Consultant: Accelerating prevention, early detection and treatment of wasting in South Africa (Pretoria, 5 months, remote)

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For every child, health.

UNICEF South Africa

Although South Africa has been on track to achieve the Sustainable development goal (SDG) 3.2 that aims to achieve under 5 mortality rates below 25 deaths per 1000 live births globally by 2030, preventable deaths in under 5 children continue to rise1.Over the past few years, severe acute malnutrition (prevalence of 2.5%, i.e. 140 000 children) remains a significant underlying cause of child mortality, being associated with one-third of all child in-hospital deaths2. Children who are both wasted and stunted are 12.3 times more likely to die than their well-nourished counterparts. Wasted children are at high risk of dying from common childhood illness such as measles, diarrhea and pneumonia.

According to the District Health Information System (DHIS) routine data, the national severe acute malnutrition (SAM) case fatality rate (CFR) has declined steadily from 19.3% in 2009/10 to 7.7% in 2019/20. This varies amongst districts and facilities, with some of these still experiencing CFR of more than 20%. It is known that mortality rates in children who are suffering from SAM are nine times higher than those in well-nourished children and those with Moderate acute malnutrition (MAM) have the mortality rate three times higher than well-nourished children3.

The 4th Committee on Morbidity and Mortality (CoMMiC) triennial report (2018-2020) showed that many cases of child illness and child death are avoidable, and that majority of the modifiable factors occur at home include delays in seeking care for the child, lack of ability to recognize danger signs or severity of illness and inadequate nutrition and the use of traditional remedies. The committee recommended optimization of the use of the Road to health book as a health record for preventive, monitoring, risk recognition and curative health interactions and activities, health promotion information, parent empowerment opportunities, and a communication tool across health service and other sites.

Despite full coverage of health facilities offering routine, curative and rehabilitative care, for common childhood diseases and wasting treatment, many children with wasting at community level are not receiving treatment they need due to missed opportunities in identifying them. The unprecedented spread of the COVID-19 pandemic has disrupted the provision of routine nutrition services and worsened the already existing nutrition gaps in South Africa. Anecdotally, this is potentially preventing children and women from accessing routine health care, nutritious diets and essential nutrition services, as well as those for the early detection and health seeking for treatment of common childhood illnesses and child wasting.

Challenges

South Africa has interventions in place to prevent child wasting. However, they are not always as effective as they could be – in part, because of the way they are designed and implemented. The fragmented approach in terms of delivering and designing interventions geared towards addressing food insecurity, social, health and nutrition makes it challenging to provide comprehensive services to the most vulnerable households and children. The result is that women and children at risk are not systematically being reached at the right time, with adequate quality and intensity, and/or for the appropriate duration.

The main roadblocks to the prevention of child wasting include:

Although generic determinants and drivers of undernutrition are well appreciated and known in the country, the determinants and drivers of wasting may vary from one province or district to another depending on the context and environment in which a child lives. However, interventions that are currently being implemented to tackle wasting in districts do not systematically identify and map-out these context specific determinants and drivers. National responses and strategies to prevent wasting are largely based on a one-size fits all approach using the generic determinants and drivers of undernutrition, without taking into consideration the contextual specificity at the local level. In certain instances, context-specific determinants and drivers of wasting for children, households and communities may be well known. However, these specific vulnerabilities are not systematically considered when designing programmes for the prevention of child wasting. At times the knowledge of context-specific determinants and drivers do not always translate into actions that prioritize the children, households and communities that are most in need.

It is estimated that only 8% of children with severe wasting in South Africa are receiving treatment, with varying coverage across provinces and districts. This low coverage could even of particular challenge for infants under 6 months of age. Early detection of children at risk and those who are severely wasted must be prioritized. It is critical to intensify active case finding which aims to recognize and treat children with wasting before they become severely wasted. Although active case finding may increase the case load, it will contribute to faster recovery by shortening the duration of an episode of malnutrition and lower the case fatality rate in the long run4. In order to achieve early identification of children with wasting, the diagnosis of wasting should be decentralized from a strictly hospital-based approach for all cases to the current model of outpatient care for children with uncomplicated wasting and inpatient care for children presenting with complications or failing to respond to treatment. In South Africa the outpatient care model has not been fully realized due to the hospi-centric health care system wherein all wasted children are treated in a hospital.

It is not known how the financial resources are spread across children with moderate and severe forms of wasting. It is well known that children with severe form of wasting are twice as likely to die than children with moderate forms. Resources should be prioritized to the children with more severe forms of wasting, particularly amongst children <24 months. The availability of screening tools such as MUAC tapes, weighing scales and other supplies (i.e. F-75, F-100 and Ready-to-Use Therapeutic Foods) should be available for screening and treatment of all vulnerable children.

Treatment of child wasting is poorly integrated into routine services for children. This is the result of the lack of a coordinated effort to accelerate the integration of early detection and treatment into primary health care, as well as the complexity of current treatment protocols, which make it difficult for healthcare providers to seamlessly add the treatment of wasting to their portfolio of services. The use of IMCI has been identified as a huge gap which contribute to early identification and classification of wasted children at facility level. At the same time, the high number of HIV infected children put more children at risk of malnutrition.

It is known that at times caregivers present late at healthcare facilities which leads to many children dying within the first few hours of admission in healthcare facilities. Therefore, community-based early detection and treatment of children with wasting must be taken to full scale.

The implementation of protocols and guidelines for treating children with severe wasting has been a challenge in many healthcare facilities due to lack of knowledge by healthcare providers, as well as not following the protocols as prescribed. The COMMIC report also highlighted that the incomplete implementation of the 10 Steps, especially the rehabilitation phase is problematic.

The Opportunity

UNICEF has been providing technical support to the National Department of Health with the revision of the Integrated Management of Acute Malnutrition Guidelines and the modelling of a phased approach on the implementation of Family Mid-Upper Arm Circumference (MUAC) in South Africa for early identification and referral of wasted children. The modelling of the simplified approach in two provinces will inform the scaling up of this simplified approach in early identification of children at risk of wasting at a community level which can

be performed by minimally trained personnel such as community health workers (CHWs) and even mothers and carers. The finalization of the guidelines also creates an enabling environment to strengthen the management of wasted children at community, primary health care and hospital level.

At a political level, the conditions today are ideal for mounting a concerted effort to address child wasting. In mid-2019, the United Nations Secretary-General commissioned United Nations agencies to develop a Global Action Plan (GAP) on Child Wasting – the first-ever global plan to achieve the SDG targets on child wasting. The GAP outlines key commitments by national governments, United Nations agencies, civil society organizations, academics and private sector partners to accelerate progress on child wasting by 2025. In addition, the recently concluded UNICEF-World Food Programme (WFP) Partnership Framework for Addressing Wasting in Children provides a framework for streamlined and impactful actions to reduce child wasting and expand treatment, particularly in humanitarian contexts. The GAP and the UNICEF-WFP Partnership Framework create a unique opportunity to recognize child wasting as a global development priority, and to mobilize inter-agency efforts at a global, regional and national level in a decisive, coordinated manner.

The UNICEF methodology of the Bottleneck Analysis (BNA) exercise is a participatory and consultative process undertaken with all stakeholders involved in severe wasting (severe acute malnutrition). It starts with orientation/inception workshops to define and contextualize the indicators used to perform the analysis, followed by collecting the necessary qualitative and quantitative information (from available database and structured questionnaires). A joint critical analysis of date will then be performed to identify and articulate bottlenecks or barriers to access to SAM treatment and effective coverage, followed by a causal analysis of the root causes. The outcome of this process will lead to the joint definition and prioritization of evidence-based solutions to address the bottlenecks, which will lead to the development of an action plan that outlines and guide the implementation of the programme reforms and set targets.

The BNA approach uses the Tahanashi model to critically examine the main determinants of effective health services coverage. The BNA for SAM management services is a real time program monitoring tool and complements other SAM programme coverage assessments methodologies in a cost-effective as well as time efficient manner. The BNA adopts a problem-solving approach that can support analysis and taking timely corrective action in addition to informing scale-up strategies and programme designs. The aim of the BNA is to identify, target and monitor key bottlenecks and put programme reforms in action toward increase in Integrated Management of Acute Malnutrition (IMAM) programme coverage.

The BNA approach is a means not only to improve the access and effective coverage of severe wasting management but very importantly to inform the SAM scale-up strategy and maximize the chance to achieve more responsive programming and better results for children of South Africa.

How can you make a difference?

• Analyse collected qualitative and quantitative information so that bottlenecks/barriers and their root causes to access care and treatment for SAM are logically identified including geospatial allocation of services, wasting prevention services, supply chains, referral systems, reporting and monitoring system as well as community mobilization and engagement.
• Define and prioritize evidence-based solutions to address bottlenecks and develop an action plan to guide the implementation of the SAM scale-up plan and its targets, particularly at community level.
• Define and contextualize the key indicators, outcomes, and tools to be used in the analysis using a consultative and participatory process.
• Document lessons and experiences in the implementation of SAM management services in provinces.

The service provider will contribute to the critical analysis of barriers and bottlenecks and the development of recommendations to improve access to severe wasting treatment and effective coverage in areas with high burden of wasting. The consultancy will also support the National Department of Health in documenting lessons learned, good practices, case studies and experiences in implementing wasting services in Provinces. The work will focus on the following key enabling areas to unlock the policy and programmatic issues regarding wasting:

• Analysis
• Prevention
• Early detection
• Treatment
• Linking caregivers and children to care and social protection systems
• Supply chain
• Evidence generation

Tasks

• Design, organize and facilitate the inception workshops on bottleneck analysis in 4 Provinces (i.e. Gauteng, Limpopo, North West and Eastern Cape) - Inception report, including the workplan for BNA, draft indicator list and tools Documentation of the workshop.
• Data collection of qualitative and quantitative information in 4 Provinces using agreed indicators and tools - Report on qualitative and quantitative information collected, 4 case documentation on experiences, best-practices, lessons learned and challenges on wasting management.
• Facilitation of analysis of Bottlenecks and development of strategic action plan through a Participatory Validation Workshops - Validation workshop, documentation of BNA and Action Planning workshop, 5 Case Studies documentation, Process documentation of the BNA exercise.
• Final Report of the Bottleneck Analysis - BNA and Action Plan document, 9 Case Studies and Process Documentation, 1 Policy Brief, 1 Peer reviewed article.

To qualify as an advocate for every child you will have…

• An advanced university degree (Master’s or higher) in Health, Nutrition, Medicine, Social Sciences or relevant field
• A minimum of 5 years of relevant professional experience in health systems/health governance/bottleneck analysis/program evaluation/operations research from developing countries on nutrition
• Practical experience in the management of nutrition programs supported by reports and documents
• Technical knowledge in the management of wasting/SAM is an advantage
• Ability to work in consultative and coordinated manner and with demonstrated skills for building consensus between a wide group of experts supported by reports and documents
• Previous with UN and other international development partners in Africa will be to your advantage
• Good written and communication, presentation, and analytical skills
• Developing country work experience and/or familiarity with emergency
• Fluency in English is required. Knowledge of another official UN language (Arabic, Chinese, French, Russian or Spanish) or a local language is an asset
• Financial proposal/daily rate

For every Child, you demonstrate…

UNICEF's values of Care, Respect, Integrity, Trust, Accountability, Sustainability (CRITAS).

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UNICEF is committed to diversity and inclusion within its workforce, and encourages all candidates, irrespective of gender, nationality, religious and ethnic backgrounds, including persons living with disabilities, to apply to become a part of the organization.

UNICEF offers reasonable accommodation for consultants/individual contractors with disabilities. This may include, for example, accessible software, travel assistance for missions or personal attendants. We encourage you to disclose your disability during your application in case you need reasonable accommodation during the selection process and afterwards in your assignment.

UNICEF has a zero-tolerance policy on conduct that is incompatible with the aims and objectives of the United Nations and UNICEF, including sexual exploitation and abuse, sexual harassment, abuse of authority and discrimination. UNICEF also adheres to strict child safeguarding principles. All selected candidates will be expected to adhere to these standards and principles and will therefore undergo rigorous reference and background checks. Background checks will include the verification of academic credential(s) and employment history. Selected candidates may be required to provide additional information to conduct a background check.

Remarks:

Only shortlisted candidates will be contacted and advance to the next stage of the selection process.

Individuals engaged under a consultancy or individual contract will not be considered “staff members” under the Staff Regulations and Rules of the United Nations and UNICEF’s policies and procedures, and will not be entitled to benefits provided therein (such as leave entitlements and medical insurance coverage). Their conditions of service will be governed by their contract and the General Conditions of Contracts for the Services of Consultants and Individual Contractors. Consultants and individual contractors are responsible for determining their tax liabilities and for the payment of any taxes and/or duties, in accordance with local or other applicable laws.

The selected candidate is solely responsible to ensure that the visa (applicable) and health insurance required to perform the duties of the contract are valid for the entire period of the contract. Selected candidates are subject to confirmation of fully-vaccinated status against SARS-CoV-2 (Covid-19) with a World Health Organization (WHO)-endorsed vaccine, which must be met prior to taking up the assignment. It does not apply to consultants who will work remotely and are not expected to work on or visit UNICEF premises, programme delivery locations or directly interact with communities UNICEF works with, nor to travel to perform functions for UNICEF for the duration of their consultancy contracts.