Consultancy to Support Contextualization of ICCM Study Tools

Terms of Reference (ToR)

Concern Worldwide is an international non-governmental humanitarian organization dedicated to the reduction of suffering and working towards the ultimate elimination of extreme poverty in the world’s poorest countries

Background and context

Low coverage of wasting treatment programme in Kenya

Kenya is among over 70 countries that have adopted the WHO protocols to treat wasting. Nevertheless, the treatment of acute malnutrition was for a long time restricted to facility-based approaches, greatly limiting its coverage and impact. However, in many settings, the implementation of national guidance for the treatment of child wasting faces challenges, owing to limited resources and capacities, which hamper efforts to reach all children in need. The launch of Community Management of Acute Malnutrition (CMAM) in the year 2000 was a promise of scale, access and coverage, a promise to make treatment truly universal. Unfortunately, the treatment was still being offered by health professionals, literary setting up pseudo health facilities at community level. In settings where human resources for health is limited like Kenya, it means health workers shall close the static health facility to go and provide treatment closer to home – proverbial digging a whole to fill another. Consequently, 20 years later, only 60 percent and less 30 percent of children with severe wasting receive treatment in Kenya and globally respectively (MOH 2013, Miller et. Al., 2020; UNICEF, 2021). This has changed over the last decade informed by new evidence that large numbers of children with acute malnutrition can be treated in their communities, with weekly or bi weekly visits to primary health facilities, without being admitted to a health facility or a therapeutic feeding centre. Recent evidence from across the world and also in Kenya[1] has shown that ccommunity health promoters can easily identify the children affected by acute malnutrition and if effectively linked with a facility-based therapeutic care for referral could prevent the deaths of hundreds of thousands of children.

[1] Cluster Randomized Control trial (RCT) conducted in Turkana and Isiolo, 2019 (manuscript submitted for peer-review)

Linking Community Management of Acute Malnutrition (CMAM) and Integrated Community Case Management (iCCM).

Faced with the programmatic and ethical question of how to expand access and coverage of management of SAM and MAM in children, especially in the hard-to-reach and underserved areas, nutrition stakeholders have recently started to explore the potential for linking Community Management of Acute Malnutrition (CMAM) and Integrated Community Case Management (iCCM). The hypothetical advantages of linking iCCM and nutrition services seems obvious given that malnutrition and iCCM target conditions of diarrhoea, malaria and pneumonia are intertwined in a self-reinforcing cycle and their prevention and management overlap considerably.

An integrated approach to addressing the twin problems of disease and malnutrition would make it possible to break the vicious cycle by addressing the presenting and underlying aspects of a child’s illness, thus contributing to reducing the burden of common childhood illnesses and maximising child survival in vulnerable communities. The big wins of integration of management of acute malnutrition with iCCM is expected to be in counties with sparsely populated Arid and Semi-Arid Lands (ASAL) where access to facilities is relatively limited with long distance as well as harsh environment to walk. Bringing free and effective treatment close to communities will likely improve access to and utilization of services for management of malnourished children that often takes weeks of follow up. To date, management of malnutrition in the Kenyan context remains confined to the health facilities by the skilled health workers. But a small scale clinical trial was conducted in 2019 using simplified protocols to explore effectiveness of integrating treatment of SAM and MAM by CHPs into ICCM. The findings support the potential of CHPs treatment outcomes being non-inferior to the standard care provided at health facilities by health workers.

The Implementation Research, Phase 2 ICCM/ CMAM Pilot Study

The Ministry of Health, UNICEF, Concern Worldwide and Save the Children have convened several meetings with national and selected counties to co-design a Phase 2 operations research protocol that will be implemented in a larger scale programmatic context to generate implementation experiences, effectiveness of integration, costing the scale up and document success factors for sustainability. Turkana, Marsabit and Mandera have been prioritized for Phase 2 pilot based on the persistent wasting burden and the health systems readiness, security and political goodwill. Additionally, Kenya has been selected as fast-runner country for piloting the WHO 2023 guideline and ICCM TAG members has convened preparatory meetings to review and understand the implications to the current the IMAM program.

Research design

A hybrid 2×2 factorial design Implementation research will be employed to determine which intervention (CMAM only, ICCM+CMAM, ICCM only, or a combination of interventions) maximizes better outcomes in terms of quality of care, coverage and treatment outcomes for children 6-59 months of age with acute malnutrition.

Research Objectives

• To examine the effectiveness of integrating management of uncomplicated acute malnutrition and iCCM (coverage, cure rate, defaulter rate, death rate).
• To determine the enabling factors for effective integration of management of uncomplicated acute malnutrition and iCCM.
• To identify the challenges, constraints and potential pitfalls in integrating management of SAM and iCCM.
• To document lessons and best practices (including data and commodity supply systems) in integrating management of uncomplicated acute malnutrition into iCCM and provide policy and programmatic recommendations.
• To determine multifactor considerations (including cost-effectiveness) for scale up and sustainability of integrating management of uncomplicated acute malnutrition into iCCM.

Purpose of the Consultancy

As part of preparation for the implementation research, a review and adaptation of the existing iCCM-CMAM tools and training materials that were employed during the RCT in Turkana and Isiolo, is needed with subsequent customization to Marsabit and Mandera communities. Hence, Concern is seeking to procure consultancy services to facilitate the revision and contextualization of the simplified tools for low literate CHPs according to the agreed treatment protocols recently adopted to the WHO Guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years (2023).

The tools will only be deployed to the research sites outlined in the research protocol.

Objectives and Specific Tasks to be undertaken by the Consultant(s)

The consultant (s) will undertake the following;

• Conduct an extensive review of the existing current iCCM national framework, tools and training materials.
• Conduct an extensive review of the existing IMAM guidelines, tools and training materials
• Review proposed changes in the current IMAM guideline and the 2023 WHO guideline on the prevention and management of child wasting.
• Conduct an extensive review of the existing Community training packages, tools and training materials including the Kenyan Electronic Community Health Information System (e-CHIS)
• Conduct an extensive review of ICCM and CMAM tools and materials used in other countries with a view of learning best practices to contextualize for the Kenyan audience.
• Revise and update the simplified SAM/MAM treatment protocol, tools, training package and Job Aids for CHPs
• Revise and update the iCCM tools and training materials and integrate the simplified SAM/MAM treatment protocol, tools and training materials harmoniously to enable management of acute malnutrition at community level
• Develop Certification/Accreditation SOPs for CHPs providing nutrition services at the Community level as per the current guidelines.
• Develop Certification/Accreditation SOPs for CHPs providing treatment of uncomplicated SAM and/or MAM
• Develop Certification/Accreditation SOPs for CHPs providing integrated treatment of uncomplicated SAM and/or MAM and childhood illnesses (Malaria, Pneumonia, Diarrhea).
• Present the revised tools to relevant groups (ENAC, iCCM TWG or others as guided by MOH) for approval and incorporate feedback
• Closely work with Principal Investigator (PI) to incorporate any changes that may be necessitated by the changes during finalization of the research protocol
• Spearhead the piloting of the produced materials to gauge their objectivity in meeting the intended purpose and making the necessary adjustments
• Train the local designer/ IP staff on the Human-Centered designs and the pre-testing methods

Outputs

• A detailed analysis of iCCM and CMAM materials with proposed changes onto the iCCM tools and training materials to be used in the implementation research, including suggestion on ways how KHIS and eCHIS could be amended in the future to reflect integrated reporting from community level.
• Simplified SAM/MAM treatment protocol, training materials and Job Aids for CHPs aligned/integrated with iCCM materials.
• Revised iCCM tools (cart booklet, registers, supervision checklists, and other tools) incorporating management of acute malnutrition at community level
• Revised iCCM training materials incorporating management of acute malnutrition
• Certification/Accreditation SOPs for CHPs providing nutrition services at the Community level as per the current guidelines.
• Certification/Accreditation SOPs for CHPs providing treatment of uncomplicated SAM and/or MAM
• Certification/Accreditation SOPs for CHPs providing integrated treatment of uncomplicated SAM and/or MAM and childhood illnesses (Malaria, Pneumonia, Diarrhea).

Duration and Location:

50 days to support Concern Worldwide in review and adaptation of the existing iCCM-CMAM tools and training materials in Turkana and field testing of updated algorithms among the communities in Marsabit and Mandera counties.

Lines of Communication

The consultant will be accountable administratively to Concern Worldwide i.e. Program Director and Health and Nutrition Coordinator and technically to ICCM TAG – an executive group comprising MOH-NDU, MOH-Child Health, UNICEF, WFP, WHO, Save the children, CWW, IRC on technical deliverables of the tools and training materials.

Essential and Desirable Experience/Qualifications

• Bachelor degree in nutrition, public health or related field. Master’s degree nutrition related field is an added advantage.
• Experience in human-centered designing and writing up tools and training materials for health workers and Community Health Promoters.
• Experience in iCCM and / or management of acute malnutrition
• Minimum 7 years relevant experience in child health and nutrition in the Horn of Africa and ideally in northern Kenya.
• Very good written and oral communication skills.
• Competency in word processing, publisher and spreadsheets.
• Experience in government District Health Information Systems

Required documentation with your proposal:

1. Company / Consultant profile
2. Certificate of Incorporation (firms) or National ID card (individual)
3. Valid Tax Compliance Certificate
4. PIN Certificate
5. Company / Consultant’s Profile
6. CVs of key staff
7. Certificate/reference information of previous undertakings of similar contracts with NGOs/UN agencies
8. Safeguarding Policy, Code of Conduct etc. or what are the necessary provisions have you put in place to keep everyone safe in the course of your engagement
9. Attach copy of Certificate of Good Conduct or proof that you have applied for the same
10. A detailed work plan with milestones
11. Confirm the gender ratio for the team that you will be engaging in this exercise
12. Technical proposal
13. Financial proposal
14. Evidence of previous related works (e.g. Technical design reports)
15. Work plan (Gantt chart) showing specific milestone

Concern Code of Conduct and associated policies

Concern has an organisational Code of Conduct (CCoC) with three Associated Policies; the Programme Participant Protection Policy (P4), the Child Safeguarding Policy and the Anti-Trafficking in Persons Policy. These have been developed to ensure the maximum protection of programme participants from exploitation, and to clarify the responsibilities of Concern staff, consultants, visitors to the programme and partner organisation, and the standards of behaviour expected of them. In this context, staff have a responsibility to the organisation to strive for, and maintain, the highest standards in the day-to-day conduct in their workplace in accordance with Concern’s core values and mission. Any candidate offered a job with Concern Worldwide will be expected to sign the Concern Staff Code of Conduct and Associated Policies as an appendix to their contract of employment. By signing the Concern Code of Conduct, candidates acknowledge that they have understood the content of both the Concern Code of Conduct and the Associated Policies and agree to conduct themselves in accordance with the provisions of these policies.