The following blog was written by Pilar Charle Cuellar, iCCM+Nutrition Coordinator Accion Contra el Hambre/ Action Against Hunger Spain
On average, more than 70% of children worldwide with uncomplicated Severe Acute Malnutrition (SAM) are cured when treated with Ready-to-Use Therapeutic Food (RUTF) at outpatient health centres (Lenters LM et al 2013). However, less than 1 out of 4 children affected are able to access the treatment they need (UNICEF 2018). Common barriers to access treatment include long distances to health facilities, transport costs and other opportunity costs to caregivers.
The Integrated Community Case Management (iCCM) model has been an effective approach to increase coverage of treatment for other life-threatening conditions such as diarrhoea, pneumonia and malaria in Mali for almost a decade. As part of iCCM, Community Health Workers (CHW) are trained, supplied and supervised to diagnose and treat children with these diseases. Consequently, expanding the iCCM model to include the diagnosis and treatment of SAM may address some of the current barriers to receiving effective and timely management.
To this end, Action Against Hunger collaborated with the Government of Mali to investigate the use of CHWs and iCCM to improve coverage of high-quality SAM treatment and to generate the evidence needed to inform the scale-up of this program. A multi-phased approach was used to first pilot, and then to further refine this idea.
Phase 1 Pilot Study
Phase 1 of the project consisted of a prospective multi-centre cohort study, which investigated the effectiveness and cost-effectiveness of this innovative approach. The study took place in 7 communes in the district of Kita in southwest Mali and was conducted in partnership with the Institute National de Recherche et Santé Publique (INRSP), the National Nutrition Direction of the Ministry of Health and Bamako University, and funded by the innocent foundation. In the control communes of Tambaga, Bougarabaya, and Kobiri, outpatient SAM treatment was provided by Health Workers at the primary health facilities (as per the standard Community-based Management of Acute malnutrition (CMAM) approach). While in the intervention communes of Guenikoro, Kassaro, Dafela, and Sebekoro, treatment was provided by both the primary health facilities and by 18CHWs, trained and equipped to treat uncomplicated SAM cases in the community. The results of the Phase 1 pilot study are summarized in Box 2.
Phase 2 Operational Research Project
Building on the success of the Phase 1 pilot study, Action Against Hunger is now working with the Government of Mali on a Phase 2 operational research project, with the aim to further test this approach and refine the level of supervision of CHWs needed to maintain the same quality of care of SAM treatment at scale. The approach is being implemented in 115 health facilities and with 166 CHWs in the districts of Bafoulabe, Kayes and Kita in southwest Mali, with each district receiving a different level of supervision (See Box 3). Evidence of effect will be generated by assessing:
- SAM treatment performance outcomes, including cure rates, default rates, etc.;
- Coverage of SAM treatment for each of the three models after 12 months of implementation;
- Additional treatment time of SAM by CHWs, and the effect on the treatment of other diseases in the iCCM package;
- Costing and cost-effectiveness analyses of the three models of supervision.
The Phase 2 study is still ongoing with results expected in 2019. So far, it has measured the baseline coverage in the three districts participating, trained CHWs in the treatment of acute malnutrition and the standard iCCM package (the management of diarrhoea, malaria, pneumonia, family planning and hygiene promotion), and admitted a total of 1,085 children with SAM to the study. Discussion is ongoing with the Ministry of Health to define a practical guide adapted to the reality in the country for the scaling up of the intervention.
Key Lessons Learned
There have been several lessons learned throughout the Phase 1 and 2. The research demonstrated that CHWs can manage the diagnosis and treatment of SAM while maintaining a high quality of care, with high cure rates and low default rates. This approach was also proven to overcome key barriers of treatment access and coverage by bringing diagnosis and treatment one-step closer to the community. Mothers and caregivers spent half as much time, and one third of the cost, under this model compared to the standard CMAM treatment.
One of the main reasons for the success of this intervention in Phase 1 was the capacity and availability of CHWs as part of the existing health infrastructure in Mali. Salaries for all CHWs in Mali are currently paid for, with commitments through 2019. As we look forward to scaling-up the integration of SAM treatment as a part of the CHW-delivered iCCM package, it will be critical to ensure the Government of Mali and partners in country continue to support CHWs as part of the public health system, with dedicated funding for training, supervision, their salaries in the long-term.
The final learning from the project was the importance of the integration of SAM into iCCM from the beginning – from the training of CHWs, to implementation and measurement of care quality. The country’s policies on specific set training modules had to be adapted, in order to properly integrate treatment of acute malnutrition as a core piece. Simply ‘tacking’ acute malnutrition onto the CHWs workload would not ensure optimum outcomes for the children treated. Understanding how additional goals, tools and training would affect the CHWs was essential to the success of the program.
So, how will the results be used? Action Against Hunger is actively working with the Government of Mali to ensure the evidence generated from this project informs their plans to implement this approach across the country. A potential third phase of this project could look at nationwide scale-up of the integration of SAM treatment into the iCCM package, which could involve the following steps:
- Developing a guide and plan for scaling up in the country: including an update to the training module, model of supervision, supply management and monitoring tools;
- Identifying priority regions in the south to start with the strategy;
- Adapting the protocol to a security context (North Mali crises).
In addition to scale-up in Mali, the success of the original pilot has spurred similar implementation research in Kenya, Niger and Mauritania. There are further contexts where this intervention could be useful, particularly where there is high prevalence of global acute malnutrition (GAM), low coverage of malnutrition treatment, and support from the Ministry of Health. Further implementation research will be critical in the successful expansion of this approach.
Lenters LM, Wazny K, Webb P, Ahmed T, Bhutta Z. Treatment of severe and moderate acute malnutrition in low- and middle-income settings: a systematic review, meta-analysis and Delphi process. BMC Public Health. 2013; 13 (Suppl 3): S23. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3847503/.
United Nations Children’s Fund (UNICEF), World Health Organization, International Bank for Reconstruction and Development/The World Bank. Levels and trends in child malnutrition: key findings of the 2018 Edition of the Joint Child Malnutrition Estimates. Geneva: World Health Organization; 2018 Licence: CC BY-NC-SA 3.0 IGO.
United Nations Children’s Fund (UNICEF). Global SAM Management Update Tool (NUTRIDASH): 2018 data. Available at: www.acutemalnutrition.org.
Charle PC. ISRCTN Study Registration: Comparison of three models of training and supervision with community health workers providing treatment of children with severe acute malnutrition in Mali. Available at: http://www.isrctn.com/ISRCTN14990746
Action Against Hunger. Treating severe acute malnutrition with community health workers the evidence from Mali and Pakistan. 2017. Available at: https://acutemalnutrition.org/en/resource-library/1qpmrLqXRCigIWYS8C2wS0
Alvarez Morán JL, Alé FGB, Rogers E, Guerrero S. Quality of care for treatment of uncomplicated severe acute malnutrition delivered by community health workers in a rural area of Mali. Maternal & Child Nutrition. 2017; 14. Available at: https://www.nowastedlives.org/mali
Alvarez Morán JL, Alé FGB, Charle P, Sessions N, Doumbia S, Guerrero S. The effectiveness of treatment for Severe Acute Malnutrition (SAM) delivered by community health workers compared to a traditional facility based model. BMC Health Services Research. 2018; 18(207). Available at: https://www.nowastedlives.org/mali-1
Rogers E, Martinez K, Alvarez Morán JL, Alé FGB, Charle P, Guerrero S, Puett C. Cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by community health workers compared to treatment provided at an outpatient facility in rural Mali. Human Resources for Health. 2018; 16(12). Available at: https://www.nowastedlives.org/documents-mali-cost-effectiveness
The Sphere Project. Humanitarian Charter and Minimum Standards in Humanitarian Response. Available at: http://www.sphereproject.org/handbook/
The Action Against Hunger Knowledge Hub. C-Project: Treatment of Severe Acute Malnutrition by Community Health Workers. Available at: https://www.knowledgeagainsthunger.org/c-project
Action Against Hunger would like to thank our partners and funders: the Government of Mali, INRSP (Institute National de Recherche et Santé Publique), National Nutrition Direction of the Ministry of Health and Bamako University, the innocent foundation, ECHO and the People’s Postcode Lottery.
We thank Pilar Charle Cuellar and Action Against Hunger for their contribution to this blog. To learn more about C-Project and keep updated with its progress go to: https://www.knowledgeagainsthunger.org/c-project