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Brian Njoroge
1. A view of NACS in Kenya from 60,000 feet
Nutrition and HIV Program – Kenya
Brian Njoroge
1
2. Outline
Concept – Approaches
Way
Continuum of Facility- Opportunities
Forward
care community
2
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. Epidemiology of malnutrition in adult PLHIV
Severely
undernourished
Population of PLHA
(5 – 11%)
Moderately
undernourished
(20 -25%)
Normal
(60 – 80%)
Over nourished
( ~ ?)
4
5. Defining the NACS Package of services
Category Package of services (What, Where and by who? )
(inferred from Assessments Interventions
anthropometric (IEC materials at all levels)
assessment)
Normal Anthropometric , dietary BCC, Group counseling, Referrals
and lifestyle
Moderately Anthropometric , dietary and BCC, Group counseling,
undernourished lifestyle assessments, (refer Individualized counseling, FBP and
(wasted) to other diagnostic services) Referrals
Severely Anthropometric , function, BCC, Referrals , Group counseling
undernourished dietary and lifestyle (refer to daily observed feeding (DOF),
(acute wasting) other diagnostic services). individualized counseling
Overnutrition / As above primary relevant to BCC, individualized counseling,
obesity, this discussion Nutritional participation group therapy, referral
overloads diseases
5
6. CONTINUUM OF NUTRITION, HEALTH & FOOD SECURITY SERVICES
NUTRITION SERVICES
HEALTH FOOD
CARE
SECURITY
6
7. Concept – Approaches
Way
Continuum of Facility- Opportunities
Forward
care community
7
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 persuade
Secure Political Commitment; Leadership Planning & Implementation; Resources
8
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 Centre
Key: Central sites Satellite sites except Nairobi Agriculture &
other Sectors
Partner coordination and collaboration 9
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 -2009
OTHER KEMSA MoH,
MoH, FBO, FBO
Private NHP
SCM Sector INSTA
INSTA SCM
partners
Scale-up Phase -2010/12
Maturation Phase –
Post 2013 Nutrition Service Register; LMIS Tools
10
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
40,000 120
No. 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. 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
100.0
Number 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. Growing NACS – community perspective
Train new
CHW [FAIR]
14000 2000
1800
12000 Retraining for
No Assesed
DQI 1600
10000
Nutritional Status - No Clients
1400
1200
8000
1000
6000
800
4 New CBO's
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 CBO's, Reporting Year 5 7 8
No Assessed SAM MAM
13
14. Model for Growing NACS/FBP Services
80,000 1,400
? ?
70,000 1,200
60,000 60,000
1,000
51,202
50,000
No. 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. Concept – Approaches
Way
Continuum Facility- Opportunities
Forward
of care community
15
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. 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. Concept – Approaches
Way
Continuum of Facility- Opportunities
Forward
care community
18
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. Thank You
Triage point
Low risk
Moderate
risk
High risk
Most vulnerable = NACS + (Specialized services)
20
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
Editor's Notes
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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.
