary articuated, using terminoogy acceptabe by a concerned. g. Other sectors and concerns must be taken into consideration. Exampes incude gender issues (men are famiy decision-makers), socia protection schemes, and food security. h. Key informants agreed that it was reasonabe to expect a iccm CHWs to assess, refer and counse acutey manourished chidren. There was agreement amongst a number of respondents that iccm coud be an effective patform for reinforcing IYCF messages, strengthening feeding practices during iness, and foowing up acutey manourished chidren. i. Respondents brought up the chaenges of integrating nutrition and heath at the nationa eve, reated to coordination across MOH directorates, funding streams, and the chaenge of ensuring that usefu nutrition indicators were incuded in the Heath Management Information System (HMIS).

8 08 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 I N T R O D U C T I O N & B A C K G R O U N D According to The Lancet Materna and Chid Nutrition Series, 20131, the goba prevaence of chid stunting is sowy decreasing, but in 2011 sti affected at east 165 miion chidren under five years of age. Wasting affected at east 52 miion chidren. Undernutrition, incuding foeta growth restriction, suboptimum breastfeeding, stunting, wasting, and deficiencies of vitamin A and zinc, cause 45% of a chid deaths, some three miion per year. The same series estimates that 90% coverage of eary and excusive breastfeeding pus appropriate compementary feeding coud save as many as 221,000 ives per year; the same coverage of the management of moderate acute manutrition woud save 435,000 ives, and of Severe Acute Manutrition woud save between 285,000 and 482,000 ives. Nutrition is crucia to both individua and nationa deveopment. The evidence in [the Lancet] Series furthers the evidence base that good nutrition is a fundamenta driver of a wide range of deveopment goas. The post-2015 sustainabe deveopment agenda must put addressing a forms of manutrition at the top of its goas. (The Lancet Materna and Chid Nutrition Series, 2013, Executive Summary) Despite the widespread need, ony about 15% of chidren who suffer from Severe Acute Manutrition receive adequate treatment. Even in countries where Community-based Management of Acute Manutrition (CMAM) exists, coverage remains ow with many subnationa services reaching ess than 50% of a cases 2. Chaenge: There is a ong way to go to meet the needed 90% rate of coverage postuated in The Lancet series. Integrated Community Case Management (iccm) of chidhood iness is a strategy to identify and treat the major diseases affecting mortaity in chidren under five years of age. It is based on an interaction during a sick chid encounter. In parae with the approach of Integrated Management of Chidhood Iness (IMCI) at the heath faciity eve, iccm takes a hoistic approach, reviewing a danger signs and providing needed treatment, prevention and foow-up for the chid s condition(s). In most countries, the iccm protoco (foowing the UNICEF/WHO package Caring for the Sick Chid in the Community 3 ) incudes the identification of acute manutrition by measuring Mid Upper Arm Circumference (MUAC) and biatera pitting oedema, and the immediate referra of chidren with Severe Acute Manutrition (SAM). It aso incudes advice on continued feeding of any sick chid treated at home, as we as advice on seeping under bednets and ensuring the correct vaccination status. iccm may be a ogica patform, perhaps currenty a missed opportunity, for increasing the reach and coverage of treating manourished chidren, and potentiay for preventing manutrition. The hypothetica advantages to inking iccm and nutrition services are manifod, given the considerabe overap between disease and manutrition. Interventions to prevent or decrease manutrition or infectious disease are expected to decrease chid mortaity, and interventions that accompish both wi have the greatest effect 4. In many countries, Community Heath Worker (CHW) programmes are in pace. It is cautioned at the outset of this review that shifting tasks and responsibiities to CHWs is sometimes considered by governments and partners as a cost-saving approach to increasing access to care. As wi be described ater, the impementation of effective CHW programmes requires soid support in the form of supervision, training, suppy and ogistics, and functiona referra systems. To ensure that this support is in pace, CHW programmes need to be firmy situated in a process of overa heath systems strengthening. 1 The Lancet Materna and Chid Nutrition Series Executive Summary, 6 June UNICEF/Coverage Monitoring Network/ACF Internationa (2012) The State of Goba SAM Management Coverage 2012 (New York & London, August 2012) 3 This package, pubished in 2011, was designated as the god standard for iccm training by the Steering Committee of the iccm Taskforce 4 Peetier DL et a. Epidemioogic evidence for a potentiating effect of manutrition on chid mortaity. Am J Pubic Heath Aug;83(8):

9 09 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Advantages for the chid and community of inking nutrition and iccm incude: Ensuring more hoistic and comprehensive management of the sick and we chid; Increasing access to acute manutrition services; Increasing efficiency of screening, by using sick chid visits to identify and foow up acutey manourished chidren; Providing a singe point of care for different heath and nutrition services for the caregiver; Earier identification of manutrition, eading to faster recovery times, ower mortaity, reduced need for inpatient care, and ess costy treatment; Providing the CHW an opportunity to communicate the inkages between disease and manutrition. In addition, there are potentia programmatic advantages to inking nutrition and iccm: Integrated services can be more cost-effective. Motivation of the CHW may be improved: since Ready- To-Use Therapeutic Food (RUTF) provides quick, visibe improvements in chidren, job satisfaction and community appreciation for the CHW who treats acute manutrition can increase. It is more ikey that chid nutrition, both curative and preventive, is given adequate attention in chid heath programming, toos and interventions. Merging funding from CMAM-specific and iccm-specific streams may ensure more sustainabe support. Athough it may be interpreted that most of the advantages isted above are seen from the nutrition perspective (what s in it for nutrition programmes?), there are aso firm arguments from the iccm perspective. The chidren most ikey to die from diarrhoea, pneumonia or maaria are those who are ma / undernourished, with manutrition underying one-third of a chid deaths. There is aso substantia evidence that chidren respond better to treatment (e.g. for maaria) if their nutritiona status is addressed. Reducing manutrition shoud aso reduce morbidity (thus reduce caseoad) and reduce the duration of iness. The effort being made to treat Severe Acute Manutrition in Niger is tremendous, and this needs to be supported. The probem in 2012 was that a massive pan for treating Severe Acute Manutrition was prepared and impemented, but it excuded other heath needs, in particuar maaria prevention and immunisations. The response was taiored to the manutrition crisis, and faied to take account of the fact that even if you provide chidren with appropriate nutrition, you can sti ose them to maaria or a respiratory infection which coud have been prevented by a pneumococca vaccination. There is a need for an integrated response, rather than for pushing one response to the excusion of others, which can have a detrimenta effect on the surviva of chidren. Addressing the underying vunerabiity of the chid is ikey to increase the effectiveness of iccm as we. Nutritiona screening activities provide significant opportunities for identifying cases of diarrhoea, pneumonia and maaria and thus increasing coverage of treatment. There are aso significant and obvious disadvantages to inking nutrition with iccm. These cover, most notaby, concerns of overworked, often underpaid (or vounteer) CHW and the famiiar reated issues of sustainabe quaity of the care provided, retention, motivation, supervision, suppy, referra systems, and imited resources. José Antonio Bastos MSF Spain president Apri 2013

10 10 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 About the Review There are mutipe converging and competing points of view on whether and how best to ink iccm and nutrition interventions. The objective of the current review is to map out and describe operationa experiences in inking nutrition and Community Case Management/ integrated Community Case Management interventions, with the goa of identifying emerging essons and identifying gaps in knowedge. The decision to undertake this review was an outcome of a meeting hed in London in May 2014 to examine potentia inkages between iccm, CHWs, and manutrition. That meeting concuded with a statement of intent that nutrition shoud be effectivey integrated into iccm, and an agreement to work towards buiding and sharing the evidence base for effective service deivery in different contexts. Moreover, curiosity about the current status of impementing inked activities had been stimuated at the iccm Evidence Symposium in Ghana in March 2014, with the presentation of a cross-sectiona survey conducted by UNICEF to expore iccm poicy and impementation in sub Saharan Africa. Methodoogy The iterature on iccm and on chid nutrition is vast. Because the present review was carried out with the aim of describing experiences and consoidating avaiabe evidence of programmes or projects that ink iccm and nutrition interventions, the anaysis was restricted as much as possibe to experiences that refect this. This review utiized two principa methods of data coection: desk review and key informant interviews. The desk review aimed to map and describe operationa experiences and existing evidence about inking nutrition and CCM/iCCM interventions. Documents reviewed incuded peerreviewed journa artices, programme reports, goba and nationa CCM/iCCM and nutrition guideines, programme proposas and study designs. Documents were soicited through the review Steering Group 5, CORE Group istserve, iccm Task Force istserve, and goba and regiona offices of WHO and UNICEF. The reviewers sought additiona materias through web searches and individua organisationa contacts. The USAID Materna and Chid Surviva Project conducted a secondary anaysis on data from the UNICEF cross-sectiona survey to determine if any additiona information was avaiabe on nutrition interventions reported in conjunction with iccm. Four countries were seected for more in-depth review: Bangadesh, Ethiopia, Niger and South Sudan. The reviewers sought extensive information on each of these countries from documentation and from key informants. Experiences were reviewed for detais reated to context, interventions impemented, costs, and evidence base. The experiences are: Bangadesh: Save the Chidren project in South Bangadesh (with the Feinstein Internationa Center at Tufts University) Ethiopia: Nationa Heath Extension Programme Niger: Internationa Federation of Red Cross and Red Crescent Societies, French Red Cross, Niger Red Cross South Sudan: Maaria Consortium, Internationa Rescue Committee, Popuation Services Internationa, Save the Chidren 5 Action Against Hunger, UNICEF, WHO, Save the Chidren, Internationa Rescue Committee and Popuation Services Internationa

11 11 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 The focus on a sma number of seected countries was intended to baance the goba scope of the review with a more in-depth and detaied examination of specific programmatic experiences. Countries were identified by the Steering Group, based on prior exporation of programmes with documented operationa experiences inking iccm and nutrition interventions. To suppement and enhance programmatic and impementation-reated information gathered during the desk review, the reviewers carried out 22 key informant interviews. Interviews were conducted using pre-defined questionnaires. The key informants incuded individuas from seven Non-Governmenta Organisations (NGOs), three donor agencies, WHO headquarters staff representing expertise in iccm and in nutrition, and UNICEF offices at headquarters, regiona, and country eves. The origina ist of key informants was provided by the Steering Group, and augmented based on recommendations. Every effort was made to reach a variety of organisations and incude representation of both nutrition and iccm expertise within organisations. A ist of organisations interviewed can be found as Annex 1. For the purpose of this review the foowing definitions were used: Nutrition interventions This term covers a range of actions, incuding one or more of the foowing ist: Identification, referra and/or foow up of acute manutrition cases (severe and/or moderate) Treatment of acute manutrition cases (severe and/or moderate) at faciity Treatment of acute manutrition cases (severe and/or moderate) at home (or in the community cose to home) Deworming Micronutrient suppementation Advising on feeding of the sick chid Advising /counseing on Infant and Young Chid Feeding (IYCF) (incuding eary and excusive breastfeeding and compementary feeding) Community Heath Worker (CHW) Various terms used incude community heath workers, community-owned resource persons, heath surveiance assistants, fied or extension workers, ady heath workers, community drug distributors. Generaizations about the profie of CHWs are difficut, however the main focus of the term in this review is on CHWs as ay (non-medica) heath workers. In various programmes, they may be men or women, young or od, iterate or iiterate, paid or unpaid. iccm vs CCM (integrated community case management vs community case management) The difference is subte. CCM can be case management of any condition, at the community eve. iccm is integrated, not singe-disease, and not combined (e.g. not: first ook for and treat pneumonia, then ook for and treat diarrhoea). It is in many ways a simpified version of IMCI. It has aso, by design, been imited to those conditions that can be fata for chidren and that can be treated reativey easiy: pneumonia, diarrhoea, maaria, pus the identification of acute manutrition. It shoud be emphasized that iccm is not intended to stand aone in its impementation. It is part of a arger set of actions that cover caring for the newborn at home and caring for the chid s heathy growth and deveopment (see box in Discussion section). Linkage/integration These are different ways to describe the connection between iccm and nutrition interventions. iccm in its generic form incudes the identification of acute manutrition using MUAC and oedema of both feet, and referra of the chid to a feeding programme or rehabiitation centre. In this case, the two programmes or types of actions are inked but are not integrated. On the other end of the spectrum is the identification and treatment of acute manutrition by the CHW. This coud be considered integration.

12 12 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Limitations The review examined numerous and assorted documents, ranging from goba poicies and protocos to reports of time-bound or sma-scae projects. The methodoogy and scope of this review present a certain number of important imitations: There is amost no hard data avaiabe on the impact or effect of inking or integrating iccm and nutrition; most of what is avaiabe concerns ony one set of interventions or the other. A reevant data found has been presented in the section on Findings. The nutrition universe is diverse, and there are many expectations on what inkages between iccm and nutrition shoud be or shoud accompish. This increased the chaenge of grouping the key informant interviews into ike statements, and the numerous interviews generated as many questions as they answered. It is aso noted that key informants were argey representatives of agencies; no nationa impementation partners or staff of ministries of heath were incuded. This coud be usefu for a foow-on exercise. The broad definition of nutrition interventions made comparison and generaization across experiences chaenging. Few countries impement iccm at nationa scae, and ony Ethiopia and Rwanda have nutrition integrated at that eve. Neary a information gathered focused on countries in Africa, with the South Bangadesh project as the notabe exception. Some information was aso reviewed from Afghanistan and the Phiippines but this was mosty focused on iccm. There is some indication that Maawi may aso have nutrition integrated at a nationa eve but the reviewers found no documentation to support this. Despite the enthusiastic support of mutiatera organisations and NGOs to request materias through regiona and country networks, the response was ess than anticipated. This may be an indication of the sma amount of written materia avaiabe.

13 13 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 R E V I E W F I N D I N G S The review identified numerous experiences that demonstrate inkages or integration between nutrition actions and iccm. Annex 2, Community-eve nutrition actions identified, shows the breadth and variety of nutrition-reated actions across countries and experiences. The tabe is incuded to demonstrate the eusive quaity of defining nutrition interventions and inkage with iccm. Many actions are imited to identifying and referring acute manutrition; others incude reguar deworming and vitamin A distribution; others cover acute manutrition treatment. Some are stricty IYCF and preventive messaging. In addition, some actions identified are outside the scope of iccm and may or may not be inked programmaticay. Anaysis of impementation experiences brought to ight four categories of approaches to integrating or inking iccm and nutrition. In this review, these categories are referred to as typoogies. These typoogies are not mutuay excusive, and many impementation experiences incude a combination of severa among the four. Typoogy 1 Advising on feeding the sick chid within existing iccm services Typoogy 3 Linkages between iccm activities and acute manutrition treatment through assessment and referra Typoogy 2 Linkages with Socia & Behaviour Change activities on chid nutrition Typoogy 4 Treatment at community eve of uncompicated Severe Acute Manutrition Findings from the desk review are organized according to these typoogies. Under each typoogy there is a description, exampes of impementation experiences, and supporting evidence identified. Key informant views on the types of typoogies or interventions to recommend or not, based on their experience, are summarized in the Discussion section of findings.

14 14 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 1 Description In this typoogy, advice on feeding during iness is provided to the caregiver of the sick chid during the sick chid consutation. The interactions between iness and manutrition in chidren are direct and we documented 6,7. Optima feeding practices support heathy immune function, rapid and sustained recovery, and growth. Optima feeding, during and after iness, is critica not ony for recovery from the current iness but necessary to reduce susceptibiity to future iness and manutrition 8. According to the UNICEF/WHO iccm protoco, the iccm worker advises the caregiver as part of home care. The task is imited to advising (providing information on the recommended behaviour). It does not invove counseing, which impies istening, refecting back and using a probem-soving process. The standard materias recommend that the CHW discuss four main points with the caregiver of any sick chid treated at home (see Figure 1, extracted from the Sick Chid Recording Form ). In principe, this advising is done in any country that impements iccm. Advising on feeding the sick chid within existing iccm services 6 Back RE et a and the Materna and Chid Nutrition Study Group. Materna and chid undernutrition and overweight in ow-income and midde-income countries. Lance 2013; pubished onine June UNICEF. Pneumonia and diarrhoea: Tacking the deadiest diseases for the word s poorest chidren. (2012) 8 LINKAGES. Facts for Feeding. Feeding Infants and Young Chidren During and After Iness Washington DC. USAID. Academy for Educationa Deveopment.

15 15 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Exampes of impementation A iccm protocos and materias considered in this review incude some form of home care advice. An earier review of iccm training materias in ten African countries 9 reveaed that much of the home care advice concerns information on when the chid shoud seek medica care (or return to the CHW), and on the correct use of bed nets. Nutritiona advice for the sick chid in Democratic Repubic of the Congo (DRC), Ethiopia, Liberia, Rwanda, South Sudan and Zambia, covers feeding and fuids for a sick chidren, whie in Madagascar, Mai and Senega this advice is imited to cases of diarrhoea. The training materias reviewed from Guinea incude a separate section on nutrition counseing for the manourished chid; however, advice on continuing feeding and fuids for chidren consuting for diarrhoea, pneumonia or fever is not evident. Supporting evidence identified A study on the quaity of care provided by iccm-trained Heath Surveiance Assistants (HSAs) in Maawi 10 shows that these workers counseed caregivers about the dose, frequency and duration of treatment for over haf of chidren provided ORS, antibiotics or antimaarias (61%), and 81% of caregivers described correcty how to give these treatments. Just over haf (55%) of caregivers of chidren with diarrhoea were advised to give extra fuids and to continue feeding the chid during the iness episode. In the project in South Bangadesh, caregivers were advised on fuids and continued feeding during a sick chid consutation for cases of diarrhoea 11. The project evauation showed that this was done correcty by 81% of iccm-ony CHWs, and 68% of CHWs trained to do iccm and treat acute manutrition, for an overa performance of 73%. The same CHWs provided counseing and feeding information during routine househod visits, which may or may not be considered part of iccm services. In a concept paper to identify effective approaches to reinforce nutritiona counseing within iccm impementation, Save the Chidren states: Research and programme evidence suggest that caregiver and heath worker support of nutrition during and after iness is frequenty suboptima Unequivocay in many contexts, recommended feeding practices are poor, with responsive and active feeding not being practiced. Heath workers sometimes share and reinforce (inappropriate) beiefs, though more frequenty they do not activey provide nutritiona counseing as a part of treatment and foow-up 13. The evidence from Maawi and South Bangadesh is from studies pubished in peer-review journas. Maawi is impemented as a nationwide scae-up; the study cited covers six districts and 131 HSAs. The South Bangadesh experience is a sma-scae tria covering one intervention and one contro Upazia (see Typoogy 4). The information from the ten-country review is descriptive and hypothetica, based on the contents of training materias and panning documents. It is noted that a of the evidence found concerns process: whether and how we certain activities were carried out. No evidence of effect or impact was identified. 9 Review of Integrated Community Case Management Training and Supervision Materias in Ten African Countries, MCHIP Giroy K et a Quaity of sick chid care deivered by Heath Surveiance Assistants in Maawi. Heath Poicy Pan. (2013) 28 (6): doi: /heapo/czs Puett C et a. Does greater workoad ead to reduced quaity of preventive and curative care among community heath workers in Bangadesh? Food and Nutrition Buetin, 33(4), The United Nations University 12 Piwoz E. Improving Feeding Practices During Chidhood Iness and Convaescence. Lessons Learned in Africa Washington, DC, USAID Academy for Educationa Deveopment, SARA project. 13 Persona communication, Save the Chidren

16 16 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 2 Linkages with Socia & Behaviour Change activities on chid nutrition Description Recent anayses of chid growth patterns iustrate that growth fatering (growth rates beow those appropriate for a chid s age and sex, by height and/or weight) in eary chidhood is greater than suggested by previous anayses and starts earier 14. Growth fatering in chidren happens mosty from three to months of age, justifying the scaeup of the promotion of a optima IYCF practices, incuding during iness and recovery. Many nutrition programmes focus on improving infant and young chid feeding practices through a range of approaches from deivering heath education messages to impementing Socia and Behaviour Change (SBC) activities 15. The inkages between these approaches and iccm appear to fit into severa categories: The CHW providing iccm is part of a arger team that incudes vounteers focusing on heath education and prevention. The same programme that manages iccm aso operates socia and behaviour change programmes focused on a arger popuation. Heath education messages, incuding nutrition, are incuded in the curricuum and responsibiities for the iccm CHW. In some cases this situation exists when the iccm responsibiities are added on to a CHW cadre originay focused on heath education. Exampes of impementation There is an overwheming number of SBC experiences that promote improved nutrition practices in countries. This review describes a imited seection that seemed to be inked at some eve to iccm. Bangadesh, Ethiopia & Viet Nam Aive & Thrive The Aive & Thrive programme was impemented on a reativey arge scae in Bangadesh, Ethiopia and Viet Nam (VN). Activities incuded counseing during home visits (Bangadesh, Ethiopia) and at heath faciities (VN), group sessions, mass media and oca media. In Bangadesh, approximatey 1.7 miion mothers of chidren under two received counseing on IYCF by a BRAC frontine worker. The Viet Nam experience is in 15 provinces. In Ethiopia the programme is caed strong and smart famiies and is promoted through the Heath Extension Workers (HEWs) and the Heath Deveopment Army in the four most popuous regions of the country. The eve of inkage with iccm services is not specified in the documents avaiabe, but because iccm is impemented in Bangadesh in the projects described (Essentia Heath Care and Materna Newborn Chid Heath programmes), and in Ethiopia through HEWs, the inkage has been inferred in these two countries. 14 Victora CG et a. Wordwide timing of growth fatering : revisiting impications for interventions. Pediatrics ;125(3). 15 An SBC approach is a strategic, interactive process that aims to change not ony individua behaviours but aso socia conditions. It requires understanding the situation, designing a focused strategy, deveoping interventions and materias, impementing, monitoring, evauating, and adjusting. Source: MCHIP, Chid Surviva Chid Heath Grants Program Technica Reference Materias, Socia and Behavior Change, 2014

17 17 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Nationa iccm Materias in Ten African Countries The ten-country review of iccm training materias found that six countries (Democratic Repubic of the Congo, Guinea, Liberia, Madagascar, Mai, and Senega) provided significant training time focused on disease prevention. Prevention messaging incuding hand washing, excusive breastfeeding, avoiding exposure to indoor air poution, instructions for re-dipping bed nets, and indoor spraying. This prevention advice is generay incuded with the training chapters and agorithms for each specific iness. The materias reviewed for South Sudan aso cover causation and prevention by disease, but specificay state that this information shoud ony be discussed with the caregiver in situations where the chid wi be treated at home. When there is need for urgent referra, prevention shoud not be discussed. In Guinea, the iccm training materias and job aids incude a modue on nutrition, with recommendations defined in six-month age bocks. It is important to note that the origina roe of the CHWs in Guinea was promotive and iccm was ater added on. Source: Review of Integrated Community Case Management Training and Supervision Materias in Ten African Countries, MCHIP 2013 Rwanda experience Word Reief Word Reief is impementing an Innovation Chid Surviva Project ( ) with USAID funding in southern Rwanda. In support of the Ministry of Heath s the Ministry of Heath s Community-Based Nutrition Programme (CBNP) protoco, Word Reief is focusing on addressing the weaknesses in the current behaviour change communication approaches and testing an approach caed Nutrition Weeks to repace the standard cooking demonstrations and nutrition taks. Nutrition Weeks are schedued three times a year at a time when women are ess busy in the fieds. They target pregnant women and a househods with chidren under the age of two (mothers, husbands and grandmothers are encouraged to participate) in order to prevent manutrition. During Nutrition Weeks, participants spend two hours per day for five days in a sma group of up to ten women, focused on earning about the nutrient vaue of oca foods and buiding the reevant skis to incorporate their use into a nutritious diet. Patterned after Positive Deviance/Hearth, the women work together to prepare and feed their chidren age-appropriate, nutrient-dense meas using ocay-avaiabe foods provided by participants. They earn about and practice responsive feeding aong with other behaviours associated with the prevention of manutrition. CHWs reinforce key nutrition messages during home visits. The Word Reief project aso supports CHWs providing iccm services; these same CHWs are among the vounteers running the Nutrition Weeks intervention. Source: Persona communication; MCHIP, Summary of Operations Research within the USAID Chid Surviva Grants Program

18 18 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Supporting evidence identified The review identified the foowing evidence for this typoogy: Word Reief is in the process of conducting operations research on the Nutrition Weeks intervention in Rwanda. Resuts from their third annua report indicate that Nutrition Weeks are effective in promoting behaviour change for better chidren s diet: resuts in the intervention area were 55% higher than in the comparison area for Minimum Acceptabe Diet, a composite indicator that incudes dietary diversity and mea frequency. Responsive feeding remained high at 97% (7% baseine (BL), 96% year 2) in Kaduha (intervention area), and 95% (13% BL, 92% year 2) in Kigeme (comparison). Ageappropriate introduction of semi-soid foods remained consistent at 79% (52% BL, 81% year 2) in Kaduha (intervention) and 75% (58%BL, 79% year 2) in Kigeme (comparison) 16. A process evauation conducted in Bangadesh and Viet Nam by the Internationa Food Poicy Research Institute (IFPRI) in 2013 found sizabe improvements in feeding practices in Aive & Thrive (A&T) programme areas between 2010 and Changes in excusive breastfeeding in intervention areas in Bangadesh were amost 25 percentage points higher than in comparison areas. The percentage of chidren who had minimum dietary diversity amost doubed, from about one-third to two-thirds of chidren in programme areas. No changes were seen in comparison areas. In Viet Nam, excusive breastfeeding rates rose from ess than 20% to more than 60% in A&T areas 17. Evidence from a three countries above was extracted from programme reports and presentations, and represent sma-to-medium-scae experiences. 16 Word Reief Innovation Chid Surviva Project Rwanda, Third Annua Report Menon et a, presentation entited Eary impact assessment of a arge-scae initiative to improve infant and young chid feeding (IYCF) in Bangadesh and Vietnam suggests improvements in IYCF practices and highights importance of potentia to benefit. Internationa Food Poicy Research Institute, 2014

19 19 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 3 Linkages between iccm activities and acute manutrition treatment through assessment and referra Description According to the standard UNICEF/WHO protoco, the iccm worker measures every sick chid over six months of age with a MUAC strap and assesses for biatera pitting oedema. Red MUAC and biatera pitting oedema are danger signs, and the CHW refers the chid to a heath centre for immediate care. There is space on the referra sip to note this. This process is consistent with CMAM recommendations. The treatment protoco for a yeow reading on MUAC is ess we-defined. The CHW shoud refer the chid to a feeding programme if one exists nearby; if this is not possibe, the recommended action is counseing on compementary feeding. An important variation on Typoogy 3 is the use of active screening or active case detection through home visits or at growth monitoring programme group activities. This aows measurement of every chid, sick or we, and may be the standard in many countries or projects. Exampes of impementation According to the ten-country review of iccm materias, it is the poicy in a countries with the exception of Senega to use MUAC to identify manourished chidren within iccm. (Note that the iccm CHW does not have responsibiity for nutrition work in Senega). A countries except Senega and Liberia use a red MUAC reading as a danger sign, thus sending the chid for immediate referra. The potentia ist of exampes is arge. Of the 45 countries in the UNICEF cross-sectiona survey, 31 reported incuding CCM of manutrition. This was defined as screening and referra by CHWs of severe manutrition Rasanathan K et a Community case management of chidhood iness in sub Saharan Africa findings from a cross sectiona survey on poicy and impementation. J Goba Heath, 2014 (in press) The use of active screening or active case detection through home visits or at growth monitoring programme group activities...may be the standard in many countries or projects

20 20 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 South Sudan Maaria Consortium Maaria Consortium worked in two counties in Northern Bahr e Ghaza starting in 2010 focusing on integrating iccm and CMAM. Maaria Consortium worked with two cadres of community vounteers: a iterate Community Nutrition Worker (CNW) trained to provide community-based treatment for acute manutrition (Typoogy 4) and an iiterate Community Drug Distributor (CDD) who was trained to conduct assessment and referra for SAM in addition to providing iccm services. CDDs were provided with a six-day training on diagnosis and management of chidhood inesses, incuding performing and interpreting the MUAC and oedema assessment for undernourished chidren. The CDD gives the caregiver of a chid fitting the cut-off criteria for admission into the Outpatient Therapeutic Programme (OTP) a manutrition referra triange. The referra triange is a aminated picture of the reason for referra (in the case of SAM, the picture is of a chid with a MUAC tape). The chid is referred to the Community Nutrition Worker (CNW) at the nearest OTP for diagnosis and admission into the OTP. Chidren requiring referra under the iccm programme (suffering from a severe case of maaria, pneumonia or diarrhoea and/or presenting with danger signs) are given a referra triange according to their diagnosis (aminated triange with a picture of a case of diarrhoea, pneumonia, or maaria) and referred to the nearest faciity. Additionay, the CNW at either the referra site (OTP) or in the community, screens chidren for manutrition, using the same criteria (MUAC, assessment of oedema). The CNW shoud aso assess the chid for compications of manutrition. If the chid is found to have SAM with compications (unabe to pass an appetite test or presenting with other medica conditions) the chid is referred to the nearest stabiization centre. As the CNW are iterate, they are abe to compete referra forms that are given to the caregiver to present to the nurse at the stabiization centre. The CDDs are responsibe for foowing up referred cases under the iccm component of the programme and the CNWs foow those referred under the OTP component. Source: Persona communication & Keene, E., Learning Paper: Integrating severe acute manutrition into the management of chidhood diseases at community eve in South Sudan, 2013

21 21 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Rwanda Kabeho Mwana Concern Wordwide, Internationa Rescue Committee and Word Reief impemented a five-year programme entited Kabeho Mwana ( Life for a Chid ) in Rwanda. The project was designed to offer community case management of chidhood iness and stimuation of key community-eve heath promotion and disease prevention actions. The programme covered six underserved districts, reaching over one-fifth of the country s estimated 1.5 miion chidren under five. The three NGO partners started in 2006 buiding the Ministry of Heath s capacity to impement IMCI at heath faciity eve, and coectivey trained, equipped, and supervised over 6,000 Community Heath Workers in community case management of pneumonia, diarrhoea, and maaria. In 2009, with the acquisition of additiona funding from a new source, CMAM was integrated into the project. CHWs were trained to conduct active (during home visits and growth monitoring and promotion sessions) and passive (during sick chid consutations) case finding of MAM and SAM using MUAC and/or weight-forage, and referred chidren to the appropriate heath faciities. Chidren with SAM were referred to the heath centre. Chidren with MAM were referred to either Positive Deviance/ Hearth sessions or Community Kitchens depending on the geographic area. Community Kitchens incuded a combination of cooking demonstrations and administration of Ready-to-use Suppementary Food (RUSF). The project aso used Care Groups and CHWs to incude messages on the prevention of manutrition into their behaviour change communication messages (Typoogy 2). Source: Concern Wordwide, Integrating Community Management of Acute Manutrition into Chid Surviva Programs: Concern Wordwide s Experience in Rwanda Niger Red Cross In conjunction with its project Community-Based Nutrition, the French Red Cross has trained vounteers from the Niger Red Cross in 85 viages. These vounteers buid community awareness through messages reating to heath and chid nutrition (Typoogy 2). They hod monthy weighing sessions for chidren aged 0-36 months, and do active screening of chidren months for acute manutrition using MUAC measurement. Chidren with a MUAC under 125 mm are referred to a heath faciity where they are weighed and their height is measured. At the heath faciity, the nutritiona status of these chidren is evauated, and they are treated if they are suffering from Moderate Acute Manutrition (MAM) or SAM. Moderatey acute manourished chidren are systematicay treated with vitamin A, iron, foic acid and mebendazoe; their vaccination status is checked, and the mother is given suppementary food (Corn Soy Bend, oi and sugar in the form of a premix) to prepare as a porridge. In cases of SAM without compications, chidren are given RUTF, administered according to the chid s weight. Source: Persona communication

22 22 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Pakistan Lady Heath Workers According to the Pakistan nationa guideines for the management of acute manutrition among chidren under five and pregnant and actating women, community outreach is carried out by community providers, incuding Lady Heath Workers, Lady Heath Visitors and community heath workers. Community vounteers can aso be recruited to assist with case finding and foow up. In order to reach as many manourished chidren as possibe, community providers must activey identify chidren who need care and refer them for treatment. Chidren can be screened through house-tohouse visits, at heath faciities and outreach programmes, at community meetings, heath campaigns and growth monitoring sessions. Active casefinding and foow up is ongoing. Chidren are identified as manourished using MUAC and assessment for oedema. The criteria used are the same as the admission criteria for OTP and Suppementary Feeding Programme (SFP). This shoud ensure that chidren referred by community providers are admitted to the programme. A simpe referra sip is used. Caregivers who have seen their manourished chidren recover are ikey to be motivated and to encourage others to seek treatment. Some caregivers wi emerge as eaders and can pay an active roe in case finding and in some cases in foow up. Community meetings with stakehoders and focus group discussions with community members and/or caretakers may be hed periodicay to raise awareness about the programme and to investigate any issues such as high defaut. Source: Persona communication Moderate acute manutrition in Mai In Mai, the nationa guideines for community case management incude both iccm and manutrition. Responsibiities are divided between two types of community workers: the reais communautaire (community reay) and the agent de santé communautaire (ASC). The draft Nationa Strategic Pan on Essentia Care in the Community emphasizes the chaenge of community-eve management of moderate manutrition, and incudes a reevant process indicator (proportion of chidren under five presenting with moderate acute manutrition managed correcty by the ASC). The reais communautaire identifies and treats diarrhoea with ORS and zinc, gives advice and demonstrations on various famiy panning methods, and advises on newborn care. He or she aso identifies fever, cough or difficut breathing, and a red MUAC reading, and refers these cases to the ASC. The ASC is attached to a heath faciity. In addition to the tasks of the reais, the ASC aso confirms maaria using a rapid diagnostic test, treats uncompicated maaria with artemisinin-based combination therapy, treats pneumonia with amoxiciin, gives nutrition advice for and treats moderate acute manutrition with ocay avaiabe enriched foods, refers cases of severe manutrition, provides micronutrients and antiparasitics, provides postnata care for mothers and newborns (cord care, therma care, specia care for ow-birthweight babies), refers cases of severe iness, and maintains registers for surveiance purposes. This exampe fits squarey under Typoogy 3, with the variation of CHW-eve treatment of moderate acute manutrition. Source: Pan Stratégique Nationa des Soins Essenties dans a Communauté

23 23 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Supporting evidence identified Despite the incusion of assessment and referra for acute manutrition in the UNICEF/WHO iccm standard protocos, itte hard evidence was found concerning how we or even whether this action was carried out during a sick chid consutation, whether the referra advice was foowed, and utimatey whether it resuted in adequate treatment. Reevant information may be avaiabe in heath faciity surveys (numbers of SAM or MAM cases seen in a heath faciity) or other surveys at a nationa scae. The review found the foowing: Assessments of quaity of care indicate that CHWs may not use MUAC correcty (anecdota evidence indicates that this probem may not be imited to CHWs). For exampe, the UNICEF 2013 evauation of CMAM 19 found that the procedures for taking anthropometric measurements needed strengthening and greater standardization. CHWs did not aways use MUAC effectivey in Pakistan s Khyber Pakhtunkhwa (KP), Nepa and Ethiopia, where the MUAC tape was either too oose or tight, which affected readings. It is noted that other data avaiabe for Ethiopia show that 94% of HEW MUAC cassifications matched the god standard 20. Litte data are avaiabe on actions taken after the chid with a red MUAC reading is referred. This represents an important gap in inkages between the screening and referra process. The Maawi Quaity of Care study showed that HSAs used MUAC in 64% of cases. There was no assessment of the subsequent actions, i.e. whether these chidren were appropriatey referred or counseed, and if they were referred, whether they were admitted for treatment. In Niger, between December 2013 and June 2014, the number of SAM cases identified and referred by CHWs in the Rapid Access Expansion Programme (RaCE) increased from 94 to This represents 5.5% of chidren seen. There is no information in the reports avaiabe about the proportion of famiies who compied with the referras, nor about the treatment received and the outcome. The UNICEF CMAM evauation showed that referras were effectivey impemented in Pakistan s KP where 60% of chidren were referred to the outpatient services by CHWs using a referra sip. However, in the other four countries (Chad, Ethiopia, Kenya and Nepa) CHWs did not record the number of referras, and data indicating percentages of chidren referred or admitted to CMAM services were not avaiabe. In the same evauation, CHWs and heath workers suggested that some caretakers did not foow through on referras because of ong distances to the heath faciity, frequent migrations of the pastora communities, preference for traditiona heaers, and stigmas associated with HIV, poverty and a manourished chid. Simiar observations were made by Pauku et a in Ghana 22. The Kabeho Mwana project in Rwanda provided RUTF to more than 8,000 severe acutey manourished chidren who woud not otherwise have received this service. Project materias state that integrating CMAM into the chid surviva project reinforced community outreach services incuding community assessment, community mobiization, active case finding and referra, case foow-up and referra, and behaviour change communication. They further state that awareness of the probem of acute manutrition has been raised at a eves, and a nationa protoco for CMAM has been deveoped and approved for impementation by the Ministry of Heath Evauation of community management of acute manutrition (CMAM), Goba Synthesis Report, UNICEF May Assessment of iccm impementation strength and quaity of care in Oromia, Ethiopia. Institute for Internationa Programmes and UNICEF, Fina report Word Vision NICe-RAcE Niger 2015, Rapport: 1erjuiet 2013 au 30 juin Pauku B, Akortey Akor S, Neequaye M, Sagoe-Moses I: Report on the Review of the Integration of Community-Based Management of Severe Acute Manutrition into the Ghana Heath Services. Washington DC: FANTA-2 Bridge/FHI 360, Aug/Sept Concern Wordwide, Integrating Community Management of Acute Manutrition Into Chid Surviva Programs: Concern Wordwide s Experience in Rwanda

24 24 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 The Maaria Consortium, South Sudan project recognizes that there are data coection issues with recording the number of referred cases that actuay reach the point of referra. In order to address this, they are working to deveop an effective method of tracking referras and counter-referras from ow-iterate CDDs 24. Athough not directy reated to the detection of manutrition, a heath system strengthening intervention in peri-urban Mai focused on removing access barriers to care through CHW active case-finding, in tandem with the remova of user fees for the poor, strengthened cinica infrastructure, a rapid referra network to ink community members to the heath system, and a package of prevention services addressing conditions of poverty. Unfortunatey the study was unabe to quantify the contributions of CHW active case finding to reducing under-five morbidity and mortaity 25. Finay, it shoud be noted that recommended actions for the CHW foowing a yeow MUAC reading are variabe (see Tabe 1). This may impy the need for a gobay-vetted protoco on the treatment of MAM, or it may refect the context-specificity of using ocay-avaiabe diets. Further information woud be usefu on what happens when a MUAC reading is yeow, and on the successes and chaenges of MAM treatment. t a b e 1 Exampes of poicies for yeow MUAC reading Country DRC Ethiopia Guinea Mai Rwanda South Sudan Zambia Poicye refer moderate manutrition cases to a heath faciity refer to targeted suppementary feeding programme (Food Distribution agents) at Woreda eve to receive corn soy bend and oi; assess the chid s feeding according to the food box, counse the mother, and foow up in five days (or 30 days if no feeding probem detected) training materias show ony red or green on the MUAC strip, but CHWs have mebendazoe and vitamin A to use if instructed to do so by the heath worker the CHW treats moderate manutrition at the heath faciity; guideines aso incude abendazoe, iron, foic acid, and vitamin A training materias suggest the use of iron foate suppements for moderate manutrition, but refer the chid to the heath faciity unti this becomes avaiabe at community eve Advise caregivers on infant feeding and foow up to see if the recommendations have been appied appropriatey advice to give for a yeow MUAC reading is in the training manua but not on the recording form Evidence for Typoogy 3 was extracted from peer-review journa artices, quaity of care studies, programme impementation reports, and muti-country evauation documents. These represent a range of scae of impementation and of types of support provided. 24 Persona Communication 25 Ari D. Johnson et a, Assessing Eary Access to Care and Chid Surviva during a Heath System Strengthening Intervention in Mai: A Repeated Cross Sectiona Survey. PLoS ONE 8(12) e81304

25 25 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 4 Treatment at community eve of uncompicated Severe Acute Manutrition Description In this typoogy the CHW assesses, cassifies, treats and foows up cases of uncompicated severe acute manutrition at the home. It is important to note that compicated SAM cases are aways referred to an in-patient faciity. It is aso important to note here that the review found experiences and evidence reated to assessment, treatment and foowup, but not reated to additiona eements of disease management such as prevention of reapse. Severa NGOs and governments adapted CMAM protocos to extend acute manutrition treatment to the community eve. These experiences fa into two categories: 1 The assessment, cassification and treatment for acute manutrition were added onto the existing responsibiities of the iccm worker. 2 The iccm worker was inked to or connected with a second community-based cadre with responsibiities and skis for addressing acute manutrition. In the experiences reviewed, the South Bangadesh project and the Ethiopian Heath Extension Programme fit in the first category. Maaria Consortium, South Sudan fits in the second category with a Community Drug Distributor for iccm and a Community Nutrition Worker for acute manutrition. In an additiona variation on impementation, it shoud be noted that in Ethiopia the HEW treats acute manutrition at a fixed ocation (heath post), whereas in the South Bangadesh and South Sudan experiences the treatment takes pace in the community or home. Whist it is acknowedged that the ocation of the services may infuence access and performance of services, there is presenty insufficient data to provide a more detaied anaysis of each approach. Exampes of impementation Tabe 2 provides an overview of seected experiences (both impemented and panned) for providing SAM treatment at the community eve. The tabe provides a comparison of the various country/programme contexts. Annex 3 provides additiona information for these same experiences with a comparison of CHW and programme profies.

26 26 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 t a b e 2 CHWs providing treatment for SAM: Country Context Note: Last three are in design/proposa stage and are expected to be impemented in 2015 Experience Govt/ Scae Location SAM Rates Context Compementary NGO OF TreatmeNT (Emergency/ Cadres Deveopment) Ethiopia Heath Govt Nationa At heath post for 2.7% deveopment Heath Deveopment Extension otp services and (mini EDHS 2014) Army (or 1 to 5 Programme community for at network = 1 femae screening active hda for 5 househods) - vounteers for case finding, heath education& foow-up South Bangadesh NGO 261 CHWs in Community N/a deveopment N/A Save the Chidren one district of one Upazia South Sudan NGO 50 CNWs in iccm is community Very high Emergency; Vounteer Community Maaria Consortium two counties; (home) based, OTP Chronic Drug Distributors 1683 CDDs is a mixture of emergency providing iccm for heath faciity and overaid with maaria, pneumonia, community (home) spasmodic diarrhoea and based acute assessment for emergencies manutrition at community eve South Sudan NGO 1 county: 619 Community Very high Emergency Community Nutrition Internationa viages (630 Vounteers who Rescue Committee Community- conduct mass Based screening and referra distributors (CBD s), 41 CBD supervisors) Pakistan Lady Govt/NGO 15 per Community % Deveopment N/A Heath Workers Union Counci in 2012 Action Against Hunger Mai Agent Sante Govt/NGO 1 CHW in Community 1.5% to 3.5% Deveopment Reais Communautaire Communautaire each town in Kayes - vounteers for Action Against with >1500 R region heath education Hunger inhabitants and and screening at more than 5km from heath Centre

27 27 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 It is recognized that the contexts for the various experiences differ widey, ranging from deveopment to emergency in severa different countries. With the exception of Ethiopia, most experiences to date have been (or wi be) conducted at a sma scae with strong supervision. In severa cases, the iccm worker is compemented by another community-based cadre that focuses on heath education and prevention. Maaria Consortium, South Sudan is the ony exampe where treatment of acute manutrition and iccm were spit into two different cadres at the community eve. Some of the exampes have buit (or wi buid) on a paid government cadre with an eighth to tenth grade education and extensive training. Exceptions to this are the South Sudan experiences where Maaria Consortium is using iterate vounteers and Internationa Rescue Committee (IRC) is panning to train iiterate vounteers. IRC is currenty in the process of adapting a protoco for iccm with acute manutrition for use by iiterate vounteers to be pioted in a research project in South Sudan. The experiences from South Bangadesh, Angoa, South Sudan and Ethiopia are further described beow. Whie the Angoa experience does not ink with iccm, the treatment of acute manutrition by community heath workers is incuded in this review for the evidence it demonstrates on CHW capacity. South Bangadesh The South Bangadesh experience was a prospective cohort study to examine the feasibiity and effectiveness of adding SAM treatment to the CCM package aready being impemented in one Upazia. It was ed and supported by Save the Chidren, Pepsico, Goba Aiance for Improved Nutrition (GAIN), and Tufts University. Profie and training: Seected CHWs had been previousy trained in preventive care and counseing (incuding nutrition), then had a 3-day training on the identification and treatment of diarrhoea and pneumonia (note: not maaria). Before adding the SAM component, a CHWs had at east two years of experience. The SAM training asted two days. Activities: CHW SAM activities incuded active case-finding (MUAC and checking for oedema) either during growth monitoring sessions or home visits, and treatment of uncompicated cases. A chidren under three years of age were screened monthy. Each CHW covered househods, or about 900 peope. CHWs made househod visits per week for iccm. This increased to for iccm + SAM. Most iness treatment was done during home visits; some but not many mothers brought chidren to the CHW s home for iness. The CHWs managed and distributed RUTF as we as antibiotics and foic acid, and foowed up each chid weeky. During the impementation period, the CHWs woud bring paperwork to the supervisor (in a community setting) once a month at which time they were given probem-soving-based refresher training and support. In addition there was a bimonthy two-day refresher course, about 25% of which was spent on SAM issues. Supervision: Supervisory visits were carried out one to two times per month. These visits were by reguar supervisors and by a team of programme officers specificay hired by the NGO to provide technica guidance for CCM and SAM. The supervisory ratio was one to CHWs, beow the optimum eve 1:10 or 1:20 recommended in poicy iterature. The Upazia heath centre medica staff were trained to support the CHWs. RUTF was suppied by the NGO.

28 28 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Angoa Word Vision The Word Vision CMAM programme was impemented in Angoa in response to high rates of Goba Acute Manutrition (GAM) foowing the 2012 drought. Due to weak heath infrastructure and a ack of access to heath centres, activities incude recruiting and training Community Heath Activists (CHAs) to screen chidren for acute manutrition, provide treatment and referras, and deiver nutrition education. The strategy of using CHAs was simiar to that for community case management of chidhood iness. On average, the project had 2,044 active CHAs, with each CHA serving an average of two to five viages. The project covered 76 Communas in 21 municipaities. Conducted in ate 2013, an independent evauation found that actions had been successfuy impemented, with coverage estimated at 82.1% in areas reached by the programme, and the cure rate for SAM being 93.8%. The CHA approach made CMAM more accessibe to the communities, and strong advocacy by impementing partners increased the profie of manutrition within the nationa government. Some chaenges incude: inconsistent suppy of the Ready- to- Use- Therapeutic Food, inadequate numbers of CHAs to cover a target areas and uncear incentive protocos. However, very few projects to date have impemented CMAM using this type of approach, and the Angoa experience demonstrates the potentia particuary in contexts where heath system capacity is very ow. Further research is recommended to refine this approach and to identify soutions to impementation chaenges. Source: Word Vision, Community-based Management of Acute Manutrition Using Community Heath Activists in Angoa, Nov December 2013 Angoa Report

29

30 With the exception of Ethiopia,most experiences to date have been (or wi be) conducted at a sma scae with strong supervision.

31 31 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 South Sudan Maaria Consortium South Sudan became a country in 2011 foowing a five year transition period. Decades of confict have ed to a coapse of basic infrastructure. The ack of infrastructure is overaid with a range of acute crises resuting from fooding, disease outbreaks and renewed ocaized and internationa conficts eading to in a arge popuation movement and dispacement. There is a very arge burden of SAM and GAM. Maaria Consortium worked in two counties in Northern Bahr e Ghaza starting in 2010 to address Severe Acute Manutrition and iccm. They buit on an existing patform of Community Drug Distributors (CDDs) providing iccm for maaria, pneumonia, and diarrhoea. Since CDDs were argey iiterate, Maaria Consortium initiay trained iterate, vounteer CDD supervisors to manage the OTP sites. In an interna evauation, they found that supervisors didn t have the time to manage both iccm supervision (a mobie task) and run the OTP sites. In phase two, a separate cadre, Community Nutrition Workers (CNWs) were recruited and trained to manage SAM treatment at communitybased OTP sites. The CDDs continued to provide case findings and referras to the OTP sites in addition to their iccm duties. Profie and training: The Community Nutrition Workers are iterate vounteers recruited from the community. They are provided with a fiveday initia training. They receive refresher training on a quartery basis and on-the-job training during supervision visits. Activities: The CNW spends two days at the OTP site and three days in the community. In their community time, they provide heath education on preventing manutrition and active case finding (MUAC screening and assessment of oedema, referra to the OTP according to the protoco, and informing caregivers of OTP hours). CNWs aso provide home visits for foow up of referred cases. They provide heath education and hygiene promotion to caregivers of undernourished chidren, providing essentia education on good nutrition, when to bring the chid back, importance of breastfeeding, basic hygiene incuding preparation of food, hand washing and safe disposa of chid faeces. Supervision: Five paid OTP nutritiona officers/ supervisors directy supervise CNW vounteers each. CNWs receive a minimum of two interactions with supervisors per month. These supervisory interactions take pace when the CNWs visit the heath posts to restock their commodities and during monthy data coection. During this visit, supervisors take the opportunity to incorporate on-the-job training. Additionay, supervisors try to visit two to four CNWs per week to provide on-the-job supervision in their communities and foow up sick/ referred chidren. CNWs are vounteers; however they receive cash incentives of 300 South Sudanese Pounds per month. A performance-based eement was introduced into the CNWs incentive structure in Phase 2. CHW cash incentives became dependent on the provision of competed reports within the expected time frame to the expected standard. They are aso suppied with commodities to assist the CNW in their daiy work; ex. a medica box to secure medica and nutritiona suppies, materias to provide heath education to caregivers of undernourished chidren whist waiting for admission into the OTP, gum boots, rain coats. Source: Keene, E., Learning Paper: Integrating severe acute manutrition into the management of chidhood diseases at community eve in South Sudan, 2013 & Persona communication

32 32 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Ethiopia Nationa Heath Extension Programme The Ethiopia Nationa Heath Extension Programme began in The core of the programme is the construction of Heath Posts in a of the estimated 15,000 kebees (viages) in Ethiopia and the training and assignment of two Heath Extension Workers (HEWs) in each Heath Post. Profie and training: HEWs are ocay-recruited women with tenth-grade education. They are trained for one year, and are formay empoyed and saaried. Reevant activities: Overa, the HEW deivers 16 packages of services incuding heath promotion, immunization, famiy panning, hygiene and sanitation and other disease prevention measures, as we as a imited number of highimpact curative interventions. iccm covers five major kiers of chidren under five; pneumonia, newborn probems, diarrhoea, maaria and Severe Acute Manutrition. In iccm, HEWs provide deworming, vitamin A suppementation, and identification of anaemia by pamar paor. There are a number of preventive interventions. They aso treat SAM in the heath post; CMAM grew out of the Community Therapeutic Centre (CTC) work done during the 2003 nutrition emergency. CMAM currenty covers community outreach/ mobiization, OTP and Stabiization Centre or Inpatient care, and in some cases MAM management depending on resource avaiabiity. CMAM is part of the nationa CMAM programme supported by different partners, except for the MAM component 26. Community outreach consists of active case finding, referra, admission and home foow-up. HEWs and Heath Deveopment Army (HDA) vounteers (one per five househods) conduct community screening with MUAC and oedema check for eary case finding using three contact points: house to house visit, during outreach and at the heath post when chidren come for basic curative and preventive services. The HDA vounteers refer SAM cases for admission to OTP, give basic nutritiona advice to mothers, and provide home foow up weeky for cases and aso for finding defauters. The HEWs conduct an appetite test and manage uncompicated cases; this incudes RUTF, antibiotic, mebendazoe if needed, and foow-up after one week. Manutrition is broken out into four categories: Severe compicated manutrition, underweight, severe uncompicated manutrition, and MAM. Various combinations of treatments incude vitamin A, amoxiciin, treat to prevent ow bood sugar, RUTF, registration in outpatient therapeutic programming, mebendazoe, referra to suppementary feeding programme, and counseing 27. Supervision: HEWs receive ski-enhancing supervision monthy by the heath centre staff, and quartery by the Woreda eve. This is compemented by four supervisory visits focusing on programme issues, two by centra-eve staff and two by Woreda eve 28. A study in two regions 29 found that HEWs spent 51% of their working time at the heath post and 37% in the community. About 16% of time was spent on curative heath activities and 43% on heath promotion and prevention. The remaining time incuded trave, training and supervision, administration, and community meetings. HEWs spent the majority (70%) of their time with individuas, famiies, and community members. 26 Evauation Of Community Management Of Acute Manutrition (CMAM) Ethiopia Country Case Study, UNICEF Review of Integrated Community Case Management Training and Supervision Materias in Ten African Countries, MCHIP Ethiopia Nationa Impementation Pan for Community-based Case Management of Common Chidhood Iness 29 Mangham-Jefferies et a. How do heath extension workers in Ethiopia aocate their time? Human Resources for Heath 2014, 12:61

33 33 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Supporting evidence identified South Bangadesh: This study confirmed that the CHW-based diagnosis and treatment of uncompicated SAM increased the proportion of manourished chidren that access care, with a high ikeihood of recovery. The coverage rate reached 89%, and recovery of SAM cases was 92%, with a defauter rate of 7.5% 30. It is postuated that the high recovery rate was due in part to the eary detection of SAM through active case-finding, and thus fewer compications. In addition, monitoring data for the comparison areas showed that chidren who were identified as SAM and referred to an OTP centre often did not compy with the referra advice; those who were treated at an OTP centre shoud be ikey to compete treatment. The workoad increased significanty after the addition of SAM treatment to the responsibiities of the CHW. Despite this, the quaity of CHW performance was not affected. The quaity of disease management (iccm) as measured by case scenarios, remained high. Median adherence to guideines for managing pneumonia was 87.5% and did not differ significanty between those CHWs doing ony iccm and those doing both iccm and SAM. Preventive tasks were aso carried out with simiar quaity between the two groups, athough those CHWs doing SAM scored somewhat higher 31. In a reated pubication, Puett et a 32 concuded after observing 55 cases that CHW treatment of SAM was aso of high quaity. Fifty eight percent of the CHWs made no errors, and 89% carried out 90% of tasks correcty. In contrast to information reported under Typoogy 3, neary a the CHWs observed used and read MUAC correcty. In addition, caretaker satisfaction was high, with an exceent eve of trust having been buit between the CHW and the catchment popuation. Ethiopia: There is strong integration between CMAM, Integrated Management of Neonata and Chidhood Iness (IMNCI), iccm, Community-Based Nutrition (CBN) and immunization services. Community mobiization for a these services is carried out through simiar modaities and systems using the same community heath workers. An evauation carried out by the Institute for Internationa Programs at Johns Hopkins University (IIP-JHU) 33 in two zones of Oromia found that 53% of chidren were correcty assessed for iccm conditions and 64% were correcty treated. This compares favouraby to care provided by community-based heath workers in other countries as we as to higher-eve heath workers in Ethiopia. At the same time, chidren with manutrition were correcty cassified for manutrition ony about haf the time (53%). The most common errors were not checking for oedema and not carrying out the appetite test. In an interesting twist, chidren with uncompicated manutrition were generay managed correcty (59%), whether or not they had been correcty cassified. On the other hand, chidren with compicated manutrition were usuay managed incorrecty, regardess of whether cassification was correct. The IIP-JHU review identified severa additiona areas that woud benefit from improvement, incuding the assessment of danger signs, referra of chidren with severe iness, management of compicated manutrition, and provision of vitamin A and mebendazoe. 30 Sader K et a. Community case management of severe acute manutrition in southern Bangadesh : an operationa effectiveness study. Medford : Feinstein iinternationa Center, Tufts University. 31 Puett C et a. Does greater workoad ead to reduced quaity of preventive and curative care among community heath workers in Bangadesh? Food and Nutrition Buetin, 33(4): 2012, the United Nations University. 32 Puett C et a. Quaity of care for severe acute manutrition deivered by community heath workers in southern Bangadesh. Materna and chid nutrition (2013) Mier N et a Integrated Community Case Management of Chidhood Iness in Ethiopia: Impementation Strength and Quaity of Care. Am J Trop Med Hyg. Aug 6, 2014; 91(2): doi: / ajtmh

34 34 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 South Sudan: Maaria Consortium produced a Learning Paper detaiing essons earned and recommendations based on an interna evauation of their Phase 1 impementation. The Learning Paper reported high programme performance, with cure rates of 89-94%, and defaut rates of 2-6% 34. Whie there were no programme evauations avaiabe for review, the project coects routine monitoring data and bi-annua Standardized Monitoring and Assessment of Reief and Transition (SMART) survey assessments. In contrast to the previous three typoogies, the review found data on a number of additiona factors for Typoogy 4. These incude time spent by the CHW, cost of impementation, and poicy impications. Time: The review identified two exampes of time anayses: The Puett et a evauation in South Bangadesh showed that, for CHWs who aready conducted home visits as part of their typica responsibiities, the addition of SAM management added three to four visits per week, for an overa time difference of about three hours per week. The data did not differentiate between time spent on case-finding and on case management, athough much of the additiona time was spent foowing up on SAM cases. The Ethiopia study reveaed that HEW spend 5.5% of their time on nutrition, of which more than haf is curative activities. Just over 7% of time is spent carrying out iccm. Cost: The current review identified two exampes of costing in situations where SAM treatment is integrated with iccm: the South Bangadesh study, and the UNICEF-ed evauation of CMAM in Ethiopia. The South Bangadesh study showed that CCM of SAM cost US $180 per chid recovered and US $26 per Disabiity-Adjusted Life Year (DALY) averted. This is simiar to other priority heath interventions (immunization, TB treatment), eading to the concusion that the intervention is costeffective. The two items that represented the greatest costs were RUTF (incuding storage and shipping), for 24%, and management (incuding saaries and overheads) for 53%. In Ethiopia the cost per treated SAM case, excuding routine drugs, was estimated to be US $110. If fixed heath service costs were removed, the cost per chid was about $73. The cost associated with the RUTF comprised about 50% of the cost per chid; and 33% was for cinica services. Poicy and Protoco: There are a number of potentia impications for nationa poicy and protoco when considering CMAM impementation at the community eve. These cover the use of the appetite test; dosages of RUTF; discharge criteria; poicies concerning CHW prescription and dispensing of specific medications; avaiabiity of medications in appropriate formuations. These are presented in the Discussion section of this report. Evidence for Typoogy 4, simiar to that for Typoogy 3, was extracted from peer-review journa artices, quaity of care studies, programme impementation reports, and muticountry evauation documents. Typoogy 4 evidence is restricted to a smaer number of countries but provides insight into a arger number of topic areas. 34 Keene, E., Learning Paper: Integrating severe acute manutrition into the management of chidhood diseases at community eve in South Sudan, 2013.,

35 35 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 D I S C U S S I O N As an introduction to the typoogy-by-typoogy discussion, Tabe 3 presents seected advantages and disadvantages for each of the four typoogies, and a set of reevant questions. The discussion of findings is presented by typoogy, with key informant feedback incuded at the end of each. Across the board, respondents brought up the importance of context for recommending any particuar typoogy. Informants cautioned that there was a great dea of variabiity across iccm deivery patforms, as we as across nationa poicies for CHWs incuding payment, training, profie, size of catchment areas, and other responsibiities. They discussed the importance of understanding the country situation and system before attempting to ink or integrate. The dearth of hard evidence avaiabe to support any specific typoogies was frequenty mentioned. One genera objective of inking iccm and nutrition interventions is to increase coverage of treatment for acute manutrition. Interventions faing under Typoogies 1 and 2 focus on prevention and woud not address this objective. Passive and active case-finding under Typoogies 3 and 4 woud be expected to increase coverage. No data was found to support this assumption. However, a comparison of outcomes between the intervention and contro popuations in South Bangadesh shows that those chidren treated by a CHW had a 92% cure rate, whie those referred to care at a heath faciity had a cure rate of ony 1.4%. In the referred group, 53% refused referra (Sader et a), in part because many of the caretakers receiving referras faced barriers to accessing faciity-based care, incuding the cost of treatment and ack of trust in the services at the heath faciity 35. These numbers, couped with the coverage rates (89% in the intervention area, and an estimate of ess than 5% in the contro area 36 ) indicate that providing treatment cose to home can have a significant positive effect. Mozambique Nationa CHW Programme The current experience in Mozambique is a demonstration of a combination of Typoogies 1, 2 and 3. The Ministry of Heath (MOH) is aiming to harmonize various cadres of community based heath workers into one. The MOH-supported CHW, caed Agente Poivaente Eementar (APE) receives four months of training and is paid a stipend of about US$ 40 per month. At the time of this writing the stipend is paid by the government, with specific support from partners in seected provinces or districts, with the vision that the APEs wi be eventuay absorbed into the Government s payro. Each APE covers a defined number of househods, and provides a package of preventative/ educationa and diagnostic actions (for maaria and acute manutrition). The APE aso provides curative services for maaria, diarrhoea, and pneumonia. After a recent review, proposed changes incude the addition of vitamin A suppementation (approved) and in the future counseing and testing on TB and HIV, and famiy panning services. Discussion on incorporating the treatment of acute manutrition is ongoing. If this is agreed, the experience in Mozambique wi cross a four Typoogies in this review. Source: Persona communication, Maaike Arts, UNICEF, and Mozambique APE fip-chart 35 Puett C, Aderman H, Sader K et a. (2013) Sometimes they fai to keep their faith in us : community heath worker perceptions of structura barriers to quaity of care and community utiisation of services in Bangadesh. Matern Chid Nutr (e-pubication ahead of print version). 36 Mark Myatt, persona communication

36 36 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 t a b e 3 Advantages, Disadvantages and Information Needs by Typoogy Typoogy Advantages Disadvantages/risks Types of information needed 1 1 Advice on feeding sick chid Advising on feeding the sick chid within existing iccm services Aready incuded in iccm process and training materias Low cost to impement Limited reach (ony sick chidren during consutation) Unknown effect (content) Does the CHW foow the iccm guideine and give adequate advice (content and process)? If not, why not? Do caregivers foow the CHW s advice? Does this have any effect (does the advising ead to improved nutritiona status)? Coud the iccm protoco be modified to improve the content and process? 2 Linkages with Socia & Behaviour Change activities on chid nutrition Proven effectiveness of IYCF messages through SBC Potentia wide (popuation-based) reach Avaiabiity of UNICEF/ WHO materias for CHWs Addressed prevention of / risk factors for manutrition Time and resource-intensive Requires expertise to deveop appropriate messages Compex: home visits or interpersona communication compemented by socia mobiization and mass communication Requires strong coordination between iccm impementation and SBC activities Is it reaistic to expect one CHW to do iccm and promote IYCF? Or is it better to have at east two cadres? What woud be the costs and effectiveness for each option? How cose does the ink need to be between iccm and SBC? Does IYCF messaging have an effect on nutrition behaviours and nutritiona status? Which has the greater impact: integrating iccm and SBC, or SBC standing aone? Does a foow-up visit to a sick chid provide a specific opportunity for SBC activities? What ski sets are needed to combine curative and preventive activities? What are the best modes for training (incuding sequencing)? 3 Linkages between iccm activities and acute manutrition treatment through assessment and referra Aready incuded in iccm process and training materias Low cost to impement Can be augmented by active case-finding Requires strong, functiona referra and counter-referra system Requires avaiabiity and accessibiity of adequate care for acute manutrition in heath faciities What is the added vaue of referra through iccm, compared to referra by nutritionfocused CHWs or mechanisms? (measured by a comparison of competed referras) Is referra advice foowed? What strategies coud be impemented to improve referra mechanisms? How can admission criteria for treatment best be harmonized between assessments made by the CHW and by the referra site? What is the quaity of CHW/iCCM assessment of acute manutrition (MUAC, oedema)? Does active case-finding aone increase coverage? Are resuts different if case finding is carried out by the iccm worker or by a specific nutrition cadre? How can the assessment and referra skis of the CHW be improved and sustained? 4 Treatment at community eve of uncompicated Severe Acute Manutrition No need for referra, thus potentia to increase coverage of treatment for acute manutrition Reinforces ink between nutrition and disease May increase community and CHW satisfaction Additiona time and workoad burden on CHW Quaity of care (iccm and/ or acute manutrition) coud be compromised Training time and compexity increased Costs Logistics of RUTF suppy Supervision Nationa poicy on CHW use of antibiotics Requires equivaent treatment poicy and practice at CHW and heath faciity treatment sites (e.g. admission criteria) How much additiona time woud be needed per day/week to manage cases of SAM? Does the additiona workoad affect the quaity of service deivery? How much additiona training woud be required? Can the acute manutrition treatment (SAM, MAM) protocos be simpified for use by CHWs (parae to IMCI protoco simpified to become iccm)? This woud incude medication, RUTF dosages, and materias adapted for ow-iterate workers. Can CHWs carry out the necessary additiona tasks to assess the chid s potentia for SAM treatment (appetite test, weight-for-height)? Woud active case-finding be an important eement to add or is the sick chid visit (initiated by the caregiver) enough? What is the added vaue in terms of coverage of services, cost-effectiveness, and treatment outcomes? Operationa issues to be investigated incuding suppy chain management when RUTF is introduced; minimum caseoad to ensure quaity of care; typoogies of CHW, size of catchment popuations; impact of treating acute manutrition on motivation of CHW; minimum eve of supervision.

37 37 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 1 Discussion Typoogy 1, advising on feeding the sick chid within existing iccm services, is probaby the simpest of the four identified typoogies to carry out or strengthen. Since the advising guidance is incuded in the UNICEF/ WHO iccm materias, there are no issues concerning poicy or protocos. Athough every CHW impementing iccm is supposed to advise the caregiver of a sick chid to continue feeding and fuids, the review found itte data about the quaity or quantity of feeding-reated counseing. No data was found on the effect of this advice on the heath status of the chid. Given the compexity of actions needed to assess and treat a chid, it may be postuated that there is a imit to how much the CHW can do and how much information a caregiver can absorb at one time. This may be even more significant given the scenario of a worried caregiver. In order to avoid an overoad of information and tasks at a sensitive moment in time, it may be more reaistic to reinforce the advice on feeding during a foow-up visit, at the chid s home or at the CHW heath post. At that point in the process, messages coud be more specific, for exampe encouraging increased breastfeeding for any chid under two years od, and appropriate compementary foods for those over 6 months. Athough the review found no data on cost for this typoogy, it is assumed that costs of strengthening the messaging woud be reativey ow, requiring the review and revision of goba and nationa iccm training manuas and recording forms to ensure that continued feeding of the sick chid is emphasized and made more expicit. It may aso mean revising training and supervision toos. This coud have impications for formative research to target specific probems, and for the time, exercises and skis needed for adequate training. It shoud be emphasized that the reach of this typoogy is imited, targeting ony those caregivers who consut the CHW for a sick chid. Key informants did not raise any issues reated to this typoogy.

38 38 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 2 Discussion Typoogy 2, inkages with socia and behaviour change activities on chid nutrition, provides a strong patform for reaching a wide popuation with preventive messages. In contrast to Typoogy 1, the potentia reach is vast, and there is some evidence of effect and impact. It is recognized that socia and behaviour change activities may be beyond the purview of iccm, and may be the responsibiity of nutrition programmes or a heath education unit. Most of the socia and behaviour change experiences reviewed are resource-intensive and require home visits compemented by socia mobiization and mass communication activities. Because messages are tighty context-specific, this impies the avaiabiity of skied personne, as we as adequate finances to carry out the needed formative research and message deveopment. It aso suggests an additiona oad on the iccm CHW to carry out the home visits, athough this coud be avoided this by using different cadres, as is being done in Ethiopia. When asked about recommended approaches for inking or integrating nutrition and iccm, some key informants brought up community-based education around IYCF. Some informants focused on the importance of prevention, whie others expressed concerns about the chaenges invoved in changing behaviour and the resource intensiveness of approaches such as breastfeeding support groups. In genera, when respondents taked about prevention and IYCF, they were not discussing integration with iccm. In the UNICEF/WHO iccm materias, information on disease prevention is imited to key advice reated to home care incuding advising caregivers to give more fuids and continue feeding, to seep under bednets in maaria areas, and to ensure fu vaccination. Other preventive messages were excuded from this package to maintain the focus of the consutation for the sick chid on the immediate care for that chid. As shown in the box, the other two parts of the package contain a strong nutrition component. Each of the three parts requires five days of training. This is in stark contrast to the ASC training in Mai, for exampe, where nutrition has a two-hour sot in a 15-day training. Caring for the Newborn at Home: Caring for the Chid s Heathy Growth and Deveopment: Caring for the Sick Chid in the Community: During five schedued home visits the CHW: promotes antenata care, and skied care at birth teaches good sef-care during pregnancy counses on care for the newborn in the first week of ife recognizes and refers any pregnant woman or newborn with danger signs to a heath faciity provides specia care for ow-birth-weight babies During home visits, in a viage cinic, or during other opportunities for interaction, the CHW counses famiies on practices that they can carry out at home for: infant and young chid feeding chid deveopment (through communication and pay) famiy s response to a chid s iness iness prevention (immunization, handwashing, use of treated bednets) The CHW assesses, cassifies and treats sick chidren age 2 months to 5 years. The treatment interventions incude the use of four simpe medicines: an antibiotic, an antimaaria, Ora Rehydration Sats (ORS) and zinc tabets. The CHW: assesses sick chidren identifies and refers chidren with danger signs to a heath faciity treats pneumonia, diarrhoea & maaria identifies and refers chidren with severe manutrition advises on home care and prevention of iness refers chidren with other probems that need medica attention

39 39 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Typoogy 3 Discussion Impementation of Typoogy 3, inkage via assessment and referra of acute manutrition, requires a strong programme in pace to treat cases of acute manutrition at the heath faciities and a functioning referra system, in addition to a we-trained, extensive network of CHWs. It aso needs the appropriate nationa poicies, protocos, and data systems for both iness management and nutrition, and a supervisory structure to ensure the adequate use of MUAC. In some countries, there may be additiona advocacy needed to simpify admission criteria for referra. The Maaria Consortium in South Sudan negotiated a modification to the nationa protoco to adjust admission criteria to be based on MUAC and oedema ony. Typoogy 4 Discussion Typoogy 4, treatment of acute manutrition at community eve, is the most compex of the four identified typoogies. Impications for impementation cover training time, training compexity, quaity of care, supervision, poicy, suppy, costs, and issues of protoco adaptations. Training time: the UNICEF/WHO standard iccm training asts five to six days, with a significant proportion of that time spent in cinica practice. Adding training on management of acute manutrition, whether this is incorporated throughout the training (as in Ethiopia, and IRC South Sudan) or added onto previousy-existing materias (as in South Bangadesh), may require that tota training time exceeds one work-week, or may ead to a decrease in cinica practice time. Training compexity: the current iccm materias and process are based on a phiosophy of simpicity and carity, where one observation eads to one action. No judgment is required. There is anecdota evidence that adding ony one medication (paracetamo, for exampe) increases significanty the compexity of earning: a chid with fever might need two medicines with different dosages. It is noted that in the South Bangadesh experience, CHWs do not treat maaria, and in South Sudan, they do not use Rapid Diagnostic Tests (RDTs), thus the incorporation of SAM treatment remains within the same eve of compexity as standard iccm. Quaity of care: Data from both Ethiopia and South Bangadesh indicate that the combination of SAM treatment and iccm did not have a negative effect on the quaity of either. The Maaria Consortium project in South Sudan reports that programme performance is we above SPHERE standards and defauter rates are significanty ower than the 9% standard rate as reported in Access For A, Vo Supervision: The more a CHW is expected to know and do, the greater the expectations on the supervisor. The Maaria Consortium experience in South Sudan found that they needed to hire staff with a nutrition background to adequatey supervise vounteers managing OTPs. Poicy: No goba statement exists to date to support the necessary poicy changes, ministeria engagement and cross-ministry coaboration for integrating the treatment of acute manutrition with iccm 37 Guerrero and Rogers (2013) Access for A, Voume 1 : Is community-based treatment of severe acute manutrition (SAM) at scae capabe of meeting goba needs? (Coverage Monitoring Network, London, June 2013)

40 40 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 guideines. Integrating treatment of acute manutrition into nationa iccm guideines wi require engagement from ministries of heath, and in countries where nutrition sits in a different ministry it wi require cross-ministry coaboration. Poicy aowing CHWs to prescribe and dispense medications: Whie iccm workers currenty treat chidren using ORS, antibiotics, antimaarias, and zinc, country-specific treatment guideines for SAM may indicate additiona medications, or different dosages or age ranges. SAM treatment at the community eve impies that the CHW be aowed to dispense an antibiotic that may or may not be the same as for pneumonia, as we as in some cases a deworming medication, iron, foic acid, or vitamin A. In addition, some countries have not put in pace poicies to aow CHWs to use antibiotics at a; this may be an important consideration for SAM treatment at the community eve. Avaiabiity of medicines in appropriate formuations and packaging: Certain medications given at the community eve within the iccm protoco may aready be in paediatric formuations (dispersibe amoxiciin, for exampe), or coor-coded for iiterate CHWs and caregivers (amoxiciin and Artemisinin-based Combination Therapy in Uganda), whie those indicated for faciity-based treatment of SAM are not at present. Suppy: Ensuring adequate and continuous suppies of RUTF at the community eve presents predictabe ogistics issues reated to distribution, stock-outs, pre-positioning, security, stock management, etc. Many of these issues currenty exist with distribution to a heath faciity eve and woud be even more difficut at the community eve. In Angoa, inconsistent suppy of RUTF was a major constraint on project activities, and there were months when no RUTF was avaiabe. In Ethiopia, athough RUTF is in theory incuded in the HEW suppy kit, in practice its buky nature prohibits distribution through the same channes and a temporary parae system has had to be estabished. Cost: Data from South Bangadesh indicates that community-eve treatment of SAM is cost-effective. In both Ethiopia and South Bangadesh, RUTF represented the most significant cost input. Treatment protoco adaptations: Appetite test: The standard CMAM protoco 38 requires an appetite test as one means of differentiating compicated versus uncompicated SAM. The appetite test is administered by a professiona heath worker in a heath faciity or OTP site. Protocos in Angoa (Word Vision), Bangadesh, Ethiopia, South Sudan (Maaria Consortium) and South Sudan, (IRC) a incude an appetite test administered by the chw. Some key informants raised questions on whether the appetite test can be accuratey administered and interpreted at the community eve. RUTF dosage: The standard CMAM protoco determines RUTF dosage based on the weight of the chid. NGOs adapting or simpifying the protoco have made modifications to address the compexity of conducting accurate weights, especiay with a ow-iteracy and numeracy vounteer. Word Vision/ Angoa and Action Against Hunger/Myanmar both provided a fixed dose of RUTF instead of basing dosage on a chid s weight. The IRC is considering a protoco in South Sudan based on dosage. not using weight (currenty under research). Discharge criteria The standard criteria for discharge is no oedema for at east two weeks and either Weight-for-Height (WFH) 2 Z-scores or MUAC 125 mm. Many nationa protocos may sti incude criteria of weight gain which, in addition to not being recommended by WHO and UNICEF is aso more compicated for community vounteers to manage. The IRC protoco for South Sudan wi incorporate ongitudina MUAC for tracking progress and discharge. 38 Word Heath Organization: Updates on the management of severe acute manutrition in infants and chidren Guideine. 2013

41 41 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 In discussing which approaches key informants woud or woud not recommend, communitybased treatment of uncompicated acute manutrition eicited strong reactions on both sides of the argument. Those informants who supported community-based treatment taked about the importance of providing ife-saving treatment to those who woud not otherwise be abe to access it and the potentia impact on decreasing mortaity by addressing manutrition in tandem with pneumonia, maaria and diarrhoea. A number of peope provided a parae to the evoution of iccm and stated that many of the concerns raised about treating acute manutrition at the community eve had aso been raised about community-based treatment of pneumonia, maaria and diarrhoea. Some key informants suggested that community-based treatment may ony be reevant to areas with very ow coverage and access, and high eves of manutrition. Two respondents who supported community-based treatment expressed concerns about a typoogy of treatment with different community-based workers for iccm and acute manutrition. Their concerns focused on dupication of services, ack of integration, and the perception that one worker coud effectivey incorporate four diseases. Whie a few peope raised concerns about the ack of scaed, tested exampes of acute manutrition treatment at the community eve, others taked about the chaenge of negotiating government poicies, or of getting government buy-in for arger scae impementation without MOH advocacy support from partners, particuary UNICEF. There were aso strong negative reactions. Comments incuded: Basic vounteers (ike CHAs in Ghana) shoud not manage SAM in the community I woud caution against using non-paid/ vounteers to deiver OTP as it brings issues around staff retention and turn-over, ogistics, service quaity, reporting as we as accountabiity We woud NOT recommend treatment of SAM by the CHW. The appetite test can be difficut to administer, and requires a certain amount of judgment. We woud not recommend a simpified version of SAM treatment. Growth monitoring shoud remain at the eve of the heath faciity. I am not sure about the viabiity of SAM treatment by CHWs

42 42 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Knowedge Gaps In addition to identifying what was known about integrating nutrition and iccm/ccm, this review sought to identify remaining gaps in knowedge in order to hep focus future impementation and research directions. Those questions directy reated to the impementation of a particuar typoogy are presented in the tabe of advantages and disadvantages. Additiona questions and suggestions raised by key informants incude: What can reasonaby and reaisticay be done in terms of nutrition at different eves of the heath system? What works, for whom, in what circumstances and why? (Context) How can nutrition best be incorporated into poicies, training toos, evauation, and toos? How can heath and nutrition best be firmy inked at the institutiona eve? How much work / how many tasks can one CHW absorb and what is feasibe for a CHW to do in addition to the iccm tasks? (reated quaification: without compromising quaity of care for iccm or for nutrition?) If we add a modue (i.e. nutrition) to iccm training, does it change the competencies needed for the worker? What are the costs, cost-effectiveness, and cost benefits of integration? There need to be studies on issues reated to equity, coverage, sustainabiity and scaabiity. Research shoud be done on how to simpify protocos for SAM treatment for the iiterate worker and the evidence of effectiveness of the training Can a CHW effectivey detect compications of SAM? What are ways to ensure the suppy and positioning of RUTF? How can RUTF be incuded on the essentia drugs ist? There is a need to deveop and vaidate better nutrition indicators. There is no standardized protoco for MAM treatment, as there is for diarrhoea, pneumonia and maaria. This coud hep the fied move forward in impementation. Discussions and meetings preceding this review aso produced ists of questions. For exampe, a presentation at the Technica Meeting on Nutrition 2014, in Oxford put forward this ist: Motivation: How ong can we sustain motivation of CHWs? What are the factors that affect CHW motivation particuary when providing additiona services? Poicy Environment: What is the minimum in terms of poicy invovement (or environment)? Protocos: Do CMAM protocos need to be simpified/aigned with iccm? What woud it ook ike? Nutrition Packages: What bundes of interventions shoud be deivered and in what order? Which aspects of nutrition (i.e. IYCF, MAM, SAM, micronutrients) are appropriate in each context? How can we promote continuity of care? Heath Systems: What are the essons about Heath System Strengthening that we can take into iccm and nutrition?

43 43 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 L E S S O N S & C O N C L U S I O N S E M E R G I N G F R O M T H E R E V I E W Generaizabe concusions are eusive. One frequent theme arising throughout the review process, in both the desk review and the key informant interviews, is the primordia importance of context; what works in one country or part of a country may not be appropriate for another. There are a number of other common essons that arose from this review: a. The profie of the CHW is decisive. The gamut runs from a paid, iterate CHW with a reativey sma catchment area and a substantia amount of training, to a vounteer, iiterate CHW with a arge number of househods to cover and one week of training. b. The organisation of work and current responsibiities of CHWs heps determine the best approach, for exampe whether the integration of nutrition activities shoud buid on a heath education patform or on a treatment patform. c. A division of responsibiities whereby the CHW who does treatment is compemented by others who do active case-finding, home visits, and/or IYCF messaging has the potentia of increasing coverage whie not overoading one particuar cadre. d. iccm is ony one deivery patform; nutrition coud be added to others, incuding the Expanded Programme on Immunization and antenata care activities. e. The poitica context is aso decisive. In paces with a high prevaence of acute manutrition, ow access to treatment and poor heath infrastructure, for exampe South Sudan, there is a stronger argument for community-eve treatment. At the same time there is more opportunity for the CHW to see acutey manourished chidren and thus to practice and retain the reevant skis. The same argument may appy to areas in emergency situations. f. There is a papabe tension between the nutrition and heath sectors. This tension reates to avaiabe funding (donor attention), funding streams, and management structures. This coud be ikened to a simiar tension often found in iccm between vertica maaria programmes and more horizonta chid heath programmes in countries. The advantages to both sectors of inking shoud be ceary articuated, using terminoogy acceptabe and accepted by a concerned. g. Other sectors and concerns must be taken into consideration. Exampes incude gender issues (men are famiy decision-makers), socia protection schemes, and food security. Two additiona points from discussions with key informants compement the essons drawn from documents reviewed: h. Key informants agreed that it was reasonabe to expect a iccm CHWs to assess, refer and counse acutey manourished chidren. There was agreement amongst a number of respondents that iccm coud be an effective patform for reinforcing IYCF messages, strengthening feeding practices during iness, and foowing up acutey manourished chidren. i. Respondents brought up the chaenges of integrating nutrition and heath at the nationa eve, reated to coordination across MOH directorates, funding streams, and the chaenge of ensuring that usefu nutrition indicators were incuded in the Heath Management Information System.

44 44 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 This paper is the resut of reviews of documented programme experiences and pubished evidence, compemented by discussions with key informants, on inking or integrating nutrition interventions and integrated community case management of chidhood iness. Based on the experiences reviewed, four non-excusive typoogies of inkage and integration emerged. The typoogies provide an organizing framework for describing, exporing and comparing existing experiences and evidence, anaysing advantages and disadvantages, and defining knowedge gaps. The construct of the four typoogies is usefu for examining current and past experiences, however it is ikey that the way forward may be through a combination of typoogies, or through the addition of new aternative approaches to inkage or integration. Nutrition is currenty incuded in the UNICEF/WHO standard iccm package with home care messaging on feeding of the sick chid, assessment using MUAC and biatera pitting oedema, and referra of chidren with acute manutrition. Discussion of future directions for strengthening the inkages or integration of nutrition and iccm coud be more ceary articuated on two eves: 1) optima impementation of the nutrition components aready incuded in iccm (Typoogies 1 and 3); or 2) adding treatment of acute manutrition onto iccm (Typoogy 4). In contrast to the abundant evidence supporting the need to integrate or ink, and the equay abundant evidence for each of the two domains separatey, the paucity of hard evidence of how inkages coud be done confirms the imited experience. Future work wi need to examine the best combination of actions probaby crossing over the proposed typoogies -- to ensure better coverage of interventions that identify and ensure treatment and prevention of chidhood iness and acute manutrition. The ist of questions put forward in this review is vast but an important subset has been suggested. Much of what is not known reates to arge-scae impementation, feasibiity, and the transferabiity of experience from one context to another.

45 45 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 A n n e x 1 Key Informant Organisations Action Contre a Faim/Action Against Hunger Chidren s Investment Fund Foundation CMAM Forum DFID Internationa Rescue Committee Maaria Consortium Micronutrient Initiative Save the Chidren UNICEF Ethiopia UNICEF Headquarters UNICEF West and Centra Africa Regiona Office (WCARO) USAID Word Heath Organization Word Vision

46 Future work wi need to examine the best combination of actions - probaby crossing over the proposed typoogies - to ensure better coverage of interventions thatidentify and ensure treatment and prevention of chidhood iness and acute manutrition.

47 47 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 A n n e x 2 Community-eve Nutrition Actions Identified Country/Action in community Identify acute manutrition Active case finding Treat uncompicated SAM Foow-up at home Mebendazoe Iron foate Or iron + foic acid Vitamin A Promote EBF Promote compe-mentary feeding Identify MAM Refer yeow MUAC Treat MAM Afghanistan x x x x x x x x Angoa x x x x x x x Word Vision/Africare mass screening Bangadesh x x x x x x Save the Chidren Bangadesh x x A&T DRC x x x Ethiopia x x x x x x x x x x x Counseing Nationa HEW HDA at heath programme vounteers post or OTP Ethiopia x x A&T Guinea x x x Counseing for the manourished chid Kenya 4 x RUTF in x x x? muac ony community seected communities Liberia?39 Madagascar x x x

48 48 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Mai 1 x x x x x x Advise Maawi x x x Niger x x x x x x x French Red Cross /IFRC months Niger x x x x x x x x Concern Wordwide Tahoua ( ) Niger x x HKI, Gaya district Pakistan x x x x x LHWs Pakistan x x RUTF at x x x x Counseing LHWs, home on appropriate Save the Chidren and caorie dense foods Rwanda x x x x Panned iccm Rwanda x x x x Word Reief Rwanda x x x x x x x x x Concern Wordwide,x Word Reief, and IRC Kabeho Mwana ( ) S Sudan x x x x Abendazoe x x x x x Counse Maaria Consortium cnw CNW Zambia x x Shaded rows = carried out with iccm (or, incuded in iccm materias) Unshaded rows = carried out separatey from iccm, or information not avaiabe Sources for the information in this tabe incude: iccm training materias (10-country review), poicy documents, impementation pans, study resuts 39 MUAC on consutation edger in ARI modue, but not in other modues or in training text 1 Mai: one study on heath system strengthening by Johnson et a showed vaue of active case-finding of diarrhoea, pneumonia, maaria by CHW home visits. This was accompanied by remova of user fee, infrastructure deveopment, community mobiization and prevention programming. No mention of nutrition, SAM, or MUAC. 3 Ethiopia: HEW aso checks for anaemia (pamar paor) 4 From Nationa impementation pan iccm

49 49 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 A n n e x 3 CHWs Providing Treatment for SAM: CHW and Programme Profies Experience Paid/Vo Average Education Training Supervision Diseases ratio CHw covered TO Househod HHs Ethiopia Heath Paid; FT 2:1,000 HHs 10th Grade 1 year; refresher 1-2 times 16 packages covering Extension government trainings every 2 per month disease prevention Programme saaried years; + 5 days of and contro, famiy position iccm training heath, hygiene, incuding SAM management environmenta sanitation, heath education, communication treatment of pneumonia, diarrhea, maaria, SAM South Bangadesh Paid monthy 1: th Grade Disease prevention; 1-2 times Diarrhea, Pneumonia, Save the Chidren stipend HHs; 1:900 3 days iccm; per month and SAM, Severe popuation 2 days Sam disease South Sudan Maaria Consortium CNW 1 CNW: CNW s are CNW: 5 day initia Minimum CNW: SAM paid monthy OTP site iterate training; quartery 2 times stipend refresher training; per month otj during supervision visits CDD do not CDDs CDD: 6 day training; CDD: Diarrhoea, receive a generay OTJ training P pneumonia, and stipend iiterate during supervision M maaria (presumptive treatment) South Sudan Vo 1:50 HHs Iiterate 1 week for ICCM 1-2 times Diarrhoea, Pneumonia, Internationa Rescue per month Maaria (presumptive Committee treatment), and SAM Pakistan Lady Paid 1:200 HHs; 8th Grade 15 months then Variabe by Outreach component Heath Workers 1:1000 peope 12 months OTJ District Heath for PHC, Reproductive Action Against Hunger Officers Heath and SAM Mai Agent Sante Paid; FT 1:35-1:110 Certificate 3-6 months 1-2 times per Diarrhoea, Pneumonia, Communautaire saaried HHs in the of Heath month by the Maaria, MAM Action Against Hunger position area of Assistant H head Doctor and SAM intervention or midwife of the cosest heath Centre Note: Last three are in design/proposa stage and not impemented

50 50 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 A n n e x 4 Operations Research Underway or Panned Country Bangadesh Timeine Agency The Hospita for Sick Chidren in Toronto, Canada Project Info: Materna Vitamin D for Infant Growth (MDIG) Tria Overa goas: The study aims to measure the impact of vitamin D suppement to pregnant women on infant s growth (primary outcome is ength of the chid). It is pacebo controed randomized cinica tria. Community Heath Workers conduct pregnancy surveiance in study area and refer them to the study faciity (a MOH run materna and Chid Wefare Cinic) where study physician conducts physica examination and coects bio-specimen from women who consented to participate in the study. CHWs aso conduct home visits, foow IMCI guideines and offer necessary referra and case management at community eve to chidren whom they find i and with signs/symptoms. Timeine: Coaborating partners: Internationa Centre for Diarrhoea Disease Research, Bangadesh, Shimantik; Bi and Meinda Gates Foundation Country Benin Timeine Agency Center for Human Services Project Info: Community-based quaity improvement mode for increasing CHW motivation Background: Save- Ouesse (SAO), Dassa- Gazoue (DAGLA), and Aada-Ze- Toffo (AZT) are the three highest need heath zones in Benin, as demonstrated by poor MNCH heath indicators (MMR: 350/100,000; U5MR: 106/1000; IMR/1,000) and a ack of motivation, ow retention, and poor performance of Community Heath Workers (CHWs). Overa goas: Strengthening community-faciity partnerships for Community Heath Worker support by estabishing a community-eve quaity improvement coaborative mode to motivate CHWs and improve their performance and retention for improved access to quaity MNCH services and outcomes; Informing Benin s 2010 Nationa Directives for Community-Based Heath Promotion poicy on CHWs motivation package Timeine: Coaborating partner: MOH (assumed) Country Burkina Faso Timeine Agency Micronutrient Initiative Project Info: Demonstration project: Community-based prevention of manutrition in Burkina Faso Overa goas: Contributing to the reduction of morbidity and mortaity in chidren 0-59 months in Burkina Faso through we-defined and impemented community interventions to improve the quaity of management of acute manutrition and infant and young chid feeding. Timeine: October 2013-March 2016 Coaborating partners: MI, Terre des Hommes, Institut de Médecine Tropicae (ITM) Antwerp, Brusses, Institut de Recherche en Sciences de a Santé (IRSS), Ouagadougou, Communities of intervention viages, Tougan heath district, Bureau Consei en Santé Country Ethiopia Timeine Agency Micronutrient Initiative Project Info: Extended piot project: Community-based production of compementary food in Ethiopia Overa goas: Improving infant and young chid feeding practices by increasing the consumption of quaity ocayproduced compementary food and the utiization of mutipe- micronutrient powder in chidren 6-23 months; Contributing to the reduction of undernutrition among chidren 6-23 months as part of the Nationa Nutrition Pan in 4 regions of Ethiopia Timeine: The project activities started in October 2014, and the first phase of this project wi run unti March Coaborating partners: UNICEF provides the main financia resources, with MI and GAIN as impementing partners and aso contributing own resources, and other impementing partners incuding RiPPLE, Ethiopian Orthodox Church, Addis Ababa University (and 4 regiona universities), and the Ethiopian Pubic Heath Institute. Country Maawi Timeine TBC Project Info: Strengthening nutrition counseing for breastfeeding and feeding during iness in CCM. Concept note and proposas submitted. Overa goas: N/A Timeine: N/A Coaborating partners: N/A Agency Save the Chidren & Partners

51 51 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Country Mai Timeine Agency ACF Project Info: Cinica cohort study: Integrating SAM treatment into the iccm package currenty deivered by CHWs in Mai Background: Mai has one of the highest infant mortaity rates in West Africa (IMR 194/1,000), with manutrition being associated with neary a third of these deaths and affecting 10.4% of chidren under 5. ACF has supported the heath district of Kita, one of 49 cerces or state-ike areas, since 2007 through the Project for Improving Food and Nutrition Security. Since the 2012 crisis, ACF has expanded into a 41 functiona areas of the heath district, impementing the project Strengthening oca capacities for integrated management of acute manutrition and access to food in Kita. A coverage assessment carried out by ACF in March 2013 found that faciity-based treatment of acute manutrition in Kita was ony reaching approximatey 25% of the affected popuation. Awareness and distance were the major barriers for accessing care. Paid Community Heath Workers (Agent Sante Communautaire, ASC) have provided iccm services for the treatment of maaria, diarrhoea, pneumonia and sometimes MAM but have not taken on a significant roe in the treatment of SAM. Overa goas: Examining the impact of integrating eary identification and treatment of SAM into iccm services deivered by ASCs in severa municipaities of the cerce Kita (where ACF supports CMAM deivered at the heath centre eve); Fiing a gap in the evidence base with respect to the potentia deivery of SAM treatment by CHWs and providing a mode capabe of bridging some of the most common barriers to access faced by traditiona service deivery modes. Objective: To compare the effectiveness of SAM treatment services provided at faciity eve with treatment services provided by trained ASCs in two areas of Kita cerce in Mai Study hypotheses: Treatment of SAM by ASCs wi improve eary identification of SAM cases compared to the Heath Faciity Treatment: ess compicated cases referred to SC and MUAC at admission coser to threshod eves Treatment of SAM by ASCs wi improve access to treatment service: Coverage rates and barriers to access as evauated by SQUEAC assessments Treatment of SAM by ASCs wi improve cost-effectiveness compared to treatment at heath faciities. Cinica outcomes of SAM treatment (incuding cure, death and in particuar defauter rates) wi not be inferior in the intervention area where treatment is deivered by ASCs Treatment of SAM by ASCs wi provide High Quaity of care (error free case management) : >80% error-free case management. Timeine: Coaborating partners: ACF Internationa, Repubique du Mai, the Innocent Foundation, and University of Bamako Country Pakistan Timeine Agency ACF Project Info: A custer randomised controed tria: Evauation of the effectiveness and impact of community case management of Severe Acute Manutrition through Lady Heath Workers as compared to a faciity-based programme Background: Severe acute manutrition exceeds 10% in many districts of Pakistan, specificay rura Sindh and southern Punjab. Current CMAM modes focus on faciity-based treatment of SAM, rather than community-based prevention of it. However, evidence indicates that Lady Heath Workers are capabe of undertaking a compex series of heath care tasks. Thus, they can potentiay detect and manage SAM in the community and foow up with cases, in order to overcome the difficuty encountered in sustaining quaity SAM treatment programmes during and after crises. Overa goas: Examining the impact of integrating eary identification and treatment of SAM with RUTF and IYCF counseing deivered by LHWs at househod eve in Dady district of Pakistan; Examining the impact on cost-effectiveness and coverage of enabing LHWs to deiver an integrated package incuding treatment of SAM and IYCF; Fiing a gap in the evidence base with respect to the effectiveness of integrating treatment of acute manutrition into iccm and the coverage that can be obtained via this mechanism during crises.objective: To compare the effectiveness of SAM treatment services provided at faciity eve with treatment services provided by trained ASCs in two areas of Kita cerce in Mai Objectives: To evauate the effectiveness (rate of recovery, reapse & coverage), of SAM treatment of chidren underfive years deivered at househod eve by first eve heath care providers (Lady heath workers) compared with the standard CMAM programme deivered at heath faciity by Government and ACF staff (primary). To evauate the cost effectiveness of treatment of SAM provided by LHWs at community eve versus treatment deivered at heath faciity by Government and ACF staff (primary). To evauate the breast feeding and compementary feeding practices in both study arms (secondary). Study hypotheses: Provision of SAM treatment at househod eve in a community through ady heath workers wi be as effective (recovery rate, surviva, cost effectiveness, coverage) as treatment provided at faciity eve. Timeine: Coaborating partners: ACF Internationa, the Aga Khan University, and the Innocent Foundation

52 52 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Country Rwanda Timeine Agency CARE Project Info: Making nutrition a focus for Eary Chid Deveopment groups Background: Kamonyi District in Southern Rwanda has high poverty indices and is a targeted area by the government s poverty eradication programme, Vision 2020, Umurenge. The region has the poorest heath indicators (U5MR of 127/1,000 compared to the nationa average of 103/1,000), arge inequities within the heath system, poor chid heath and deveopmenta outcomes, and imited access to basic services for chidren 1-5 years od from poor famiies and those in remote areas. Overa goas: Integrating MNCH/Nutrition and Eary Chid Deveopment within community-based Eary Chid Deveopment groups, with support of CHWs for universa coverage and increased uptake of interventions, positive heath behaviours, and enhanced chid outcomes; Supporting Rwanda government for cross-sectora integration of the Community Heath Poicy, Nationa Nutrition Poicy, and Eary Chid Deveopment Poicy. Timeine: Coaborating partner: MOH (assumed) Country Rwanda Timeine Agency Word Reief Project Info: Integrating group earning into nationa nutrition programme Background: Nyamagabe district in Southern Rwanda suffers from poor soi quaity, high poverty, and high eves of under-nutrition that contribute to high infant and chid mortaity rates (U5MR: 54/1,000; IMR: 38/1,000). Chid manutrition is a major probem due to ow uptake of Community-Based Nutrition Programme (CBNP) interventions. Overa goas: Improving community behaviours critica to the 1,000 days period to improve chid nutrition by integrating participatory group earning sessions ( Nutrition Weeks ) into the nationa community-based nutrition programme; Informing the MOH to guide the impementation, scae-up, and impact of its new CBNP interventions on behaviour change to improve chid nutrition Timeine: Coaborating partner: MOH (assumed) Country South Sudan Timeine TBC Agency IRC Project Info: Piot project: Home-based treatment of severe manutrition by iiterate Community Heath Workers in South Sudan Background: iccm has been estabished in South Sudan since 2004, whie faciity-based CMAM services have ony existed since The IRC has created a simpified SAM protoco for use by iiterate CHWs in order for SAM to be integrated into iccm of maaria, diarrhoea, and pneumonia and considered the 4th condition for treatment at the home eve. Overa goa: Measuring the impact of the simpified protoco on programme coverage and quaity, compared to faciity-based treatment. Objectives: Simpify the treatment protoco of Severe Acute Manutrition to provide home-based treatment by iiterate community heath workers in South Sudan Evauate the quaity and coverage of home-based treatment of Severe Acute Manutrition compared to faciity-based treatment Describe the impact to the iccm programme by adding on a fourth treatment (severe manutrition), in addition to diarrhoea, maaria, and pneumonia Study hypotheses: Iiterate community heath workers using a simpified SAM treatment protoco are abe to provide quaity SAM treatment that is comparabe to standard faciity-based services Home-based treatment of SAM wi improve coverage of SAM treatment in South Sudan compared to faciity-based services The addition of SAM wi not reduce the quaity of care (error free case management) for diarrhoea, pneumonia, and maaria. Timeine: The first phase of this project began in 2014 to simpify the SAM protoco. The second phase of project impementation and research wi begin in Coaborating partners: TBD

53 53 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Country Zambia Timeine N/A Agency Boston University Project Info: Custer randomised controed tria: Improving eary chid deveopment in Zambia (rura Pemba and Choma Districts in Southern Province) Background: A cadre of heath care workers caed chid deveopment agents conduct fortnighty visits to homes to screen chidren for signs of maaria, pneumonia, and diarrhoea. Athough they are not deivering iccm, they are connected to the CHWs and heath centres that can provide the necessary services. Overa goas: Estabishing a new cadre of heath workers, chid deveopment agents (CDA), with the soe mission to monitor and support a aspects of chid deveopment under the age of 2; Determining the feasibiity of adding screening with MUAC for MAM and SAM during monthy home visits to the responsibiities of the chid deveopment agents ion order for them to ensure immediate treatment through oca CHWs or faciities; Reducing stunting and improving eary chidhood deveopment; Integrating screening for acute manutrition into iccm in Zambia Objective: Integrate eary chid deveopment support (incuding management of acute manutrition) in routine heath and communityeve care. Study hypotheses: Stunting decreases in the study popuation from 35% to 15% and cognitive deveopment indicators improve? Timeine: N/A Coaborating partners: The impementers are the Boston University Center for Goba Heath and Deveopment, Zambia Center for Appied Heath Research and Deveopment, Harvard Schoo of Pubic Heath, Centre for Infectious Disease Research in Zambia, Ministry of Community Deveopment, Mother and Chid Heath, MOH, Save the Chidren, District Community Medica Offices from Choma and Pemba, and Southern Provincia Medica Office, with Grand Chaenges Canada, Saving Brains and UJMT Fogarty Goba Heath Feows Training Program as the funders. Country N/A Timeine Project Info: WHO is supporting a study evauating three home-based feeding regimes for uncompicated SAM: centray-produced RUTF; ocay-produced RUTF; and augmented home-prepared foods. N/A Agency WHO

54 54 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 A n n e x 5 Documents Reviewed ACF Internationa 2011, Guideines for the Integrated Management of Severe Acute Manutrition: In- and Out-patient Treatment. Ahmed, T, Ai, M, Uah, MM, Choudhury, IA, Haque, ME, Saam, MA, Rabbani, GH, Suskind, RM & Fuchs, GJ 1999, Mortaity in severey manourished chidren with diarrhoea and use of a standardised management protoco, The Lancet, vo. 353, no. 9168, pp Ahmed, T, Hossain, M, Mahfuz, M, Choudhury, N, Hossain, MM, Bhandari, N, Lin, MM, Joshi, PC, Angdembe, MR, Wickramasinghe, VP, Hossain, SMM, Shahjahan, M, Irianto, SE, Soofi, S & Bhutta, Z 2014, Severe acute manutrition in Asia, Food and Nutrition Buetin, vo. 35, no. 1, pp. 14S-26S(13). Ajwang, F 2014, Pre-Harvest SMART Nutrition Survey Report: Awei Centre County, Northern Bahr e Ghaza State, South Sudan. Aive & Thrive 2011, Aive & Thrive s Strategies for Improving Infant and Young Chid Feeding Practices. Aen, S & Hamer, C 2004, Improving quaity of care for severe manutrition, The Lancet, vo. 363, no. 9426, pp Amthor, RE, Coe, SM & Manary, MJ 2009, The Use of Home-Based Therapy with Ready-to-Use Therapeutic Food to Treat Manutrition in a Rura Area during a Food Crisis, Journa of the American Dietetic Association, vo. 109, pp Arifeen, SE, Hoque, DME, Akter, T, Rahman, M, Hoque, ME, Begum, K, Chowdhury, EK, Khan, R, Bum, LS, Ahmed, S, Hossain, MA, Siddik, A, Begum, N, Rahman, QS, Haque, TM, Biah, SM, Isam, M, Rumi, RA, Law, E, A-Hea, ZAM, Baqui, AH, Scheenberg, J, Adam, T, Mouton, LH, Habicht, JP, Scherpbier, RW, Victora, CG, Bryce, J & Back, RE 2009, Effect of the Integrated Management of Chidhood Iness strategy on chidhood mortaity and nutrition in a rura area in Bangadesh: a custer randomised tria, The Lancet, vo. 374, no. 9687, pp Ashraf, H, Ahmed, T, Hossain, MI, Aam, NH, Mahmud, R, Kama, SM, Saam, MA & Fuchs, GJ 2007, Day-care management of chidren with severe manutrition in an urban heath cinic in Dhaka, Bangadesh, Journa of Tropica Pediatrics, vo. 53, no. 3, pp Ashworth, A, Chopra, M, McCoy, D, Sanders, D, Jackson, D, Karaois, N, Soguaa, N & Schofied, C 2004, WHO guideines for management of severe manutrition in rura South African hospitas: effect on case fataity and the infuence of operationa factors, The Lancet, vo. 363, no. 9415, pp Ashworth, A, Hutty, S, Khanum, S 1994, Controed tria of three approaches to the treatment of severe manutrition, The Lancet, vo. 344, no , pp Ashworth, A & Khanum, S 1997, Cost-effective treatment for severey manourished chidren: what is the best approach?, Heath Poicy and Panning, vo. 12, no. 2, pp Austraian AID, Ministry of Heath Myanmar & UNICEF 2012, Tookit for Community Case Management of Chidhood Inesses: ARI/Pneumonia and Diarrhea: Impementation Guide (Myanmar). Austraian AID, Ministry of Heath Myanmar & UNICEF 2012, Tookit for Community Case Management of Chidhood Inesses: ARI/Pneumonia and Diarrhea: Technica Suppements (Myanmar). Barbera Lainez, Y 2014, Supervision: is it showing us the rea picture?, presentation for Integrated Community Case Management (iccm): Evidence Review Symposium Accra, Ghana. Beachew, T & Nekatibb, H 2007, Assessment of outpatient therapeutic programme for severe acute manutrition in three regions of Ethiopia, East African Medica Journa, vo. 84, no. 12, pp Bennett, S, George, A, Rodriguez, D, Shearer, J, Diao, B, Konate, M, Dagish, S, Juma, P, Namakhoma, I, Banda, H, Chiundo, B, Mariano, A & Ciff, J 2014, Poicy chaenges facing integrated community case management in Sub-Saharan Africa, Tropica Medicine and Internationa Heath, vo. 19, no. 7, pp Bernabe, BP 2013, Coverage Assessment: District Sanitaire de Gaya, Niger, Mai, Bhutta, ZA, Ai, S, Cousens, S, Ai, TM, Haider, BA, Rizvi, A, Okong, P, Bhutta, SZ & Back, RE 2008, Interventions to address materna, newborn, and chid surviva: what difference can integrated primary heath care strategies make?, The Lancet, vo. 372, no. 9642, pp Bhutta, ZA, Soofi, S, Cousens, S, Mohammad, S, Memon, ZA, Ai, I, Feroze, A, Raza, F, Khan, A, Wa, S & Martines, J 2011, Improvement of perinata and newborn care in rura Pakistan through community-based strategies: a custer-randomised effectiveness tria, The Lancet, vo. 377, pp Back, RE, Victora, CG, Waker, SP, Bhutta, ZA, Christian, P, de Onis, M, Ezzati, M, Grantham-McGregor, S, Katz, J, Martore, R, Uauy, R & the Materna and Chid Nutrition Study Group 2013 Materna and chid undernutrition and overweight in ow-income and midde-income countries, The Lancet, doi: /S j36(13)60937-X. Biss, J 2014, Access Barriers to Chid Heath and Nutrition Services in Marsabit County, Kenya: Resuts for Concern Wordwide. Brewster, DR, Manary, MJ & Graham, SM 1997, Case management of kwashiorkor: an intervention project at seven nutrition rehabiitation centres in Maawi, European Journa of Cinica Nutrition, vo. 51, no. 3, pp CCM Centra 2012, CCM Expanded Resuts Framework, image. Chaiken, MS, Deconinck, H & Degefie, T 2006, The promise of a community-based approach to managing severe manutrition: A care study from Ethiopia, Food and Nutrition Buetin, vo. 27, no. 2, pp Chamois, S 2009, Decentraisation of out-patient management of severe manutrition in Ethiopia. Chamois, S 2011, Decentraisation and scae up of out-patient management of SAM in Ethiopia ( ). Choudhury, N, Ahmed, T, Hossain, MI, Manda, BN, Mothabbir, G, Rahman, M, Isam, MM, Husain, MM, Nargis, M & Rahman, E 2014, Community-based management of acute manutrition in Bangadesh: Feasibiity and constraints, Food and Nutrition Buetin, vo. 35, no. 2, pp (9). Ciiberto, MA, Manary, MJ, Ndekha, MJ, Briend, A & Ashorn, P 2007, Home-based therapy for oedematous manutrition with ready-to-use therapeutic food, Acta Paediatrica, vo. 95, no. 8, pp Ciiberto, MA, Sandige, H, Ndekha, MJ, Ashorn, P, Briend, A, Ciiberto, HM & Manary, MJ 2005, Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of manourished Maawian chidren: a controed, cinica effectiveness tria, American Journa of Cinica Nutrition, vo. 81, pp Coins, S, Dent, N, Binns, P, Bahwere, P, Sader, K & Haam, A 2006 Management of severe acute manutrition in chidren, The Lancet, vo. 368, no. 9551, pp Coins, S 2007, Treating severe acute manutrition seriousy, Archives of Disease in Chidhood, vo. 92, pp Coins, S, Sader, K, Dent, N, Khara, T, Guerrero, S, Myatt, M, Saboya, M & Wash, A 2005, Key issues in the success of community-based management of severe manutrition: Technica background paper, Word Heath Organization, Geneva. Concern Wordwide 2009, Integrating Community Management of Acute Manutrition Into Chid Surviva Programs: Concern Wordwide s Experience in Rwanda. Concern Wordwide & Aive & Thrive 2012, Two years on: addressing the causes of manutrition in Dessie Zuria: A project integrating Infant and Young Chid Feeding and the Productive Safety Net Programme in Ethiopia. Concern Wordwide, 2011 Comparison of outcomes for Rwandese chidren treated for moderate acute manutrition by community based Community Kitchen or Positive Deviance Hearth Interventions, unpubished draft. CORE Group, Save the Chidren, BASICS & MCHIP 2010, Community Case Management Essentias: Treating Common Chidhood Inesses in the Community: A Guide for Program Managers, Washington, D.C. Deconinck, H, Swindae, A, Grant, F & Navarro-Coorado, C 2008, Review of Community-based Management of Acute Manutrition (CMAM) in the Post-emergency Context: Synthesis of Lessons on Integration of CMAM into Nationa Heath Systems: Ethiopia, Maawi & Niger, Apri-June Department of Heath Phiippines 2011, Protoco on the Phiippine Integrated Management of Severe Acute Manutrition (PIMAM): Draft for consideration by the DOH: Version 1. Department of Heath Phiippines, Davao City Heath Office 2013, Addressing Severe Acute Manutrition (SAM) in Davao City: a concept note towards aunching an initiative. Druetz, T, Ridde, V & Haddad, S 2014, The divergence between community case management of maaria and renewed cas for primary heathcare, Critica Pubic Heath, doi: / Duke, T 2014, Randomised trias in chid heath in deveoping countries , Centre for Internationa Chid Heath, Victoria. Edeh, OA 2013, Addressing Chid Manutrition in Kopanga: Lessons in Transitioning from a Homegrown Nutrition Program to a Community-Based Program, Master s thesis, University of Washington, Washington, viewed 30 December 2014, researchworks/hande/1773/ EmCCM Working Group 2014, Case studies of community case management in emergencies: Research Protoco Eniyew, A, Mengistu, B, Enyew, A, Demeke, B, Muuye, F, Tsegaye, S, Yitbarek, A, Tesfaye, H & Marsh, D 2013, Effect of Performance Review and Cinica Mentoring Meetings on the Quaity of Care Provided by Heath Extension Workers in Ethiopia. FANTA 2010, FANTA-2 Guide de formation PCMA: Modue Sept: Panification de a PCMA au niveau du districtfedera Ministry of Heath Ethiopia 2007, Nationa Impementation Pan for Community-based Case Management of Common Chidhood Inesses. Federa Ministry of Heath Ethiopia 2013, Nationa scae up of iccm, Ethiopia, viewed 30 December 2014, Federa Ministry of Heath Ethiopia, Heath Extension and Education Center 2007, Heath Extension Program in Ethiopia profie.

55 55 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Frontine Heath Workers Coaition 2014, A Commitment to Community Heath Workers: Improving Data for Decision-Making. Gabouaud, V, Dan-Bouzoua, N, Brasher, C, Fedida, G, Gergonne, B & Brown, V 2006, Coud nutritiona rehabiitation at home compement or repace centre-based therapeutic feeding programmes for severe manutrition?, Journa of Tropica Pediatrics, vo. 53, no. 1, pp Generation Nutrition, ACF Internationa & UNICEF 2014, Integrated Management of Acute Manutrition: Davao City Phiippines. Giroy, KA, Caaghan-Koru, JA, Cardemi, CV, Nsona, H, Amouzou, A, Mtimuni, A, Daemans, B, Mgaua, L & Bryce, J 2013, Quaity of sick chid care deivered by Heath Surveiance Assistants in Maawi, Heath Poicy and Panning, vo. 28, no. 6, pp Giugiani, C, Duncan, BB, Harzheim, E, Breyesse, S & Jarrige, L 2010, The impact of a short-term intervention using the WHO guideines for the management of severe manutrition at a rura faciity in Angoa, Archives of Disease in Chidhood, vo. 95, pp Goba Heath Workforce Aiance & Word Heath Organization 2008, Country Case Study: Pakistan s Lady Heath Worker Programme. Goden, MH & Greety, Y 2012, Protoco: Integrated Management of Acute Manutrition. Government of Ethiopia 2014, Guideines for the Management of Acute Manutrition: NNP Impementation Guide 4: First draft January Government of Ethiopia 2013, Nationa Nutrition Programme, June 2013-June Government of South Sudan, Ministry of Heath 2009, Interim Guideines: Integrated Management of Severe Acute Manutrition. 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58 02 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014