Linking Integrated Community Case Management & Nutrition

02 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014 Linking Integrated Community Case Management & Nutrition NEW YORK, NY MEETING REPORT 11-12 DECEMbER 2014

02 ICCM & NUTRITION MEETING - NEW YORK December 2014 GLOSSARY CCM CHW CMAM iccm IYCF MAM MUAC OTP RUSF/RUTF SAM SbCC TbA Community Case Management Community Heath Worker Community-based Management of Acute Manutrition integrated Community Case Management Infant and Young Chid Feeding Moderate Acute Manutrition Mid Upper Arm Circumference Outpatient Therapeutic Programme Ready-to-Use Suppementary Food/Ready-to-Use Therapeutic Food Severe Acute Manutrition Socia and Behaviour Change Communication Traditiona Birth Attendant INTRODUCTION On 11-12 December 2014, a meeting of a broad range of stakehoders with experience in nutrition and/or integrated community case management (iccm) was convened to expore the inkages between these two domains of heath programming. A ist of participants is found in Annex A and the agenda is incuded in Annex B. The objectives of the meeting were to: deveop a common understanding of the iccm and nutrition andscape and identify key essons and experiences to date; expore options for strengthening inkages between iccm and nutrition activities, and identify and prioritize opportunities to support their impementation. This meeting buit on two previous meetings. The iccm Evidence Review Symposium hed in Ghana in March 2014 reveaed that nutrition was being impemented as part of iccm, but eft unanswered questions about the specific activities this represented, and the practica inkages between the two. A meeting in London in May 2014 of a sma group of stakehoders with experience in impementing community-based nutrition programmes identified the need for a comprehensive review of the inkages between iccm and nutrition, and for diaogue with a wider range of stakehoders. The meeting in New York began with introductory remarks by David Miiband and Emmanue d Harcourt (Internationa Rescue Committee), stressing the importance of and need for inking the two domains. Sau Guerrero (Action Against Hunger UK) then provided the background for the meeting and the proposed objectives. Participants identified the foowing expectations for the meeting: to earn about what other partners are doing in iccm and nutrition; to initiate/continue diaogue on iccm and nutrition and to deveop consensus on strengthening the reevant inkages; to identify what is and is not known about inking iccm and nutrition, and to pan for next steps.

03 ICCM & NUTRITION MEETING - NEW YORK December 2014 PRESENTATION OF REVIEW FINDINGS Lynette Friedman and Cathy Wofheim presented an overview of the review they had conducted of operationa experiences and evidence for inkages/ integration of iccm and nutrition [Linking nutrition and (integrated) community case management: a review of operationa experiences (see fu report here)] The presentation began by situating iccm within the broader framework of communitybased infant and chid heath actions outined in a three-part package, Caring for newborns and chidren in the community, deveoped by WHO and UNICEF. This UNICEF/WHO package incudes: Caring for the sick chid in the community (iccm) http://www.who.int/materna_chid_adoescent/documents/imci_community_care/en/, Caring for the newborn at home http://www.who.int/materna_chid_adoescent/documents/caring_for_newborn/en/, Caring for the chid s heathy chid growth and deveopment http://www.who.int/materna_chid_adoescent/documents/care_chid_deveopment/en/ iccm is intended to prevent chid deaths in settings where there is poor access to care in heath faciities. It provides guidance, training materias, and job aids for Community Heath Workers (CHWs) to identify, treat, and/or refer chidren with diarrhoea, pneumonia, and maaria. Screening and referra of severe acute manutrition (SAM) is aso incuded, and a red mid upper arm circumference (MUAC) reading is one of the key danger signs. Since iccm is focused on sick chidren, the nutrition component in the UNICEF/WHO protoco is imited to: 1) advice on feeding during and after iness and 2) SAM identification and referra. The other two parts of the package, caring for the newborn at home and caring for the chid s heathy growth and deveopment, incude counseing and promotion reated to optima infant and young chid feeding practices.

04 ICCM & NUTRITION MEETING - NEW YORK December 2014 The review grouped interventions and experiences that inked or integrated iccm and nutrition into four categories, caed Typoogies, defined as foows: Typoogy 1 Advising on feeding the sick chid within existing services Advice on feeding during iness is provided by the CHW to the caregiver of the sick chid during the sick chid consutation. The standard UNICEF/ WHO materias recommend that the CHW advise (not counse) the caregiver of any sick chid treated at home to do the foowing: give more fuids and continue feeding, return to CHW or go to a heath faciity immediatey if the chid has danger signs, seep under a bed net, and return for foow up in three days. Many nutrition programmes focus on heath education messages or socia and behaviour change approaches to improving infant and young chid feeding. The inkages between these approaches and iccm 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. Typoogy 2 Linkages with Socia and behaviour Change activities on chid nutrition Typoogy 3 Linkages between iccm activities and acute manutrition treatment through assessment and referra According to the standard UNICEF/WHO protoco, the CHW 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 faciity for immediate care. This process is consistent with Community-based Management of Acute Manutrition (CMAM) recommendations. The treatment protoco for yeow 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. In some countries or projects, CHWs use active screening or active case detection through home visits or at growth monitoring activities to assess every chid, sick or we. The iccm CHW assesses, cassifies, treats and foows up cases of uncompicated severe acute manutrition at community eve or in the home. Compicated SAM cases are referred to an in-patient faciity. Adaptations of CMAM protocos to extend acute manutrition treatment to the community eve fa into two categories: Assessment, cassification, and treatment for acute manutrition are added onto the existing responsibiities of the iccm CHW. The iccm CHW is inked to a second community-based cadre with responsibiities and skis for addressing acute manutrition. Typoogy 4 Treatment of uncompicated SAM at community eve

05 ICCM & NUTRITION MEETING - NEW YORK December 2014 The review noted that the combination of iccm and nutrition interventions may be inked or integrated. In the generic materias, iccm is inked to nutrition through the identification of SAM and referra of the chid to a feeding programme or rehabiitation centre. iccm and nutrition are integrated in programmes where the CHW identifies and treats uncompicated acute manutrition. Exampes of country and programme experiences with iccm and nutrition inkage or integration were highighted in the review. There was a great dea of variabiity in the types of programmes and inkages, argey dependent on differences in contexts or settings. Avaiabe evidence on impementation, effectiveness, and cost of inked/ integrated iccm and nutrition was described and significant gaps were identified. DISCUSSION OF REVIEW FINDINGS The penary discussion on the findings of the review brought up a number of key points: The Typoogies shoud be understood as a description of what currenty exists, but are not necessariy representative of iccm and nutrition inkages that coud or shoud exist. As iccm and nutrition programming evoves, additiona or revised Typoogies may be needed. Typoogies 1-3 from the review are aspects of nutrition that are aready incuded in the UNICEF/WHO package (Caring for newborns and chidren in the community), whereas Typoogy 4 is an addition, which requires more testing and evidence. To date, impementation of the UNICEF/WHO CHW package has focused mainy on iccm. It is crucia to improve what is aready being done and to understand the cost and impact of adding activities. There is aso a need to emphasize the preventive nutrition aspects (e.g., in the other two parts of the package) as part of the range of what CHWs can do. Chid surviva has to be the overa goa of inked/integrated iccm and nutrition. The Evidence Review symposium in Ghana found that the impact of iccm aone on surviva seems to be imited; reasons for this shoud be expored. A research agenda is needed to understand how best to operationaize the integration of iccm and nutrition as we as the impact of integration. This may impy reviewing the iccm agorithms to find ways to improve the incusion of nutrition, and the CMAM agorithms to better address the needs of the sick chid.

06 ICCM & NUTRITION MEETING - NEW YORK December 2014 IDENTIFYING AND PRIORITIZING KNOWLEDGE GAPS AND OPERATIONAL OPPORTUNITIES During two sma-group sessions, participants identified, prioritized and then further refined knowedge gaps reated to strengthening inkages/integration of iccm and nutrition. Summaries of the output from these activities are incuded in Annexes C, D and E. Research priorities focused argey on issues reated to impementation of inked/ integrated iccm and nutrition. Participants expressed interest in identifying the best approaches, Typoogies or patforms for heath promotion and services in communities to achieve better chid heath outcomes. Specificay, they wanted to understand what is and is not working in current systems through which CHWs provide nutrition socia and behaviour change communication (SBCC) or advise on feeding the sick chid. They aso had questions on how to operationaize the addition of a new component (i.e., SAM treatment) to iccm and how additiona activities affect existing components. Severa questions were incuded reated to CHWs skis, the quaity of care they provide, and their abiity to take on more activities. KEY ObJECTIVES FOR INTEGRATING iccm & NUTRITION The discussions around the Typoogies and knowedge gaps deved into operationa detais, but aso brought out some of the broader issues with impementation and how iccm or iccm/nutrition is part of a arger system for promoting chid heath and treating inesses. To further expore these issues, five key objectives for integrating iccm and nutrition were proposed and discussed: 1 Improving coverage and quaity of services for the sick chid, thereby expoiting the synergy between the heath issues and ideay resuting in greater reductions in mortaity. 2 Optimizing the preventive aspects of iccm to maximize its contribution to chid nutrition. 3 Improving impementation of the UNICEF/WHO package. 4 Strengthening inkages between community and faciity. 5 Linking heath and nutrition at the institutiona eve. CHALLENGES TO IMPLEMENTING INTEGRATED iccm AND NUTRITION ACTIVITIES Discussion of the main chaenges to impementing iccm and nutrition activities resuted in a ist of key bottenecks. These incude: poory functioning suppy chains for RUTF, vertica funding streams, ack of standardized nutrition indicators in heath information systems and across organisations, inadequate coordination mechanisms for impementation and funding, ack of operationa guideines for impementing iccm and CMAM, ack of an advocacy pan for the integration of iccm and nutrition, weak heath systems, and ow utiization of heath services.

07 ICCM & NUTRITION MEETING - NEW YORK December 2014 THE WAY FORWARD Participants agreed to identify and set up a governance mechanism for a group that wi take forward the work discussed during this meeting. The most feasibe option seems to be the creation of a Nutrition subgroup within the iccm Task Force. Members of the steering committee of this task force agreed to bring this idea before the iccm Task Force during its December 2014 meeting. Goas for the Nutrition subgroup within the coming two years are as foows: Getting nutrition-iccm inkages on the goba heath and nutrition agenda Articuating a common agenda, incuding a business case Deveoping a pan for strategic advocacy and communication Aim for a specia session on nutrition-iccm in the 2016 iccm evidence review Supporting impementation and consoidation of information, knowedge, and evidence to inform normative standards/guidance Optimize nutrition advising in iccm guideines Expore ways to expand nutrition in iccm (potentiay incuding SAM treatment) Expore how to improve care of chidhood iness within the CMAM guideines Deveop a patform to move the inkages forward by engaging reevant stakehoders CONCLUSIONS There was consensus that the operationa inkages between iccm and communitybased nutrition interventions are feasibe and necessary, and are ikey to provide benefits to both areas. The review of experiences reveaed the imited number and types of experiences, as we as the scarcity of avaiabe evidence. A number of research questions need to be expored in order to guide the way forward. There is evidence that CHWs can provide high-quaity care for chidhood iness and for SAM, as we as highquaity advising on nutrition behaviours. The conditions under which these actions can be carried out remain to be defined, as does the best mix of iccm and nutritionreated actions and the supports needed to carry them out. It was recognized that athough participants embodied a range of organizations, expertise and knowedge, the ist of research questions wi need to be examined, refined and vetted by a more representative group before being finaized.

08 ICCM & NUTRITION MEETING - NEW YORK December 2014 ANNEX A PARTICIPANTS & background NAME AGENCY EMAIL Ivy Mushamiri 1mCHW Campaign ivy.mushamiri@mienniumpromise.org Sau Guerrero ACF UK s.guerrero@actionagainsthunger.org.uk Jose Luis Avarez ACF UK j.avarez@actionagainsthunger.org.uk Choe Puett ACF USA cpuett@actionagainsthunger.org Maureen Gaagher ACF USA mgaagher@actionagainsthunger.org Cecie Basquin ACF USA cbasquin@actionagainsthunger.org Sike Pietzsch ACF USA spietzsch@actionagainsthunger.org Angeine Grant ACF USA agrant@actionagainsthunger.org Saim Sohani Canada Red Cross Saim.Sohani@redcross.ca Sau Morris CIFF Smorris@ciff.org Hedwig Deconinck CMAM Forum hdeconinck@gmai.com Sonya Kiber Concern sonya.kiber@concern.net Abigai Perry DFID A-Perry@dfid.gov.uk Tina Loren FANTA TLoren@fhi360.org Sheby Wison Gates Foundation Sheby.Wison@gatesfoundation.org Pau Robinson IMC probinson@internationamedicacorps.org Juan Caros Martinez Bandera Independent jmartinezbandera@gmai.com Lynette Friedman Independent friedmanynette@gmai.com Cathy Wofheim Independent wofheimc@buewin.ch Vaerie Fax University of North Caroina fax@unc.edu Casie Tesfai IRC casie.tesfai@rescue.org Abigai McDanie IRC abigai.mcdanie@rescue.org Hannah Tayor IRC hannah.tayor@rescue.org Emmanue d Harcourt IRC harcourt@rescue.org Katja Ericson IRC South Sudan katja.ericson@rescue.org Miche Pacque MCSP/JSI miche_pacque@jsi.com Prudence Hamade Maaria Consortium p.hamade@maariaconsortium.org Meghan Gifian MDG Heath Envoy Meghan.Gifian@mdgheathenvoy.org Katie Macdonad PSI kmacdonad@psi.org Zaeem U Haq Save the Chidren UK Z.Haq@savethechidren.org.uk Emiy Keane Save the Chidren UK E.Keane@savethechidren.org.uk Rashed Shah Save the Chidren USA mshah@savechidren.org Eric Swedberg Save the Chidren USA Eswedberg@savechidren.org Sarah Buter Save the Chidren USA sbuter@savechidren.org Miion Shibeshi Save the Chidren, Ethiopia Miion.Shibeshi@savethechidren.org Addis Ashenafi Bogae Save the Chidren, South Sudan Addis.Bogae@savethechidren.org Forence Njoroge Save the Chidren, South Sudan Forence.Njoroge@savethechidren.org Diane Hoand UNICEF dhoand@unicef.org Mark Young UNICEF myoung@unicef.org Nathan Mier UNICEF nmier@unicef.org France Begin UNICEF fbegin@unicef.org Maaike Arts UNICEF marts@unicef.org Judy Canahuati USAID jcanahuati@usaid.gov Anne Peniston USAID apeniston@usaid.gov Samira Aboubaker WHO aboubakers@who.int Sarah Carr Word Vision sarah_carr@wordvision.ca Afonso Rosaes Word Vision arosaes@wordvision.org

09 ICCM & NUTRITION MEETING - NEW YORK December 2014 ANNEX b THURSDAY DECEMbER 11TH 2014 PROPOSED AGENDA TIME TOPIC SESSION PRESENTER/FACILITATOR 09:00-09:30 Registration 09:30-09:45 Wecome Penary Presentation David Miiband, CEO IRC 09:45-10:00 Introduction: Penary Presentation Emmanue d Harcourt, IRC Agenda, Who is in the room, Objectives of the Meeting 10:00-10:15 Background: How We Got Here, Penary Presentation Sau Guerrero, ACF UK Introduction to the Review 10:15-10:25 The Basics: What are the basic Penary Presentation Cathy Wofheim & Lynette Friedman, consutants eements/processes associated with iccm? 10:25-11:15 Presentation of the iccm & Nutrition Penary Presentation Cathy Wofheim & Lynette Friedman Review: Operationa Typoogies, Poicy Environment, Concusions & Recommendations 11:15-11:30 break 11:30-12:15 Q&A Penary Discussion Vaerie Fax, faciitator 12:15-13:00 Mapping iccm & Nutrition Typoogies: Penary Discussion Vaerie Fax What Typoogies for inking Nutrition and iccm are there? What actions woud need to be taken to hep strengthen existing/potentia inkages? 13:00-13:45 Lunch 13:45-14:45 Identifying Remaining Knowedge Gaps Group Work Vaerie Fax 14:45-15:00 Presentation of Remaining Knowedge Gaps Penary Presentation Vaerie Fax 15:00-15:15 break 15:15-17:00 Prioritising Knowedge Gaps and Operationa Group Work Vaerie Fax Opportunities: using different criteria, each working group prioritises knowedge gaps and specific operationa opportunities 17:00-17:15 Wrap Up Penary Presentation Vaerie Fax FRIDAY DECEMbER 12TH 2014 TIME TOPIC SESSION PRESENTER/FACILITATOR 09:00-09:30 Recap from Day One Penary Presentation Vaerie Fax 09:30-10:00 Presentation of Knowedge Gaps and Penary Presentation Vaerie Fax Operationa Opportunities Ranking 09:30-11:00 Mapping Ongoing Initiatives: are existing Penary Presentation Vaerie Fax initiatives panned that wi address priority knowedge gaps? 11:00-11:15 break 11:15-13:00 Panning Future Initiatives: how can we Vaerie Fax move forward operationay to address some of the knowedge gaps and to buid on operationa opportunities? 13:00-13:45 Lunch 13:45-14:45 Poicy Anaysis: what are the main poicy Group Work Vaerie Fax opportunities and chaenges facing the further deveopment of successfu Typoogies? What actions can and shoud be taken? 14:45-15:00 Presentation of Key Actions to infuence Penary Presentation Diane Hoand, UNICEF poicy environment 15:00-15:15 break 15:15-16:15 Future Coordination and Governance: Penary Discussion Sau Guerrero, ACF UK how wi the Working Group connect with key patforms/stakehoders in taking this forward? What are the key objectives of the Working Group in moving forward? 16:15-16:30 Wrap Up Penary Presentation Vaerie Fax

10 ICCM & NUTRITION MEETING - NEW YORK December 2014 ANNEX C OUTPUT OF GROUP WORK ON IDENTIFICATION OF KNOWLEDGE GAPS Typoogy 1 Advising on feeding the sick chid within existing services Do CHWs foow the iccm guideines and give correct probem soving advice? Why don t CHWs give advice? Can the iccm protoco be enhanced to improve nutritiona outcomes? Are caregivers abe to feed the sick chid after having been advised to do so by the CHW? Does adding the message on feeding the sick chid have an impact on nutritiona status? Discussion: If there is no inkage between iccm and nutrition in a country, Typoogy 1 is the minimum. Typoogies 1 and 3 are not mutuay excusive. If CHWs are not advising on feeding the sick chid, we need to understand why. We need to understand whether advising or counseing is more effective in terms of changing feeding practices during iness. What has the argest impact integrated iccm and socia and behaviour change communication (SBCC) or standaone SBCC? What skis do CHWs or other heath cadres need to combine curative activities with SBCC? What are operationa Typoogies to combine curative and preventive tasks (e.g., singe muti-tasking CHWs versus mutipe CHWs versus a team approach)? Coud existing cadres (curative and preventive) be brought together into one team? What are costs and effectiveness of each option? What are effective Typoogies for professiona deveopment of iccm workers (incuding sequencing)? Typoogy 2 Linkages with Socia and behaviour Change activities on chid nutrition

11 ICCM & NUTRITION MEETING - NEW YORK December 2014 Discussion: We need to define what type of impact shoud be measured. Nutrition outcomes? Heath outcomes? What is the range of practices covered in SBCC? In the review, SBCC is focused on infant and young chid feeding, but it coud incude other nutrition topics. How much of a burden on CHWs is integration of nutrition interventions? Wi adding those activities break the system? Typoogy 3 Linkages between iccm activities and acute manutrition treatment through assessment and referra What is the added vaue of referra through iccm? How many competed referras come from iccm versus usua referra mechanisms? What are strategies to improve referra mechanisms? If there is no good referra system, this Typoogy won t work. Are there different Typoogies in which the addition of assessment and referra woud be easier/more effective (e.g., in some iccm programmes, CHWs do home visits for screening/referra, not just waiting for the sick chid)? How do we improve and sustain quaity/skis of CHWs to assess and refer? Typoogy of more case finding/home visits versus Typoogy of waiting for the sick chid to come: Does number of SAM cases increase because of that? Increased CMAM coverage. Barriers to access (e.g., socia access to coming to that service). Might be a gradua evoution (e.g., might see increase in peope coming on their own after the programme has taken root in the community). If assessment and referra are aready part of the iccm guidance, why doesn t it happen in every pace where iccm is being impemented? Is this Typoogy cost effective compared to systems/typoogies to assess and refer that are not through iccm (e.g., non-iccm CHWs do the assessment and referra)? Are the current iccm guideines sufficient (e.g., yeow MUAC isn t incuded)? If we fee that what we have is not enough, where can the iccm guideines be strengthened? What work oad impications might additions have? Discussion: What about identification and referra of MAM?

12 ICCM & NUTRITION MEETING - NEW YORK December 2014 Typoogy 4 Treatment of uncompicated SAM at community eve Evidence gap: Asking the same questions as the Bangadesh paper in terms of coverage of services, quaity of care, cost effectiveness, treatment outcomes but in different contexts incuding the intervention deivered by the heath system, not ony NGO supported. How can the outpatient therapeutic program (OTP) protoco be simpified for CHWs, incuding CHWs with ow iteracy (e.g., medication & RUTF dosages, etc.)? What is the impact on the CHW (incuding risk) on suppy chain management of RUTF / RUSF? How does this impact on the CHW community reationship? What is the additiona workoad of the CHW and how does that impact on the quaity of service deivery? Comparison of Typoogy 3 and 4 and what are the outcomes, given a of the underying characteristics of the programme? Operationa Questions: What is the impact of the introduction of RUTF to the overa iccm suppy chain management? When adding on SAM, what impact does it have on the other iccm interventions and quaity of care, both the existing iccm components and nutritiona components What is the minimum capacity (education, iteracy, training) of the heath worker to treat SAM? Is it better to impement a 4 components simutaneousy or to sequence them? Is this affected by the maturity of the iccm intervention? What is the increased workoad of the heath worker when SAM is added and what impact does it have on service provision and motivation? How can the addition of SAM treatment be used as an opportunity to evauate current quaity of care and strengthen the patform? Shoud there be a component of active case finding in addition to the passive case finding? What is the minimum SAM caseoad to ensure that the CHW can maintain quaity of care? Genera Questions common for iccm with addition of SAM treatment: Variabes to consider: different types of CHWs, active versus passive case finding, ratios of popuation to CHW and CHWs to supervisor, minima eve of supervision (frequency of contact, quaity of exchange, suppy chain), essons earned from ICCM, inking to what aready exists, country setting, education, SAM prevaence, popuation density, epidemioogica picture affecting manutrition Discussion: Is there trust from the caregivers for treatment by CHWs? If SAM treatment occurs at the community eve, how do we avoid turning iccm into a vertica programme? We ack indicators to capture data in reation to a four Typoogies in order to monitor trends in outcomes. What are appropriate indicators for each Typoogy? Many of the questions deveoped during this session are simiar to those identified through the iccm Task Force s CHNRI process. How can these research gaps be addressed? What resources are avaiabe to do so?

13 ICCM & NUTRITION MEETING - NEW YORK December 2014 Questions are ranked from those that received the most votes to those that received the east. RESEARCH QUESTION ANNEX D OUTPUT OF GROUP WORK ON PRIORITIZATION OF KNOWLEDGE GAPS Does integrating SAM treatment into iccm improve the coverage of one or a services? 15 What is the additiona workoad of the CHW and how does that impact on the quaity of service deivery? 14 What are the outcomes of treating vs. just referring SAM cases? 14 When adding on SAM, what impact does it have on the other iccm interventions and quaity of care of both the existing 13 iccm components and nutrition components (e.g., breastfeeding promotion)? How can the OTP protoco be simpified for CHWs, incuding CHWs with ow iteracy? 12 What are operationa Typoogies to combine curative and preventive tasks (e.g., singe muti-tasking CHWs versus mutipe 9 CHWs versus a team approach)? What are strategies to improve referra mechanisms? 8 What is the impact of SAM (or MAM) treatment on the CHW motivation and service uptake? 7 Does adding the message on feeding the sick chid have an impact on nutritiona status? 6 How do we improve and sustain quaity/skis of CHWs to assess and refer? 6 If assessment and referra are aready part of the iccm guidance, why is it not happening in every pace where iccm is being 6 impemented? Is this Typoogy cost effective compared to systems/typoogies to assess and refer that are not through iccm (e.g., non-iccm 6 CHWs do the assessment and referra)? What is the impact on the CHW (incuding risk) on suppy chain management of RUTF/RUSF? How does this impact on the 6 CHW/community reationship? Is it better to impement a 4 components simutaneousy or to sequence them? Is this affected by the maturity of the iccm 6 intervention? Can the iccm protoco under Typoogy 1 be enhanced to improve nutrition outcomes? 5 Shoud there be a component of active case finding in addition to passive case finding for SAM? 5 Do CHWs foow the iccm guideines and give correct, probem soving advice? 4.5 Does the foow up visit of a sick/recovering chid provide a specific opportunity for SBCC? 4 What is the added vaue of the referra through iccm? How many competed referras come from iccm versus 4 other referra mechanisms? Why is the current protoco not being appied in reation Typoogy 3? 4 Are the current iccm guideines sufficient (e.g. yeow MUAC isn t incuded)? If we fee what we have is not enough, 4 where can the iccm guideines be strengthened? What work oad impications might additions have? What is the impact of the introduction of RUTF to the overa iccm suppy chain management? 4 What is the minimum capacity (education, iteracy, training) of the heath worker to treat SAM? 4 What are the costs and effectiveness for each option? 3 Why don t CHWs give advice? 2.5 What has the argest impact: integrated ICCM - SBCC or standaone SBCC? 2 Are there different Typoogies in which the addition of assessment and referra woud be easier/more effective (e.g. in some 2 iccm programmes CHWs do home visits for screening/referra, not just waiting for the sick chid)? Can standardized definitions/indicators of performance be deveoped to start evauating performance of existing services/typoogies? 2 What skis do CHWs or other heath cadres need to combine curative activities with SBCC? 1 Coud existing cadres (curative and preventive) be brought together into one team? 1 What are effective Typoogies for professiona deveopment of iccm workers (incuding sequencing)? 1 How does gender impact on appropriateness and effectiveness of SBCC? 1 Typoogy of more case finding/home visits vs. Typoogy of waiting for sick chid to come. Does number of SAM cases increase because of that? 1 Does Typoogy 3 differ in reation to referra for SAM ony, MAM ony or SAM/MAM? 1 What is the minimum SAM caseoad to ensure that the CHW can maintain quaity of care? 1 Do we know if the caregiver is abe to feed the sick chid, after having been tod to do so by the CHW? 0 How can the addition of SAM treatment be used as an opportunity to evauate current quaity of care and strengthen the patform? 0 SCORE Write in candidates: What is the perception/wiingness to access nutrition treatment through CHWs by caretakers/decision makers/community? What factors infuence the perception? Comparison between Typoogy #3 and #4 - cost- effectiveness, coverage (CMAM iccm), impact Coud iccm be an effective deivery patform for other nutrition-specific interventions, particuary vitamin A and deworming?

14 ICCM & NUTRITION MEETING - NEW YORK December 2014 ANNEX E OUTPUT OF GROUP WORK ON REFINING KNOWLEDGE GAPS IN RELATION TO KEY ObJECTIVES FOR THE INTEGRATION OF iccm AND NUTRITION Objective 1 Improving coverage and quaity of services for the sick chid Does the incusion of SAM improve the coverage of SAM services and the rest of the iccm services? Can you achieve optima SAM services by inking referra? Is passive case finding sufficient to achieve coverage? Can the incusion of SAM treatment be added safey by the same workers deivering the iccm protoco? Does incusion affect quaity of care of SAM treatment and the three-part UNICEF/WHO package? Is advising on continued feeding being done? Is foow-up on day 3 being done? Indicators on quaity of care shoud be measured and incorporated into performance reviews. Is advising on feeding the sick chid effective at changing behaviour? Is the timeframe of measurement of performance appropriate? What is the indicator of effectiveness? Do caregivers beieve in the CHW s advice? Does confidence in the advice vary by age/gender of the CHW? Is advising on feeding the sick chid enough? Are parents abe to foow the advice? If not, what other options shoud be suggested? Referras to integrate into agorithm? Shoud advising be expanded to IYCF counseing? Shoud micronutrients and deworming be incuded through iccm or another package? What are the obstaces to effective advising? (For exampe, is there a need for a different job aid? Do peope not beieve in it? Is there capacity to do more than advising? Shoud someone ese be doing it? Is it reaistic to do it? Impementation ink with other packages? Supervisory or training issues/ options? Minimum criteria for CHW?) Who ese coud provide advice on feeding the sick chid? TBA, mothers, other? How can performance management be improved? Other: Links to other packages? Links to community eve SBCC? Objective 2 Optimizing the preventive aspects of iccm impementation to maximize its contribution to chid nutrition Objective 3 Improving impementation of the UNICEF/WHO package What essons can we earn from other integration efforts (e.g., HIV/TB)? What are the issues reated to the impementation of the existing package? How can the design of the existing package be improved? What operationa patforms exist to deiver the three-part package? What are the differences between operationa systems in different ocations/countries? What is the impact of the 3-part package on the workoad of CHWs? Woud this compromise quaity? Which aspects of nutrition are aready being integrated into programmes in the fied with the package (e.g., excusive breastfeeding into newborn care, SAM into iccm)?

15 ICCM & NUTRITION MEETING - NEW YORK December 2014 Objective 4 Strengthening inkages between community and faciity Coverage Does the incusion of SAM treatment improve (popuation-based) coverage of SAM services and/or other iccm packages? Does the incusion of SAM case-finding and referra into iccm improve coverage of faciity-based SAM treatment services? Is passive case-finding sufficient to deiver optima coverage? What woud be the main factors affecting uptake and utiisation of iccm and SAM treatment? Quaity of Care Can CHWs deiver SAM treatment safey? Can CHWs identify SAM with compications? Is the referra of SAM cases with compications foowed? Does the integration of SAM treatment into iccm affect quaity of care, for SAM and/or the other packages? How does the SAM caseoad affect the quaity of care, for SAM and/or the other packages? How do different ways of integrating SAM treatment into iccm (after 3 packages, from the start, etc.) affect quaity of care, for SAM and/or the other packages? What are the poicy and strategy gaps in chid heath/nutrition that may present opportunities to incude integration/inkages between iccm & nutrition (some poicies may be in drafting stages or facing obstaces for impementation depending on country)? Learning from country experiences Ethiopia exampe: heath sector transformation pan (HSTP) as overarching poicy/strategy that inks heath and nutrition sectors at nationa eve Nepa exampe: heath sector impementation pan and joint financing arrangement for a donors; consoidated nutrition pan with a sectors What are the existing patforms for diaogue on chid heath/nutrition with nationa and state eve institutions and stakehoders? Does a champion exist or how can you find a champion within the system to continue to move initiatives forward? How can we deiver/communicate effective and succinct messages on the benefits of integration and/or inkages between iccm & nutrition to foster buy-in and poitica wi (based on benefits to overa chid heath/surviva and evidence)? How can we identify, engage and coordinate the major donors of drugs/ suppies to advocate and work with the Ministry of Heath for a unified and consoidated suppy chain system? Objective 5 Linking heath and nutrition at the institutiona eve

02 LINKING NUTRITION & (INTEGRATED) COMMUNITY CASE MANAGEMENT December 2014