Enlisting community health workers to help diagnose and treat acute malnutrition may significantly increase coverage and save lives, according to new research from the global humanitarian group Action Against Hunger.
The Community Health Workers (CHW) model – local residents trained to provide both basic prevention and treatment services – has been around for decades. Governments from Brazil to Ethiopia have rolled out CHW programs to help provide better services to remote corners of their countries – and have seen people live longer and healthier lives as a result.
But identifying and treating acute malnutrition has never really been part of the CHW portfolio.
In 2014 Action Against Hunger, with support from the Innocent Foundation, decided to find out if they could successfully integrate treatment for acute malnutrition into existing CHW programs in Mali and Pakistan. The answer is yes, according to the research that has started to emerge from those efforts.
Researchers found that CHWs could improve access to treatment, with that treatment often coming at a lower cost than in a health center. This has sparked a new round of research in sites across sub-Saharan Africa to look at the effectiveness of different approaches.
Malnutrition Deeply spoke to Saul Guerrero, Action Against Hunger’s director of technical expertise and research, about what inspired the decision to consider CHWs and what the findings mean for future efforts to combat acute malnutrition.
Malnutrition Deeply: Why did you decide to focus on CHWs?
Saul Guerrero: In 2007 the world finally made a decision to treat acute malnutrition on an outpatient basis and that really led to a huge increase in the number of kids that were being treated. But we started to assess the reach of these services, and the coverage of these services, and we started to find that only one in three children who needed treatment were actually using it in the areas in which it was available. That didn’t really make an awful lot of sense to us and so we started digging in.
What we found was that there are a couple of reasons why people weren’t using them. The first was that there were issues about the diagnosis of the condition, and there were issues about just physical access and distance. It became a permanent feature of every assessment that we did.
And we started to look at what other services had faced, in terms of challenges, and we found out that obviously this is not unique to acute malnutrition. For many of them, the journey had taken them to community health workers, and for some reason, for acute malnutrition, that step hadn’t really been fully taken.
Malnutrition Deeply: Were there advances in the way CHW programs are structured or in how acute malnutrition is treated that made you think this approach might be successful?
Guerrero: On the CHW level, there’s now a better established mechanism for the payment of CHWs in many countries. That obviously made it possible, because the issue of incentive and motivation is such a critical part of it.
I think from the perspective of acute malnutrition, there were some things that also made it possible, some which were new, and some which were not. The introduction of ready-to-use therapeutic foods [RUTFs] a decade and a half before had really, obviously, created the conditions for outpatient treatment overall. But, I guess our feeling was we hadn’t maximized the contribution that RUTFs were making, because we weren’t taking it as far in the decentralization process as we could have done, given how incredible the product is.
The other thing was increasingly the evidence that you could run programs purely based on the use of mid-upper arm circumference as an anthropometric criteria for programming.
So, all of these things sort of created the conditions for us to say well, some of it is evidence that has been available for a while, but maybe now is a good time to bring it all together.
Malnutrition Deeply: Are there lessons from the training of CHWs that could guide future efforts?
Guerrero: One is to make it part of the wider training, not separated. If you have a standalone training for it, it really conveys the message that this is add-on.
The second thing is, [make it] as practical as possible. Especially if it’s the first time that they’re dealing with a lot of it.
But also, I think, for me the biggest lesson out of a lot of that is are you training a cadre of health workers that is already part of a national system that is remunerated or incentivized in a formal way, or are you trying to work with a cadre of people who are expected to derive some more philanthropic value out of this activity? Because how you frame the importance of adding this to their portfolio really depends on whether they are, I think, a professional group of community health agents or not.
Malnutrition Deeply: What about on the implementation side? What lessons did you learn there?
Guerrero: I think for us the training part was a lot, perhaps, less critical in retrospect than was the supervision and monitoring. For us, that has been a huge lesson, and in fact it has sort of defined what the phase two in Mali now looks like, which is not a research to demonstrate the efficiency or effectiveness or efficacy of the model, but rather to establish what is the minimum type of monitoring and supervision that is necessary in order to achieve that kind of outcome.
For me, it is the learning that will come out of that second phase in Mali that will be most critical in terms of informing how well their countries approach it. Because, so much of the learning that will come out of it will be really about once you have it up and running, how do you manage it to achieve those kind of results?
Malnutrition Deeply: Overall, what do you see as the big takeaways from the first round of research?
Guerrero: One, this isn’t a debate between do you offer this treatment at a facility or in the community with your community health workers? It is both. That much we know. It’s a false dichotomy to think that we’re asking people to make a decision, what we’re saying is see this as a booster to your facility-based services, because that’s what it is.
The second big thing is that it’s safe. The one thing that Pakistan and Mali were unequivocal about is that it’s safe.
More importantly, I think what it does is that it enables acute malnutrition to be made part of health services at the most basic level. I think at a time when there’s a lot of conversations about how do you integrate nutrition into health, and see things operating more seamlessly at a national level, sometimes we have to start with the most basic.