by Sarah McClung
Sarah describes her experience helping to implement community based nutrition services in Islamabad, Pakistan.
Most of us are familiar with CMAM – Community Based Management of Acute Malnutrition. Despite some criticism related to sustainability and cost, CMAM is generally considered international best practice for dealing with wasting. CMAM would be categorized as a “supply-side” intervention meaning that services and assistance are provided by a health facility to the end user, in this case, an individual at risk of acute malnutrition. Alternatively, a “demand-side” intervention would originate from the end user. Most health-related interventions would be categorized as supply-side, think medicine, mobile medical units, doctors, community health workers, etc., but what might demand side action look like?
I spent the last three months in Islamabad, Pakistan working on the DFID-funded Empowerment, Voice & Accountability for Better Health and Nutrition (EVA-BHN) project which was designed to be the demand-side project supporting the broader Provincial Health and Nutrition Program (PHNP). EVA-BHN draws from many governance and voice and accountability principles for an approach developed to increase demand for quality health and nutrition services. Where does one begin in an effort to generate demand? Good question. EVA-BHN began by analyzing a community’s capability to utilize health and nutrition services, their opportunity to utilize those services and their motivation to utilize those services and has tailored project activities focuses primarily on motivation. One of the main activities to influence motivation is community based monitoring (CBM) of public health and nutrition services.
The theory behind CBM is that by engaging citizens in the monitoring process they develop a better understanding of their rights and who to hold accountable for service delivery. EVA-BHN uses a checklists to collect different types of information – one checklist collects information on the Basic Health Unit’s (BHU – Pakistan most basic healthcare facility) infrastructure, staff, and stock, another guides administrators through exit interviews for information on the experience of patients, and the third is at the household level and collects information from those living around the community BHU. “It is not only about the data they [citizens] collect,” says Annette Fisher, Technical Project Manager of EVA-BHN, “but their involvement in the monitoring process.”
The questions on the checklist are based on the Essential Health Service Package (EHSP), a guide developed by each province laying out the most basic services public health facilities are required to provide. Some health issues are more appreciated than others, the need for skilled birth attendants and adequate facilities for delivery for example is clearly understood by both citizens and government. For nutrition the situation is a bit complicated – EHSPs in Pakistan do contain guidelines for nutrition services however the capacity of BHUs across the country to supply them is limited. Furthermore, the adequacy of the nutrition guidelines in the EHSPs is debatable and citizen’s knowledge of nutrition is limited, effecting their motivation to demand quality service. Nevertheless, the CBM checklists create an opportunity for raising awareness of the importance of nutrition. If a community member volunteers to collect data through a CBM checklist he or she would receive training and would understand the significance of each question. The administrator would then impart knowledge onto the checklist participant, for example, a volunteer might ask a patient in an exit interview if their mid-upper arm circumference (MUAC) was measured – screening for acute malnutrition. Regardless of the individual’s answer the message that such screening is important is reinforced for both parties.
EVA-BHN is only just beginning its second year but the staff are optimistic about the CBM tool. The project team feel as though if the CBM checklists are the only legacy the EVA-BHN project leaves in KP and Punjab, they will have made a positive impact and attitude that can be applied in other sectors.
Sarah McClung is a first-year FPAN student who enjoys running to trap music and forcing vegetables on friends and family.