KZN DOH APPROACH TO NUTRITION

(Integrated Nutrition Programme INP)

25 March 2014

Info 4 Africa Forum

Presenter: Ms Zamazulu Mtshali

The Integrated Nutrition Programme

Vision

Optimum Nutrition for all South Africans

Mission

Improvement of the nutritional status of all South Africans through the implementation of integrated nutrition

strategies

The Integrated Nutrition Programme

Vision

Optimum Nutrition for all South Africans

Mission

Improvement of the nutritional status of all South Africans through the implementation of integrated nutrition

strategies

Principles Good nutrition for all South Africans should be promoted as a basic

human right and as an integral component and outcome measure of the country’s social and economic development

Nutrition programmes should be integrated, sustainable, environmentally sound, people and community driven

There should be a clear strategy for promotion of nutritional well being and the nutritional status of the population must be monitored

Nutrition policies, strategies and programmes are dependent on the development of human and institutional capacities and the provision or adequate financial resources

Existing structures and programmes should be used to address nutrition concerns

An integrated primary health care approach, which includes monitoring to generate useful information for better targeting of services, will be adopted in this programme

Nutrition

• Nutritional status influenced by three broad factors: food, health and care

• Optimal nutritional status: when people have access to affordable, diverse, nutrient-rich food; appropriate maternal and child-care practices; adequate health services; and a healthy environment including safe water, sanitation and good hygiene practices.

• These factors directly influence nutrient intake and the presence of disease

• Food, health and care are affected by social, economic and political factors

Millennium Development Goals

KZN Scenario1 in 20 children die before their 5th birthday

Of these…38% die outside the health service55% die in association with HIV33% have underlying severe malnutrition

(Save Children, 2011)

KZN SCENARIO KZN bears a disproportionately high burden of poverty with 63% to

82% of households living on less than R800 per month (District Health Barometer)

Malnutrition remains one of the leading comorbidities for children under the age of 5 years. Between 2010/11 and 2011/12, the severe malnutrition under-5 year incidence decreased from 7/1000 to 6.7/1000 (DHIS).

HIV incidence 37,4% (Antenatal Seroprevalence Survey, 2011) > 50% child deaths were related to HIV Diarrhea & Pneumonia: 2 leading causes of death in children

<5yrs SANHANES-1 2012 found more stunting (H/A<-2SD) in KZN Increase in overweight and obesity (W/H > +2SD) in Children 2-5

years Nationally and KZN

Nutrition Scenario

• Concern: Malnutrition; HIV, AIDS & TB• PLWHA, poor nutrition worsens the effects of HIV by further weakening the

immune system.• HIV interferes with the ability to access, handle, prepare, eat and utilize

food, thus increasing the risk of malnutrition • Food and nutritional intake can affect adherence to antiretroviral drugs

(ARVs) as well as their effectiveness.• Food insecurity and inadequate knowledge of good nutrition• Nutrition in transition situation where both under and over nutrition

(underweight, stunting, wasting, overweight & obesity) exist in same community

• Consequences: Non communicable diseases: diabetes, hypertension, cardiovascular illnesses

KZN Situational AnalysisYear Stunting Underweight Wasting Overweight

1994 (SAVACG) 16% 4% 1% 7%

1999 (NFCS) 19% 6% 9% 4%

2005 (NFCS) 15% 5% 1% 6%

2012 (SANHANES)BoysGirls

 

13.5% 14.4%

 

3.4%1.5%

2.4% 6.3%

Table indicating the anthropometric status of children aged 1-9 years in KwaZulu NatalSource: Health Review 2008, Health Systems Trust, SANHANES 2013

INDICATOR PROVINCIAL STATUS NATIONAL STATUS

Infant mortality rate (IMR)18 42/1 000 45/1000

Child mortality rate (U5MR)18 61/1 00018 59.4/1000

Maternal Mortality Rate18 165.5 /100 00018 150/100 000

Low birth weight19 12.5% 8%

Exclusive Breastfeeding20

0 – 3 months (14weeks) 0 – 5 months

 34.3%

 10%7%

Stunting9

BoysGirls

 13.5%14.4%

 16.7%13.7

Wasting9

BoysGirls

2.4%-

3.8%1.7%

Severe Malnutrition 0.5%18 2.8%

Underweight9

BoysGirls

3.4%1.5%

1.4%3.6%

 

Household food insecurity 63-73% 75% of householdsFood consumption 43.4% of children eat less than they

should. 43.2% experience hunger1

10% of children 6 to 15 years don’t eatBreakfast. 50% of children 1 to 9 years consume less than half of the RDA for key vitamins and minerals

Consumption of iodised salt 87.6%1 62.4% of householdsRtHC coverage 62.2% 75%Poverty 63% 57% of population live in povertyDiarrhoea 17.8% 13.2%HIV/ AIDS (ANC) 37.5% 24.8%Measured Hypertension9 8.4% 10.2%Cardio vascular unfitd

(18-40 years)Females Males

 35.2%25.5%

 --

Diabetes (Self-reported)FemalesMales

 9.6%4.6%

 6%4%

CHD (Self-reported)FemalesMales

 5.6%2.3%

 2.9%1.5%

Hypertension Self-reported)FemalesMales

 24.9%15.8%

 20.6%12.0%

VAD prevalence Too low observations to record (SANHANES 2012)

43.6%

Iodine deficiency: 

16.5% 

21.4% 

Iron deficiency(16 – 35years)

Too low observations to record (SANHANES 2012)

9.7%

HIV/ AIDS23 15.8% (1,622,870) 

 

Opportunities to scale-up Nutrition Interventions• Four priority areas of government for the health sector:

• Increasing life expectancy, • Decreasing maternal and child mortality• Combating HIV&AIDS, decreasing burden of disease from TB,• Strengthening health system effectiveness

• Window of opportunity: the first 1000 days of life• Renewed focus on Breastfeeding• Focus on Non-Communicable Diseases (NCD)• Re-engineering of the PHC ( 3 Streams)

– Ward-based health care teams– District-based health care teams– School health services

• Community health worker cadre• Political will to address all forms of malnutrition

Provincial Strategic Direction

• Guided by the:– Provincial Growth and Development Plan

– KZN Health Strategy

• Nutrition is included in the Annual Performance Plan– Prevalence of underweight Children under 5 years

– Child under 5 severe acute malnutrition incidence

– Children not gaining weight rate under 5 years

– Vitamin A Coverage 12-59 months

Strategic Direction Enhancement of IYCF (MBFI, HBM Banks, Regulation 991) Complementary feeding Micronutrient Supplementation Communication Strategy: Social Media & Marketing Integrated Management of Acute Malnutrition Re-orientation of HCW (including CCGs, NAs, Family Health

Outreach Teams) Phila Mntwana Centres, Framework for Accelerating

Community-based MNCWH and Nutrition Interventions Focus on Non-Communicable Disease (NCD)

KZN Specific Nutrition Policies

Infant and Young Child Feeding in the context of HIV Policy (G68.2010)

KZN Guidelines for the Preparation of Powdered Infant Formula in the Public Sector (Cir G10.2010)

Implementation Guidelines for Nutrition Interventions at Health Facilities (Cir G73.2013)

Vitamin A Supplementation Programme (Cir G96.2012) MNCWH & Nutrition Community Framework Kwazulu-Natal Provincial Guidelines on the Integrated

Management Of Acute Malnutrition -IMAM (Cir 2014)

KZN Specific Nutrition Policies• Infant and Young Child Feeding in the context of HIV Policy

(G68.2010)– 20th of April 2010: KZN-DOH Head of Department approved

implementation of IYCF policy revision for implementation with effect from 1 January 2011This included a decision to stop issuing of free infant formula to

mothers in the PMTCT programme Phased out approach

– 2 Indicators added to DHIS in April 2011• Early breastfeeding initiation (1 hour of birth)• Exclusive breastfeeding at 14 weeks

• KZN Guidelines for the Preparation of Powdered Infant Formula in the Public Sector (Cir G10.2010)

KZN Specific Nutrition Policies• Implementation Guidelines for Nutrition

Interventions at Health Facilities (Cir G73.2013)– Comprehensive policy that provide guidance for

implementation of nutrition services at all levels of care

• Vitamin A Supplementation Programme (Cir G96.2012)– Update of the supplementation protocol– Issuing of Vitamin A by CCGs to increase 12-59 months coverage– Stopping Vitamin A to post-partum mothers

KZN Specific Nutrition Policies• MNCWH & Nutrition Community Framework

– In August 2010, the Head of Department approved the framework for accelerating community based maternal, neonatal, child and women’s health and nutrition interventions.

– This framework focuses on the community based approach to care for women and children at the household level, with the community care givers (CCGs), being recognized as key role players.

• Kwazulu-Natal Provincial Guidelines on the Community-Based Management Of Acute Malnutrition (Cir G 102.2012)– Policy includes management of malnutrition at these levels of care:

• Inpatient Care• Community Outreach• Outpatient Care

Target Groups

Children 0 - 23 months.Children 2 – 14 yearsAt risk pregnant womenAt risk lactating womenHIV and AIDS and TB clientsChronic diseases of lifestyle

PRIMARY PREVENTION INTERVENTIONS

Provide nutrition education and other relevant information on: Protect, support and promote breastfeeding Encourage appropriate complementary feeding of young

children Nutrition during pregnancy and lactation Growth monitoring and promotion Food Based Dietary Guidelines Supplementation with High Dose Vitamin A Capsules

SECONDARY TREATMENT INTERVENTIONS

IMAM (Integrated Management of Malnutrition)

NACS (Nutrition Assessment Counselling & Support)

Details on Entry and Exit Criteria for Therapeutic Feeds and Multivitamin Intervention Supplementation

Nutrition Assessment Screening Counselling and Support

• Malnutrition in children as a proxy of family malnutrition• Proper assessment and screening to ensure that all underweight

children are detected early and treated accordingly• Provision of adequate anthropometric equipment (baby scales and

length measures) was procured for all PHC facilities. • The National Road-to Health-Booklets (RtHBs) are essential tools in

ensuring that regular growth monitoring and promotion occurs at all levels of care, especially PHC.

Therapeutic Supplementation Programme

• A programme currently exists to ensure that all patients presenting with underweight and severe malnutrition receive therapeutic feeds.

• Food supplements to underweight children • Nutrition supplements for those with AIDS/TB related malnutrition

porridge and milk supplements for legible clients • Legible pregnant and lactating women receive therapeutic

supplements• Therapeutic supplements for the aged, chronically ill and children

>5yrs.

Nutrition Indicators• Number of underweight Pregnant women receiving

therapeutic supplements.• Number of underweight lactating women receiving

therapeutic supplements.• Number of underweight HIV+ patients 15 years and older

receiving therapeutic supplements.• Number of underweight TB patients 15 years and older

receiving therapeutic supplements.• Malnourished children under 5 years of age receiving

therapeutic supplements.• Child under 5 food supplementation coverage

Nutrition Advisor Programme In 2011 the structure was approved to have Nutrition Advisors at

PHC Part of Primary Health Care engineering strategy All fixed clinics are earmarked to have Nutrition Advisors Posts were filled from a pool of CCGs and Youth Ambassadors Currently, 396 Nutrition Advisors are working at PHC facilities Phase 2 newly trained Nutrition Advisors starting 1 April 2014 Job Purpose: To promote nutrition services at the primary Health

Care level according to the needs of the community in order to promote optimal nutritional status.

Nutrition Advisor Programme Providing support in the implementation of integrated Nutrition

Programme interventions such as Nutrition Supplementation Programme, Growth Monitoring and Promotion, Vitamin A Supplementation Programme Infant feeding, Young child feeding, Nutrition and Health Education

Participate in (and conduct) community outreach programmes in the districts by being involved with Family Health Outreach Teams; School Health Teams; Operation Sukuma Sakhe.

Conduct nutrition interventions in Phila Mntwana sites / centres such as nutrition education, growth monitoring

Provide nutrition interventions such as nutrition and health education, screening and distribution of nutrition IEC material during community events

MUAC• The introduction of Mid-Upper Arm Circumference Tapes (MUAC) • MUAC tapes aim to ensure early detection of underweight and

prevent severe malnutrition at community level.• Reliable screening tool and a population based indicator to address

the Millennium Development and monitor progress:– MDG Goal 1 – Reduction in Poverty – MDG Goal 4 Reduction in Child mortality

• This tool can be utilized at all levels from Community Based Care Workers up to Medical Professionals.

• Community Health Worker cadre is trained on how to use MUAC for screening and refer to health facilities for intervention where required

• Main tool used for screening at Phila Mntwana centres

Ngiyabonga