A view of NACS in Kenya from 60,000 feet

Nutrition and HIV Program – Kenya

Brian Njoroge

1

Outline

Concept –Continuum of

care

Approaches

Facility-community

Way Forward

Opportunities

2

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

Severely undernourished

(5 – 11%)

Moderately undernourished

(20 -25%)

Normal

(60 – 80%)

Epidemiology of malnutrition in adult PLHIV

Population of PLHA

Over nourished ( ~ ?)

4

Defining the NACS Package of services

Category (inferred from anthropometric assessment)

Package of services (What, Where and by who? )

Assessments Interventions (IEC materials at all levels)

Normal Anthropometric , dietary and lifestyle

BCC, Group counseling, Referrals

Moderatelyundernourished(wasted)

Anthropometric , dietary and lifestyle assessments, (refer to other diagnostic services)

BCC, Group counseling, Individualized counseling, FBP and Referrals

Severelyundernourished(acute wasting)

Anthropometric , function, dietary and lifestyle (refer to other diagnostic services).

BCC, Referrals , Group counseling daily observed feeding (DOF), individualized counseling

Overnutrition /obesity, overloads

As above primary relevant to this discussion Nutritional diseases

BCC, individualized counseling, participation group therapy, referral

5

NUTRITION SERVICES

FOOD

SECURITY

HEALTH

CARE

CONTINUUM OF NUTRITION, HEALTH & FOOD SECURITY SERVICES

6

Concept –Continuum of

care

Approaches

Facility-community

Way Forward

Opportunities

7

System Approach for NACSAgenda 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

Dispensaries

Health Centers

Sub-District Hospitals

District Hospitals

Provincial Hospitals

National ReferralHospitals

Dispensaries

Lower-LevelHospitals

HealthCenters

Higher-Level Hospitals

Faith-Based/Non Governmental

Organization Hierarchy

CommunityMedicalCentre

Clinic

Lower-LevelHospitals

Nursing Homes

Maternity Homes

Higher-Level Hospitals

Private Sector Hierarchy

Key: Central sites Satellite sites except Nairobi

Health System: NACS Service Delivery in Kenya

MOH/ Other Public Hierarchy

USG I PartnersUSAIDCDCWFPGlobal FundUNICEFMSFWHOOthers

Partner coordination and collaboration

Agriculture & other Sectors

9

Pilot Phase -2006 Transition/Adaptation Phase - 2008

Scale-up Phase -2009

Scale-up Phase -2010/12

Nutrition Service Register; LMIS ToolsMaturation Phase –

Post 2013

MoH, FBO

INSTA INSTA NHP

NHPINSTA

MoH, FBO

SCM

MoH, FBOINSTA NHP

NHP

MoH, FBO,Private Sector

KEMSA

SCM

partners

OTHER

INSTA

MoH, FBO

Moving From Pilot to Scale (Creating a critical mass) …..

10

5,618

30,293

36,432

40,473

49,474 51,202

7

57 57

105

130

158

-

20

40

60

80

100

120

140

160

180

-

10,000

20,000

30,000

40,000

50,000

60,000

2006 2007 2008 2009 2010 2011

No

. o

f C

entr

al

Sit

es

No

. o

f N

ew P

ati

ents

en

roll

ed

YEAR

Growing NACS – health facility perspective

No. of New patients enrolled

No of FBP Central Sites

11

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

180.0

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000 Ja

nu

ary

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

De

cem

be

r

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

De

cem

be

r

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

De

cem

be

r

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 2010 2011

Met

ric

Ton

ne

s

Nu

mb

er

of

Clie

nts

Reporting Period

New Clients Revisits FBF Delivered

Trends in Uptake of NACS/FBP and Flow of Food Commodities

12

Growing NACS – community perspective

0

200

400

600

800

1000

1200

1400

1600

1800

2000

0

2000

4000

6000

8000

10000

12000

14000

Jul-Sep Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec

3 1 5 7 8

Nu

trit

ion

al S

tatu

s -

No

Clie

ntsN

o A

sse

sed

No CBO's, Reporting YearNo Assessed SAM MAM

4 New CBO's onboard

(Nyanza, Western)

Retraining for DQI

Train new CHW [FAIR]

13

5,618

30,293

36,432

40,473

49,474

51,202

60,000

7

57 61 130

158200

250

280

300

-

200

400

600

800

1,000

1,200

1,400

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

No

of

Site

s

No

. of

Clie

nts

Years

Clients Central Sites Total Sites (Central + Satellites)

Asymptote

?

??

?

Model for Growing NACS/FBP Services

14

Concept –Continuum

of care

Approaches

Facility-community

Way Forward

Opportunities

15

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

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

Concept –Continuum of

care

Approaches

Facility-community

Way Forward

Opportunities

18

Going ForwardAccelerate scale-up of NACS as part of the community

strategyHarmonize 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

Most vulnerable = NACS + (Specialized services)

Low risk

Moderate risk

High risk

Triage point

Thank You

20

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