Linking CMAM and iCCM in Kenya
There are over 50 million children under the age of five suffering from severe and moderate acute malnutrition (SAM/MAM) worldwide (UNICEF, 2015). In many vulnerable communities, these children are either brought to health facilities too late to receive life-saving care, or never brought at all. Children suffering from SAM are over nine times more likely to die than those who are well-nourished (Black et al., 2008). In fact, nutrition-related complications contribute to about 45% of deaths in children under five, and the direct relationship between illness and malnutrition is well-documented (Rice, et al 2000). Malnutrition is a significant underlying factor and increases the risk of death from the leading causes of child mortality: pneumonia, diarrhea, and malaria (UNICEF et al, 2017).
The Community-based Management of Acute Malnutrition (CMAM) model, currently implemented in many nutrition programs, allows children with uncomplicated SAM to be diagnosed at the local level by community health volunteers (CHVs) and referred to an Outpatient Therapeutic Feeding Program (OTP) at the health facility. At the OTP, the caregiver is given a weekly supply of Ready to Use Therapeutic Food (RUTF); treatment for children suffering from SAM. The caregiver must return to the OTP every week to check her child’s progress and to pick-up the week’s RUTF supply until the child has completed treatment, averaging about 6-7 weeks. High coverage of SAM treatment (>90%) has the potential to be the most impactful and cost-effective nutrition intervention (Bhutta et al., 2013), though this level of coverage is rarely reached. Families face many challenges to accessing treatment for both malnutrition and infectious diseases, like distance to health facilities and cost of services, which also limits optimal follow-up care. Integrated community case management (iCCM) is an effective strategy in achieving high coverage and quality care for sick children, as CHVs are trained to both diagnose and treat several childhood illnesses during home visits in the communities in which they work, eliminating the need for the child to be taken a health facility. In current iCCM programming however, CHVs are only able to take action on SAM when OTP services exist at the health facility, requiring that children identified as needing treatment be brought to the health center on a weekly basis.
Although there are already beneficial operational linkages between iCCM and CMAM interventions, there is an evidence gap regarding the outcomes of implementing an integrated approach. Knowing this, and following up on recent linkages between iCCM and nutrition (Friedman & Wolfheim, 2014), the Implementation Research on Linking the Community Management of Acute Malnutrition and Integrated Community Case Management (iCCM for short) research project was launched in Isiolo and Turkana counties in Kenya in August 2017. This research project will build new evidence on the potential impact and effectiveness (including cost-efficiency) of integrating CMAM as part of the iCCM package. Increasingly, this approach is seen as a way to increase the reach and coverage of malnutrition treatment, as well as address the problem of childhood disease and malnutrition together.
Partners have worked together to design a randomized control trial, applying both quantitative and qualitative data collection methods for assessing nutrition, iCCM, and health outcomes. The research project will examine the following research questions:
- What is the feasibility and effectiveness of integrating CMAM and iCCM?
- What are the enabling factors for effective integration of CMAM and iCCM?
- What are the challenges, constraints, and potential negative effects of integrating CMAM and iCCM?
In addition to investigating these specific questions, the research team will document lessons learned throughout the course of the project, and produce best practice, policy, and programmatic recommendations for the integration of both community approaches.
To date, a research protocol refining the approach and methods has been developed, and ethical approval is expected in August 2018. Both the Semi-Quantitative Evaluation of Access and Coverage (SQUEAC) survey and baseline surveys for the two study sites have been completed. CHVs have been identified, and the updated protocols and tools for the CHVs have been tested and finalized.
Results from the study are expected to be ready in Spring 2019. If successful, Action Against Hunger would support the Government of Kenya in the roll out of this approach across the country, by adapting national health and nutrition policies to enable CHVs to deliver treatment for acute malnutrition, and by strengthening the rest of the health system to facilitate such expansion. This evidence would also contribute to global efforts to adapt global iCCM policies and guidelines.