The objective of the study was to assess the preparedness of the health system to take on CMAM in the two sub-districts of Ukhiya and Teknaf. Table presents a synthesis of key findings obtained through the use of the adapted themes and criteria.
Synthesis of findings obtained from the use of the adapted WHO six building blocks
Improving child nutrition is a government priority in Bangladesh, and the national health and nutrition policy fostered CMAM advocacy and potential integration into the health system [26
]. The MOHFW considered CMAM as a relevant intervention and developed adapted inpatient and outpatient guidelines. The UN Joint Statement on CMAM states that the development of national protocols is crucial prior training of health workers on a standardised CMAM approach delivered at all levels of the health system pyramid [7
]. Bangladesh has made a remarkable progress in this regard, treatment of SAM children being implemented in 39 inpatient facilities across the country. However, while moving forward with the issue of CMAM integration in the country, the MOHFW should lead the nutrition coordination process (including the nutrition working group). This would harmonise and strengthen the identification and allocation of available resources for CMAM to priority districts, for better impact.
For CMAM integration to be sustainable, it is essential to have a commitment for long-term funding [7
]. Available funds dedicated to CMAM at the time of the study were earmarked for short term interventions (3 years). Successful design and implementation of CMAM pilot projects would serve as advocacy instrument for pledging more funds from both government and partners. The free-of-charge medical care for children represents an opportunity for many malnourished children to access health and nutrition services, as most of them generally come from poor families. However, such policy, although internationally supported by some funding agencies [48
] and global health actors [49
], might be challenging in the context of short-term funding projects. Bangladesh joined the Scaling-Up Nutrition (SUN) movement as an active participant [50
], therefore the government and partners should use this opportunity to secure long term funding for CMAM. The Renewed Efforts Against Child Hunger (REACH) initiative [51
], disaster risk reduction as well as HIV and AIDS initiatives should also be scrutinised. In addition, options such as participation of private investors, foundations, donor states, solidarity lottery and small tax levy on financial transactions should be examined in order to widen the pool of available funds for nutrition [52
Services delivered within the hospitals and the health centres of the two sub-districts offered opportunities to include inpatient, outpatient and outreach CMAM activities. For example, services provided in the Upazilla health complexes demonstrated that health workers would be able to manage complications related to malnutrition if they were trained and if the hospitals were rehabilitated, equipped and supplied.
Outpatient services provided in the Upazilla health complexes, Union sub-centres, family welfare centres, community clinics and NGO health centres offered opportunity to integrate outpatient activities for SAM and MAM management. In order to achieve this objective, these health centres would need to be provided with anthropometric and medical materials, storage facilities would have to be improved, a permanent supply of medicines and therapeutic foods would need to be secured, and non-functional health centres would require rehabilitation.
Health assistants and family welfare assistants alternatively visit the households, which is an opportunity to include CMAM outreach in their activities. In this regard, the assistants would have to be trained and provided with mid-upper arm circumference tapes, referral slips and sensitisation materials such as flyers or pamphlets containing Information, Education and Communication (IEC) messages on prevention of acute malnutrition.
In countries like Ethiopia, Sierra Leone, Malawi and Ghana, CMAM activities have been closely linked to antenatal care, IYCF, immunisation, Integrated Management of Childhood Illness (IMCI) and growth monitoring interventions [53
]. In Mozambique, CMAM is integrated into the reproductive and maternal child health, HIV and AIDS and tuberculosis services, health promotion, and community involvement. In Kenya, most outpatient treatment services for SAM management are located in the Maternal and Child Health clinics [57
]. The two main facilitating factors in these countries are (1) the leadership of the government for the implementation of primary health care package, in which they have included CMAM activities, and (2) good coordination between the government, NGOs and donors for strategizing integration within the health system and scaling up CMAM services throughout the country [17
]. Similar approach should be considered in the context of Bangladesh for successful inclusion of CMAM activities into the national primary health care package.
Staff shortage would be an important challenge to overcome when planning and implementing CMAM through the health centres of the two sub-districts of Ukhiya and Teknaf. Shortage of health personnel is a recognised issue globally [61
]. All countries in Southeast Asia face problems of uneven distribution of health workers, with rural areas often understaffed [62
]. The study findings confirmed that health workers prefer to work in the cities and for NGOs because of better working conditions and salaries. This is in accordance with reports from the Asia-Pacific and Africa regions, which indicate that salaries and benefits, together with working conditions, supervision and management, education and training opportunities are factors affecting health worker motivation and retention [63
]. Proper distribution of health workers, along with assessing appropriate strategies for attracting and retaining them in the rural area would be critical in the context of both sub-districts, prior and during implementation of CMAM [62
One appropriate strategy to offset health facility staff shortage would be the identification, training and involvement of community health workers and volunteers into outpatient SAM and MAM management, since most of the affected children can be successfully treated in the community [30
]. A study carried out in Burkina Faso showed that 77% of children suffering for acute malnutrition were successfully managed in the community [66
], while CMAM evaluations conducted in Nepal and Pakistan demonstrated that this was the case for more than 80% of children admitted in the programme [67
]. Recent studies conducted in southern Bangladesh showed that community workers were able to achieve quality care in managing cases of SAM without complications, provided they received good training and regular supervision [69
]. The intervention achieved high coverage, low default, high recovery and low mortality rates, and it was cost-effective [70
]. The approach was also successful in other settings for early detection of malnutrition cases and considerable reduction of death rate [57
]. Therefore, involving community workers in CMAM implementation in Bangladesh would be an effective strategy to make up for the health facility staff shortage, and would eventually reduce their workload.
The needed staff for outpatient SAM and MAM management was estimated on the basis of standards developed in the contexts of emergency relief interventions, where most of nutrition activities are implemented and managed by NGOs. These standards might not apply in non-emergency contexts when planning the implementation of CMAM through the regular health facilities. Studies should be conducted on the relevance of these standards in such contexts, for example by assessing health workers’ workload during outpatient SAM and MAM management.
The assessment of only two sub-districts and the fact that respondents were selected purposively are two potential limitations of the study. The findings are therefore not representative of the whole health system in Bangladesh, and this may hamper the external validity of the study. There is also a potential source of social desirability bias because interviewees might have answered to questions in such a way that would encourage the study team, ACF and other implementing partners to initiate CMAM in the area. This bias was anticipated and mitigated by triangulating the data collected through three different techniques.
In the absence of standardised criteria and indicators for CMAM integration, the WHO six building blocks were adapted and subdivided into 16 criteria to assess the health system preparedness for CMAM implementation. A systematic review conducted in 2009 used a similar approach to examine the extent and nature of the integration of targeted health programmes into the health system, and it showed that specific interventions are seldom fully integrated into health system functions [73
]. In 2012, the use of the WHO building blocks to assess the effects of user fee exemption policies on health system functions gave an idea of what should be expected if such policies did not implement all the required conditions in terms of preparation, planning and complementary measures [74
]. In the present study, each criterion provided useful information which helped to make a diagnosis of the health system preparedness, highlighting areas that needed strengthening prior and during implementation of CMAM. This is one of the contributions of the study. Several developments have occurred in the country since the completion of the study, which confirmed the progressive integration of CMAM into the health system. For example, CMAM has been included in the nutrition policy and service delivery, additional funding has been secured, the guidelines have been developed and the health personnel trained, and activities such as hiring more health workers, improving the national health information system, and building and rehabilitating health centres have been planned [25
]. Additional research conducted both within and outside the Bangladesh context is necessary to sharpen the criteria used in this study.