Surge Capacity for Communitybased Management of Acute Malnutrition. Regine Kopplow and Sinead O Mahony

Transcription

1 Surge Capacity for Communitybased Management of Acute Malnutrition Regine Kopplow and Sinead O Mahony

2 Rationale In many contexts severe acute malnutrition (SAM) is endemic Treatment of SAM increasingly part of the basic health care package provided by the government Spikes in caseloads of SAM are frequent and sometimes extreme Response required often beyond the system s capacity Need for timely and adequate response to save lives Need to strengthen the capacity of the health system Need to increase the preparedness of the system

3 Surge model objective Strengthen the capacity of government health systems to effectively manage increased caseloads e.g. of severe acute malnutrition during predictable emergencies without undermining on going systems strengthening efforts.

4 Pre-requisites Recurring, seasonal spikes in the prevalence of acute malnutrition, with risk of significant disaster/s Management of severe (moderate) acute malnutrition has been introduced and is endorsed by the government as a standard health service Government health systems function to a moderate standard during non-emergency times and on-going health system strengthening efforts are in place, where needed

5 Surge model components 1. Risk analysis 2. Threshold setting 3. Monitoring against thresholds/ triggering surge support Health system (strengthening where needed) 4. Provision of surge support 5. Scaling down of surge support

6 Health system strengthening Caseload Health System Capacity External support Ongoing health systems strengthening efforts Time *Adapted from P. Hailey and D. Tewoldeberha, ENN, 2010, issue 39

7 Health system strengthening Performance analysis Gap assessment Identified gaps Possible action(s) No technical staff/ staff shortage Make request for staff allocation Has the health facility achieved the performance indicator? (use checklist) No Yes Determine actual reasons for poor indicators Lack of reference materials Inadequate supplies Request materials from district Purchase equipments Inadequate technical knowledge Train staff on knowledge gaps Inadequate working space at HF Construct makeshift shelter *On-Job Training Guide for High Impact Nutrition Interventions, Oct. 2011, MOPHS, Kenya

8 Model component 1: Risk analysis Analysis of the drivers of increased caseloads Understand what factors impact on prevalence and health seeking behaviour Understand how these factors interlink Done by staff in Butiye Health Centre, Moyale District, Kenya

9 Caseload Model component 2: Threshold setting Emergency Serious Alert Normal Time

10 Model component 3: Monitoring against thresholds and triggering surge support

11 3a. Monitoring caseloads against thresholds Diarrhoea Pneumonia Severe malnutrition (SAM) Butiye Health Centre, Moyale District, Kenya, photos by R.Kopplow

12 Model component 3b: Triggering surge support Scale up DHMT approaches NGO for additional support where needed During DHMT meeting issue is discussed and the scale up of support approved Health facility contacts DHMT Caseload reaches threshold Monitoring of malnutrition and disease caseloads, the health seeking influencing factors and mobilisation activities carried out in the area Health systems strengthening

13 Model component 4: Provision of surge support Performance analysis Gap assessment Identified gaps Possible action(s) No technical staff/ staff shortage Make request for staff allocation Has the health facility achieved the performance indicator? (use checklist) No Yes Determine actual reasons for poor indicators Lack of reference materials Inadequate supplies Inadequate technical knowledge Request Define support materials in line from with district the phase the health facility Purchase is in: equipments normal alert serious Train emergency staff on knowledge gaps Inadequate working space at HF Construct makeshift shelter *On-Job Training Guide for High Impact Nutrition Interventions, Oct. 2011, MOPHS, Kenya

14 Model component 4: Provision of surge support Emergency e.g.>25 cases Mentoring continues plus direct implementation by supporting NGO Follow up request & secondment of 1 additional NGO nurse Serious Normal e.g cases Surge support is: Defined for district Agreed in advance Formalised Alert in MoU Prepared Funded e.g cases e.g. <10 cases Mentoring continues plus implementation of short-term solutions to overcome gaps Intensified mentoring focuses on crucial gaps and hot spot facilities Health system strengthening through mentoring approach Follow up request & secondment of 1 nurse from another clinic Follow up request & train non-clinical staff to fill gaps Make request for staff allocation under MOH AWP Threshold Caseload Support provided Example: shortage of technical staff

15 Model component 5: Scaling down of surge support Scale up DHMT approaches NGO for additional support (where needed) During DHMT meeting issue is discussed and the scale up of support approved Health facility contacts DHMT Caseload reaches threshold Caseloads go below predefined threshold Health facility contacts DHMT During DHMT meeting issue is discussed and the scale down of support approved DHMT with support of NGO scales down the support Scale down Monitoring of malnutrition and disease caseloads, the health seeking influencing factors and mobilisation activities carried out in the area Health systems strengthening

16 Proof of Concept Response is timely and adequate Complicated vs. uncomplicated SAM cases Staff and patient satisfaction (working hours, waiting time) Cure/ death rate Coverage Health system is strengthened; surge has not undermined the system Health system performance (benchmarks ) Health system is prepared for future spikes in caseload Preparedness plan in place Resources secured Surge support is cost effective over traditional emergency response

17 Experiences from Uganda Context 1. Risk analysis 2. Threshold setting Chronically high SAM and morbidity Concern supporting IMAM since 3 years Checklist for gap analysis in use Nutrition survey carried out 3 times a year Routine disease monitoring at health centres Early warning system in place Based on current numbers in program General guideline 25% increase from hunger season caseload Only one threshold defined Surge support formalised in MoU with health facilities

18 Experiences from Uganda 3. Monitoring against thresholds and triggering surge support Early peak in OTP caseload observed High SAM prevalence in May 2012 survey Focus group discussion Rapid assessment to verify 4. Provision of surge support Originally surge support included staff increase only Mass screening Improved service efficiency: patient flow, taking measurements, simplified reporting Provided essential supplies and logistics: drugs, job aids, equipments Assisted with additional staff Set-up of mobile clinic

19 Experiences from Uganda 5. Deactivating surge support Proof of Concept Few referrals only after active case finding exercise Onset of good harvest High numbers of cured discharges Programme performance Coverage Improved alignment between supplementary and therapeutic feeding programmes Beneficiary feedback Namior Regine with 11 month old daughter Nakiru Korang, Tokora ITC, Karamoja, September 2011.

20 Lessons learned from Uganda Improving coverage is essential for effective surge Co-ordination with all nutrition and health stakeholders in the area is key to success Annual revision of thresholds is needed Lessons Learned District health office should take the lead Surge support needs to go beyond an increase in staff Training DHT on emergency preparedness allows for ownership

21 Experiences from Kenya Context 1. Risk analysis 2. Threshold setting Concern supporting IMAM in Moyale since 2009 Chronically high SAM with high risk of spikes Health facilities chronically understaffed Discussion on drivers of increased caseloads considered a real eye opener Also understood by non-clinical staff DHMT in Sololo did a district wide risk analysis Based on 2011 drought experiences Thresholds defined for severe and moderate malnutrition Took longer than expected

22 Experiences from Kenya 3. Monitoring against thresholds and triggering surge support 4. Provision of surge support Concept well understood Up-dating charts considered easy, requires little time and generates a lot of understanding Health workers appreciate being in the driver s seat Not yet tested in Kenya 5. Deactivating surge support Proof of Concept Not yet tested in Kenya Not yet tested in Kenya

23 Lessons learned from Kenya Coverage is key; not yet clear how to incorporate Overreliance on external support; little confidence in own resources/ capacities Introduction easy if straight after an emergency Lessons Learned Regular revision of thresholds is needed Acceptance of the model is closely related to its simplicity Incorporating community systems into the model requires further thinking

24 Plenary session: Feedback on Concern s surge capacity model