Linking Food by Prescription with CMAM & other MNCH in Ethiopia: opportunities,

challenges and lessons learned

Integration beyond HIV: Building on CMAM and MNCH

Part 1: Ethiopia case study

•Overview of NACS/FBP

•Achievements and progress toward Integration

•Challenges

•Lesson Learned

•Next steps

Outline

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

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Number of clients and facility scale up for NACS, Sept 2010 to Dec 2011

Assesed & Counseled Malnourished clients received therapeutic food

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Achievements

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

Challenges

I’m so confused!

Which protocol should I use?!?

Separate guidelines are confusing for health staff

(Nutrition and HIV, CMAM, MAM)

• 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 follow up/defaulter rate (20%) and long stay in the program (graduation rate 20-30%)

Hey wait…. don’t forget to come back!

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

Challenges

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?

Presented by Tina Lloren, Regional Nutrition Advisor, Save the Children

NACS SOTA workshop, February 22-23, 2012, Washington, DC

Integration beyond HIV: Building on CMAM and MNCH

Part 2: Mozambique Case Study

Overview of Mozambique’s CMAM program with an integrated focus on HIV

1. The starting point as CMAM (HIV integration vs stand-alone NACS project)

2. Benefits and challenges

3. Learning agenda going forward

History of integration

Plumpynut Program for HIV+ children

CMAM covering all under fives

MOH TWG

Let’s have one national protocol to treat malnutrition where HIV

is integrated!

And infants, adolescents, and adults

History of integration

Plumpynut Program for HIV+ children

CMAM covering all under fives

CMAM covering:• I

nfants through adults

• HIV+, exposed and negative

• SAM and MAM

Benefits of integrated approach: Increased collaboration among 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

Can screening for malnutrition within CMAM improve earlier diagnosis of HIV?

What are the most effective referral systems given the realities in the field?

With a strong community component, can we decrease defaulting?

Can CMAM be an effective platform for improving IYCF in HIV+ and – populations?

What is the profile of children admitted to CMAM, e.g. HIV+, HIV-?

Learning agenda potential

AMESEGINALEHU & OBRIGADA

THANK YOU