1 www.icddrb.org Solving public health problems through innovative scientific research Integrating nutrition into health systems: opportunities and challenges Kathmandu July 08, 2017 Shams El Arifeen International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
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www.icddrb.orgSolving public health problems through innovative scientific research
Integrating nutrition into health systems: opportunities and challenges
Kathmandu
July 08, 2017
Shams El ArifeenInternational Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)
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Why are health systems important for nutrition interventions?
• Help achieve high coverage of a broad range of health and nutrition
services, especially for low-resource settings
• Offers critical contact opportunities to provide nutrition interventions
especially for priority interventions during the first thousand days of life
• Provides broad-based contact opportunities at different tiers of health
service delivery, expanding the reach of critical nutrition interventions
• Relevant and efficient programming using health systems has the promise
to deliver these interventions at scale
• Synergistic impact of health and nutrition interventions
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10 priority nutrition-specific interventions
Bhutta et al 2013
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0
10
20
30
40
50
60
70
80
90
100
Bangladesh Ethiopia India
ANC 4+ ANC Delivery Immunization Received treatment for pneumonia/ARI
*
*From any provider Bangladesh: BDHS 2014, Ethiopia: EDHS 2016 (Key findings), India: ROSC 2013-14
Health system platforms
5
0
10
20
30
40
50
60
70
80
90
100
Bangladesh Ethiopia India
ANC Delivery Early Initiation of BF Exclusive Breastfeeding 3 IYCF practices
*
*From any provider Bangladesh: BDHS 2014, Ethiopia: EDHS 2016 (Key findings), India: ROSC 2013-14
Health system platforms & Nutrition
6
0
10
20
30
40
50
60
70
80
90
100
Bangladesh Ethiopia India
Immunization Received treatment for pneumonia/ARI Vitamin A supplementationPaediatric IFA supplementation Deworming 3 IYCF practices
*
Bangladesh: BDHS 2014, Ethiopia: EDHS 2016 (Key findings), India: ROSC 2013-14
Health system platforms & Nutrition
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Choosing the right health system platform
Only 13-17% sick children sought care from public sector facilities
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Integrating nutrition interventions in routine health systems in Bangladesh: sick child visits
0
5
10
15
20
25
Observation of service delivery
Weighed and recorded weight
Measured and recorded height
Clinically diagnosed for SAM
Demonstrate IYCF practice using visual job aids
Checked child's weight against a growth chart
Counselled on ensuring Vitamin A capsule
Give age specific advice on inclusion of salt incomplemetary food
Used BCC materials to raise awareness on nutrition
Counselled mothers on food and care required forunderweight children
Nutritionalassessment
Nutrition counseling
N=>500 sick child case management observations
Billah et al. 2017 Plos One
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0
10
20
30
40
50
60
70
80
90
100
Bangladesh Ethiopia India
ANC 4+ ANC Delivery Immunization Received treatment for pneumonia/ARI
*
*From any provider Bangladesh: BDHS 2014, Ethiopia: EDHS 2016 (Key findings), India: ROSC 2013-14
Low utilisation of health system platforms
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Antenatal care (ANC) during pregnancy for the most recent birth, n=3948Provider Place
83%
59%52%
75%
17% 17%
Any ANC ANC frommedically
trainedprovider
Qualifieddoctor
Otherprovider
NGOworker
No one
40%33%
41%
61%
13%
Home Publicsector
Privatesector
NGO Other
Initial Assessment (DNSO Evaluation), 2016
Low utilisation of health system platforms, particularly the public sector
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Health system platforms: providing the right inputs
Percentage of service providers receiving training on nutrition (N= 364)
0
10
20
30
40
50
60
70
80
90
100
Physician Nurse SACMO FWV FWA CHCP
Basic nutrition training IYCF training Any other nutrition training
* CBT coverage is not presented here Initial Assessment (DNSO Evaluation), 2016
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45.1
24.3
11.3
5.8
13.5
No visit
< 50% recommended visits
50 - 74% recommended visits
75 - 99% recommended visits
≥ 100% recommended visits
Utilization of nutrition counseling at health facilities in Vietnam was less than optimal despite availability and quality [demand side constraints]
Nguyen et al., 2015
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Monetary incentives, good record-keeping and community events associated with better frontline worker performance in Bihar, India• Data: A 2012 cross-sectional survey of 6,002 households in 400 randomly selected villages in 1
district of Bihar state, as well as an integrated survey of 377 AWWs and 382 ASHAs from the same villages.
• Immunization: Higher with monetary `immunization incentives for AWWs, and above-median household head education
• Receiving pregnancy care information: ASHAs who received incentives for institutional delivery and ASHAs who maintained records of pregnant women
• Receiving general nutrition information: AWWs who received immunization incentives, suggesting a spillover effect of incentives from product- to information-oriented services.
• Study conclusion: Product-oriented incentives affect delivery of both product- and information-oriented services, although household factors are also important. Existing government programs can mitigate supply- and demand-side constraints to receiving essential interventions by optimizing existing incentives for FLWs in national programs, helping FLWs better organize their work, and raising awareness among groups who are less likely to access services.
Kosec et al., Global Health Science and Practice, 2015
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Recent initiatives: Ethiopia
• Introduced the Health Extension Program (HEP) in 2003 to accelerate expansion of primary health care coverage – and seen as a potential platform for expanding nutrition intervention coverage
• Weak capacity for nutrition leadership and insufficient drive to push the nutrition agendas
• Government funding for nutrition is poor, most nutrition funding coming from donors
• HEP credited with greatly improved utilization of MNH services
• Lack of uniformity in HEP implementation (coverage and quality issues); high turnover; some health posts not equipped or with supplies; and weak referral linkage
• Poor capacity and weak routine supervision, monitoring and data management
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Recent initiatives: Bangladesh
• The 2015 GNR reports Bangladesh being off-course for 3 out of 5 WHA targets
• 7th FYP included establishment of an effective multi-sectoral leadership, public-private partnerships for collaborative engagement, stronger focus on the critical 1000 day period
• In 2011, the National Nutrition Service (NNS) initiated to mainstream essential nutrition interventions through the existing health systems
• The NNS leverages various health platforms to deliver its core direct nutrition interventions, however, there is heavy focus on facility-based curative contacts
• Community clinics (CC) considered as the “main contact points”, however, CCs is still largely a curative platform
• Effectiveness of interventions constrained by poor quality of service provided at routine contacts, often driven by lack of skills and motivation of the health care providers
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Recent initiatives: India• Over the last decade, MoHFW has slowly developed guidelines and strengthened platforms for improving the
delivery and coverage of nutrition interventions within the health system.
• National Health Mission initiated in 2006:
• Initial training modules introduced for the ASHAs included some nutrition modules, especially around interventions in pregnancy and breastfeeding.
• 2011, guidelines for Facility-based Management of Children with Severe Acute Malnutrition,
• 2013, guidelines for enhancing optimal infant and young child feeding (IYCF) practices
• 2014, Reproductive, Maternal, Newborn, Child and Adolescent Health strategy developed with a continuum-of-care approach across the lifecycle
• Between 2013 and 2015, iron supplementation and calcium supplementation guidelines developed and launched.
• 2014, a National Deworming Day instituted for children between ages 1 and 19. Fortnightly campaign to promote ORS and zinc to manage diarrhoea
• 2016, the MoHFW launched the “Mother’s Absolute Affection” campaign to promote awareness regarding early initiation of breastfeeding and to support counseling for breastfeeding.
• Interventions to be delivered in concert by frontline workers from both MoHFW and ICDS. While challenges exist, there are multiple areas of success, although marked by state-level variability.
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Why are health systems important for nutrition interventions?• Health systems platforms are a natural entry point for nutrition interventions and go to
scale, especially for low-resource settings• Synergistic impact of health and nutrition interventions
• Critical contact opportunities to provide nutrition interventions during the first 1,000 days of life
• Provides broad-based contact opportunities at different tiers of health service delivery, expanding
the reach of critical nutrition interventions
• New global ANC guidelines already recognize this, as do IMCI guidelines
• Research by TN identifies several opportunities but also several challenges in how best to
ensure delivery of nutrition interventions in the context of health systems
• As we roll out UHC/ health systems strengthening, important to consider how best to
support scaling up of nutrition interventions alongside
• Learning opportunities abound!
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icddr,b thanks its core donors for their on-going support
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