A view of NACS in Kenya from 60,000 feet      Nutrition and HIV Program – Kenya                 Brian Njoroge             ...
Outline Concept –     Approaches                                               WayContinuum of     Facility-   Opportuniti...
Understanding the IssuesIntegrating nutrition assessment, education and counseling as a universal service  Positioning o...
Epidemiology of malnutrition in adult PLHIV                                  Severely                               undern...
Defining the NACS Package of servicesCategory                    Package of services (What, Where and by who? )(inferred f...
CONTINUUM OF NUTRITION, HEALTH & FOOD SECURITY SERVICES                  NUTRITION SERVICES HEALTH                        ...
Concept –     Approaches                                               WayContinuum of     Facility-   Opportunities      ...
System Approach for NACS   Agenda Setting – Alignment with existing policies ,    statutes etc   Leadership at national ...
Health System: NACS Service Delivery in Kenya       MOH/ Other Public       Faith-Based/Non                               ...
Moving From Pilot to Scale (Creating a critical mass) …..    Pilot Phase -2006            Transition/Adaptation Phase - 20...
60,000                                                           Growing NACS – health facility perspective               ...
Trends in Uptake of NACS/FBP and Flow of Food Commodities                    7,000                                        ...
Growing NACS – community perspective                                                                                      ...
Model for Growing NACS/FBP Services                 80,000                                                                ...
Concept –   Approaches                                            WayContinuum     Facility-   Opportunities              ...
Beyond HIV – Opportunities for optimizing NACS• Trend of non communicable diseases in  developing countries  – Type II dia...
Beyond the health sectors - NACS informing Agriculture& Industry, education & Disaster preparedness Agriculture Value Cha...
Concept –     Approaches                                               WayContinuum of     Facility-   Opportunities      ...
Going Forward Accelerate scale-up of NACS as part of the community  strategy Harmonize protocols for SAM and advanced MA...
Thank YouTriage point                                            Low risk                     Moderate                    ...
WonderingWhat is the meeting point between GHI and FtF – in the Kenyan context and others?How can we amplify NACS agenda...
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  • Alternate Title – DEMYSTIFYING KELLOG’S FINACIAL HEALTH AND PERFORMANCEVision and Mission ……Kellogg Company’s Vision and Mission statements define our focus upon sustainable growth, our broadened definition of social responsibility and the true strength of our company – our people and our brands.Our Vision encompasses the full spectrum of our stakeholders including shareowners, employees, customers, consumers and communities.  Our Mission articulates where we are as a company today and where we wish to be in the future.
  • NHP understood that utility of NACS is cross-cutting and goes beyond Nutrition in the context of HIV related diseases.Therefore, we saw the need to advocate for nutrition assessment as a vital sign in clinical care (outside private hospital and well established clinics) where nutrition assessment is carried out along with vital signs. Here the public sector which is the target for NHP can learn a best practice from the private sector – lobbying for documentation of patient in the “blue” card, lobbying for strengthening of nutrition section in NASCOP.With a compulsory basic education system, we saw the need to consider reinforcing key aspects NACS in basic and post basic education subject of nutrition and health. This intervention should elevate NACS as among lifestyle training subjects.NHP/Kenya strongest point of entry was a response to the HIV emergency and to use the strategy to create a critical mass of believers and move from push operation to a pull operations.
  • Malnutrition covers a set ofnutrient deficiency diseases. Transitions across the different risksstaes necessitated a good understanding of the risks. NHP’s opportunity was to advocate and facilitate rapid scale-up of FBP to primary/central sites and satellite sites using the ART scale-up platform. Favourable conditions included having many nutritionists in the country but NHP also sought from the outset to create a multidisciplinary team by training nurses and clinical/medical officers, pharmacists.
  • classification, and primary relevant to this discussion Nutritional diseases fall into the following broad categories – malnutrition associated with protein and energy deficiencies; malnutrition associated with protein and energy deficienciesnutritional deficiencies of vitamins, minerals and trace element; obesity and other hyperalimentation; and metabolic disorders of proteins, fats, and carbohydrates.
  • The system approach is necessary because of the overall understanding that the lead risk mitigating factors are informed by the health care, and access, availability and intake of food. The linkages ensuring continuum with the health system and food security supporting systems (food availability and access) among others (water, hygiene and sanitation). Kenya Health system:Health – positioning of FBP with registered public, FBO/NGO health facilities.Agriculture – interface nutrition as part of home economics and livelihoods supportWater and sanitation – cut down the contribution by diarrhoea related diseasesSocial services – Social workers support for the most vulnerable eg cash transfer for OVCsFor each system, understanding the resources available (HRH, Monitoring and evaluation including electronic supported systems; Food production systems – agriculture and animal health.
  • To create needed momentum, NHP aligned its objectives with those of the MoH as part of its first phase operation. The aim was to create a critical mass and turn the program from a push to a pull system. What is the critical mass? – raise the number of facilities providing with nutrition care for the malnourished to at least half of those providing ART, provide NACS supporting information and materials to all ART sites (underway). Use the community strategy as the platform for engaging social systems operating at community – CBOs and FBOs to be champions of NACS and reach out to upstream production systems – agriculture extension service and food manufacturers.
  • Using primary sites as distribution points so as to maximize on their supervisory responsibilities for peripheral facilities (health centres and dispensaries).Kenyans are served by close to 8,000 health facilities. Close to half of these are private sector (for profit). How and when do we reach them? What can we learn from PPP in management of TB? What can we learn from the child immunization program?
  • Coordination to facilitate piggybacking on other implementers in delivery of services at community level. Harmonization of indicators and data capture tools by partners. Create the Quality improvement waveObservation of the three-ones principle in NACS is required. Alignment of NACS service use reporting with ART & Care.
  • The ratio of Central sites (primary sites) is 1:3. Whilst NHP experienced major challenges in commodity flow for close to 18 months (2010/2011), it would appear that the growth in number of patients may be approaching a plateau. Most of the large sites are covered by NHP and AMPATH. NHP supports AMPATH in management of SAM cases only.The ART entry point has been raised from CD4 count of 200 to 350 cell/mL. Meaning that many patients are initiated on ARVs before reaching immunological and nutritional crises (at least for majority). We are closely watching to see the impact of improved flow of commodities during this quarter. If this plateauing is maintained – then it is time to re-think the strategy? {let us examine the relationship between commodity flow and uptake of services in the public/FBO subsector?}
  • FBP commodities have a strong effect of NACS service utilization in a referral set up. At site levels, health workers appear to give preference to revisiting clients over new clients except in SAM cases.Recovery of client flow lags behind stock replenishment by about one month. Surges in restocking sites is disruptive in NACS+FBP service utilization.Reforms to institute Assessment Education and Counselling as a vital sign assessment will smoothen growth of NACS service utilization. For HIV clinics, this action was taken shortly after the last review meeting but the revised patient “blue” cards have only recently reached these clinics. (NHP to follow-up)
  • During the last 15 months NHP has accelerated collaborating with CBOs to reach out to OVCs, pregnant and post-partum mothers and support HCBC. The main activity is screening using MUAC, education and referral. Over 80% of those screened are < 5 yr-olds. 1. The potential and need for scaling up is explicit. The target should be coverage of all community health units (1CU covers about 5,000 people) across the country.2. Strengthening the capacity of CHW/Vs is crucial – Full implementation of the Community Strategy (health sector driven) will anchor the NACS push to implementers among them CBOs. 3. The outcome of the scale-up could be increased numbers at facility level. They may not be able to cope! So it is right time to review the strategy. Concurrently, NHP is piloting a version of CTC targeting OVCs. This action is informed by the low uptake of referrals despite fostering linkages between the CBOs/CHWs and local NACS-FBP sites. We are also piloting mobile telephony targeting alert signals when a child with SAM is identified. The aim is to reinforce referral and track actions/outcomes for each case. 4. The AOTRs have intervened to have affirmative action on NACS by all the APHIA plus partners. These partners have potential to escalte the service in majority of the Cus.
  • Theoretically, all malnutrition precipitating factors held constant, demand for FBP could decrease after period X years of NACS+FBP implementation. The FBP +NACS model is therefore limited in the context of a referral service. The correct positioning of NACS is strengthen preventive and promotive service, and offer more efficacious FBP service for the clinical malnutrition with respect to therapeutic foods for SAM patients and prophylaxis (supplementary??) foods for the rapid progressors in moderate/mild situations. NHP dreamt that it was practical reach the mode in the uptake of FBP + NACS service and even witness witness the decrease in the pool of malnourished ART and ART-naive patients decrease to an asymptote. The asymptote would then vary with new infections, food insecurity etc. It was envisaged that the government of Kenya and partners would be able to handle asymptote numbers. Does this hypothesis still hold water? Only to some extent!An aggressive community and facility NAC(S) holds the key. The community swing allows a true reflection and estimation of the demand curve. Effective NACS should spur other interventions and multidisciplinarity in combating infectious diseases and food security associated malnutrition.
  • Majority of developing countries are experiencing rapid urbanization of the population. This is realistic response for state to keep adequate land for food production and maintain a stable environment to support the population. Urbanization and change in life style (diets, dietary practices and physical activity) means that we will experience significantly higher % of overnutrition population and its consequences. In Kenya, it is estimated that the that rate of overweight and obesity in the urban population is 3 fold that of the rural population (15% vs 5%). Impaired Glucose Tolerance (IGT) (> 12% ) and overt diabetes (~ 5%) among free living individuals. The latter has been place at ~ 10% in urban and peri-urban areas in the large towns and cities.There is growing concern that Kenya and many other countries will not attain the MDGs (1-4). Can accelerated NACS spur realization of these goals? Yes Kenya has set its eyes on raising the number on ART to ~ 800,000 clients who need ARV by 2014. Even within ART programming, NACS (with or without FBP) should be scaled up to reach all the targeted clients. This means going beyond the confines of ART programming – best is to use the PMTCT as the denominator. This would reach ~ 4,500 sites out of the ~ 8,000 facilities (all) in Kenya.
  • {What, which, where, when, why and how ?} - Must we do from here?The US Ambassador’s initiative dubbed “let’s live” that was launched with MoH and USG implementing partners aims at bringing all cause mortality in Kenya by 50% by end of 2012 (a rapid response initiative - RRI). Ways improve access to services by communities and household that for one reason or another (culture, economic, stigma etc) can not access health facilities require attention. NACS taken at multisectoral and mulitidisciplinary or transdisciplinary level has big potential to contribute to this initiative.
  • Brian Njoroge

    1. 1. A view of NACS in Kenya from 60,000 feet Nutrition and HIV Program – Kenya Brian Njoroge 1
    2. 2. Outline Concept – Approaches WayContinuum of Facility- Opportunities Forward care community 2
    3. 3. Understanding the IssuesIntegrating nutrition assessment, education and counseling as a universal service Positioning of nutrition assessment as a vital sign Positioning nutrition assessment & education as a life skillIntegrating FBP as a targeted (referral) service to those with clinical nutritional deficiency diseases  Standardized treatment protocolsUnderstanding nutritional risk and their relative importance to progression of malnutrition – Biomarkers : slow progressors vs rapid progressors 3
    4. 4. Epidemiology of malnutrition in adult PLHIV Severely undernourishedPopulation of PLHA (5 – 11%) Moderately undernourished (20 -25%) Normal (60 – 80%) Over nourished ( ~ ?) 4
    5. 5. Defining the NACS Package of servicesCategory Package of services (What, Where and by who? )(inferred from Assessments Interventionsanthropometric (IEC materials at all levels)assessment)Normal Anthropometric , dietary BCC, Group counseling, Referrals and lifestyleModerately Anthropometric , dietary and BCC, Group counseling,undernourished lifestyle assessments, (refer Individualized counseling, FBP and(wasted) to other diagnostic services) ReferralsSeverely Anthropometric , function, BCC, Referrals , Group counselingundernourished dietary and lifestyle (refer to daily observed feeding (DOF),(acute wasting) other diagnostic services). individualized counselingOvernutrition / As above primary relevant to BCC, individualized counseling,obesity, this discussion Nutritional participation group therapy, referraloverloads diseases 5
    6. 6. CONTINUUM OF NUTRITION, HEALTH & FOOD SECURITY SERVICES NUTRITION SERVICES HEALTH FOOD CARE SECURITY 6
    7. 7. Concept – Approaches WayContinuum of Facility- Opportunities Forward care community 7
    8. 8. System Approach for NACS  Agenda Setting – Alignment with existing policies , statutes etc  Leadership at national and sub-national levels & Managerial capacity  Resource Needs (Inputs) – HRH, Equipment, Infrastructure, Financing & Social Capital  Service Package – single intervention vs multiple interventions  Delivery channels – vertical vs integrated  Identify novel approaches – private sector delivery channels vs public sector  Identify synergies & partners and persuadeSecure Political Commitment; Leadership Planning & Implementation; Resources 8
    9. 9. Health System: NACS Service Delivery in Kenya MOH/ Other Public Faith-Based/Non USG I Partners Private Sector Hierarchy Governmental USAID Hierarchy Organization Hierarchy CDC WFP Higher-Level Higher-Level Global Fund National Referral Hospitals Hospitals Hospitals UNICEF MSF Provincial Lower-Level WHO Lower-Level Hospitals Hospitals Hospitals Others District Hospitals Health Nursing Maternity Centers Homes Homes Sub-District Hospitals Dispensaries Health Centers Clinic Medical Dispensaries Community CentreKey: Central sites Satellite sites except Nairobi Agriculture & other Sectors Partner coordination and collaboration 9
    10. 10. Moving From Pilot to Scale (Creating a critical mass) ….. Pilot Phase -2006 Transition/Adaptation Phase - 2008 MoH, MoH, INSTA INSTA NHP FBO FBO MoH, INSTA NHP FBO Scale-up NHP Phase -2009OTHER KEMSA MoH, MoH, FBO, FBO Private NHP SCM Sector INSTAINSTA SCM partners Scale-up Phase -2010/12Maturation Phase – Post 2013 Nutrition Service Register; LMIS Tools 10
    11. 11. 60,000 Growing NACS – health facility perspective 180 No. of New patients enrolled 158 160 No of FBP Central Sites 49,474 51,202 50,000 140 130 40,473 40,000 120No. of New Patients enrolled 36,432 No. of Central Sites 105 100 30,293 30,000 80 20,000 60 57 57 40 10,000 5,618 20 7 - - 2006 2007 2008 2009 2010 2011 YEAR 11
    12. 12. Trends in Uptake of NACS/FBP and Flow of Food Commodities 7,000 180.0 New Clients Revisits FBF Delivered 160.0 6,000 140.0 5,000 120.0 4,000 Metric Tonnes 100.0Number of Clients 3,000 80.0 60.0 2,000 40.0 1,000 20.0 - 0.0 February February February December December December September September September November November January November January April June April June April June July July October January July October October May May May March March March August August August Y1-Q4 Y2-Q1 Y2-Q2 Y2-Q3 Y2-Q4 Y3-Q1 Y3-Q2 Y3-Q3 Y3-Q4 Y4-Q1 Y4-Q2 Y4-Q3 2009 Reporting Period 2010 2011 12
    13. 13. Growing NACS – community perspective Train new CHW [FAIR] 14000 2000 1800 12000 Retraining forNo Assesed DQI 1600 10000 Nutritional Status - No Clients 1400 1200 8000 1000 6000 800 4 New CBOs onboard 4000 (Nyanza, Western) 600 400 2000 200 0 0 Jul-Sep Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec 3 1 No CBOs, Reporting Year 5 7 8 No Assessed SAM MAM 13
    14. 14. Model for Growing NACS/FBP Services 80,000 1,400 ? ? 70,000 1,200 60,000 60,000 1,000 51,202 50,000No. of Clients 49,474 No of Sites 800 40,000 40,473 36,432 Asymptote 600 30,000 30,293 ? 400 20,000 280 300 10,000 250 200 5,618 130 158 200 ? 57 61 - 7 - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Years Clients Central Sites Total Sites (Central + Satellites) 14
    15. 15. Concept – Approaches WayContinuum Facility- Opportunities Forward of care community 15
    16. 16. Beyond HIV – Opportunities for optimizing NACS• Trend of non communicable diseases in developing countries – Type II diabetes, hypertension, end stage renal disease (as complications), cancers• Filter of NACS allows (index of suspicion) for early identification of chronic diseases• Using NACS to stimulate actions towards realization of MDGs• Increased service uptake, adherence to treatment and Quality Improvement 16
    17. 17. Beyond the health sectors - NACS informing Agriculture& Industry, education & Disaster preparedness Agriculture Value Chain – Productivity, commercialization and competitiveness Information dissemination - - Policy Regulation/ Standards/ Food safety/ production/ value addition Private sector investment and participation  Food security and livelihood support initiatives & Food fortification programs  Social marketing of specially formulated foods for better access and sustainability.Education  Basic and higher level education curriculum – Life skillsDisaster preparedness 17
    18. 18. Concept – Approaches WayContinuum of Facility- Opportunities Forward care community 18
    19. 19. Going Forward Accelerate scale-up of NACS as part of the community strategy Harmonize protocols for SAM and advanced MAM management e.g. use of combination therapy and Scale up QI Demystify FBP by expanding NACS+FBP for management of mild and early moderate malnutrition at community level –targeting those with overt risks (6-24 mo), adolescent mums and geriatrics Strengthen advocacy and lobby for policy review to promote improved access – quota system, review taxes & tariffs on minerals & vitamins pre-mixes and therapeutic foods as public goods R&D of more efficacious formulations and strengthening capacity of local food industry 19
    20. 20. Thank YouTriage point Low risk Moderate risk High risk Most vulnerable = NACS + (Specialized services) 20
    21. 21. WonderingWhat is the meeting point between GHI and FtF – in the Kenyan context and others?How can we amplify NACS agenda using Radio Frequency at 60,000 and net work at ground level?How feasible is it to navigate regional approaches e.g. at East African Community – given the economic sense? 21
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