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Integration beyond HIV: Building on CMAM and MNCH Part 1: Ethiopia case studyLinking Food by Prescription with CMAM & other MNCH in Ethiopia: opportunities, challenges and lessons learned
Outline •Overview of NACS/FBP •Achievements and progress toward Integration •Challenges •Lesson Learned •Next steps
Ethiopia USAID/FBP Overview• Started in October 2009• Technical assistance program• Purpose is to integrate NACS into heath facilities with ART and Pre- ART services and other services (MNCH,CMAM)• Target beneficiaries: • Adults attending pre-ART and ART services; • Pregnant and post-partum HIV positive women • Malnourished OVC (irrespective of HIV status)• Health facilities: health centres and hospitals• Covering four big regions of Ethiopia: Oromia, Amhara, Tigray, and SNNPR
Achievements• Scaled to a lot of facilities and reached a lot of clients in a short period of time: • 206 Health centers and hospitals in two years • >150,000 Assessed and Counseled • > 50,000 malnourished OVC and PLHIV provided RUTF• Capacity of health facilities to implement NACS strengthened: • 6- 8 health workers per facility trained (1,259 trained) • NACS materials produced: Flip charts, job aids, radio programs, Anthropometric equipments• NACS is partially integrated to MNCH and comprehensive HIV care services
Achievements Number of clients and facility scale up for NACS, Sept 2010 to Dec 2011 140000 250 124810 120000 200 No of Facilities 100000 80000 150 68125 60525 60000 100 40000 27732 14727 50 20000 13448 1301 0 0 0 Mar-11 Sep-10 Dec-10 Sep-11 Dec-11 Jun-11 Assesed & Counseled
Progress toward integration• Integration of NACS and CMAM for under five children • Same protocol • Same register • Same follow up mechanism• Integrated with ICCM (integrated Community Case management) for SAM cases but the counseling is weak• RUTF distribution to health facilities integrated into government supply and logistic system (PFSA)• Demand for NACS services created among beneficiaries and health facilities/regional health bureaus
ChallengesSeparate guidelines are confusing I’m so confused!for health staff Which protocol should I use?!?(Nutrition and HIV, CMAM, MAM)
Challenges• Comprehensive NACS is still a challenge: assessment and support scale up faster than the counseling because of high case load and health workers find it easier to treat than counsel• Different classification and eligibility criteria for children above five years and adults for NACS and CMAM/MNCH• NACS targets only HIV-positive pregnant and lactating women (PLW) where as ANC is for all PLW• The community component is less well developed and referral linkages are weak (contract limited the program to health facilities and relied on other CMAM and HIV partners at the community)
Challenges• High loss to Hey wait…. don’t follow forget to come back! up/defaulter rate (20%) and long stay in the program (graduation rate 20-30%)
Challenges• No consensus on how to manage MAM at health facilities under CMAM/MNCH programs• Separate supply chains for RUTF for NACS and CMAM/MNCH• Information system: • Already had heavy burden of HIV indicators in the HMIS • Nutrition/HIV indicators are not integrated into HMIS
Lesson Learned• NACS is potentially scalable and the demand is high• Assessment and Support scale up faster than Counseling: • Initiate all NACS services together, not just assessment and support • Counseling should be targeted • Task shifting to case managers and lay counselors• Harmonize guidelines of NACS and MNCH/CMAM from the outset• NACS should have a strong community component from the beginning• Economic Strengthening interventions should be part of the NACS continuum but has its challenges• Simplify and harmonize the information to be collected by busy health providers
Question for discussion in countries like Ethiopia where CMAM is already scaled up:For children under five years where CMAM is already in place, do we roll out “NACS” to the community, or just build on the existing CMAM and MNCH programming?
Integration beyond HIV: Building on CMAM and MNCH Part 2: Mozambique Case StudyPresented by Tina Lloren, Regional Nutrition Advisor, Save the Children NACS SOTA workshop, February 22-23, 2012, Washington, DC
Overview of Mozambique’s CMAM program withan integrated focus on HIV1. The starting point as CMAM (HIV integration vs stand-alone NACS project)2. Benefits and challenges3. Learning agenda going forward
History of integration Plumpynut Program for HIV+ children CMAM covering all under fives
Let’s have one national protocol to treat malnutrition where HIV is integrated! Andinfants, adole scents, and adults MOH TWG
History of integration Plumpynut Program for HIV+ children CMAM covering all under fives CMAM covering: • Infants through adults • HIV+, exposed and negative • SAM and MAM
Benefits of integrated approach: Increased collaborationamong partners, donors, and funds
Benefits of integrated approach• One national protocol• No stigma associated with RUTF and NACS – “it’s for everyone”• HIV testing is standard part of the CMAM package (caretakers can opt-out)• HIV and nutrition is included as a topic for community cadres
Challenges of integrated approach• Referral systems need to be set up• HIV focus is more diluted when it is subsumed under broader malnutrition as opposed to the stand-alone approach• Adding HIV to CMAM reporting forms makes them more complicated
Learning agenda What are the most potential Can screening for malnutrition within CMAM effective referral systems improve earlier diagnosis given the realities in the of HIV? field? Can CMAM be anWith a strong community effective platform forcomponent, can we improving IYCF in HIV+decrease defaulting? and – populations? What is the profile of children admitted to CMAM, e.g. HIV+, HIV-?