The National Nutrition Care, Support, and Treatment (NCST) Operational Plan

National Nutrition Care, Support, And Treatment Operational Plan. 2018-2022 Recommended Citation Ministry of Health (MOH). 2017. National NCST Operational Plan 2018–2022. Lilongwe, Malawi: MOH. Contact Information Nutrition Unit of the Ministry of Health P.O. Box 30377 Lilongwe 3 Malawi Telephone: +265 (01) 789 400 Fax: +265 (01) 789 431 This operational plan is made possible by the generous support of the American people through the support of the Office of Health, Infectious Diseases, and Nutrition, Bureau for Global Health, U.S. Agency for International Development (USAID), the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and USAID/Malawi, under terms of Cooperative Agreement No. AID-OAA-A-12-00005, through the Food and Nutrition Technical Assistance III Project (FANTA), managed by FHI 360. The contents do not necessarily reflect the views of USAID or the United States Government. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 ii Preface Malnutrition remains a major public health problem in Malawi and is compounded by the high prevalence of infections, such as HIV and tuberculosis (TB). The Government of Malawi (GOM) recognises the important role that food and nutrition interventions play in the care and treatment of these diseases and is therefore committed to delivering effective food and nutrition interventions. The GOM developed the 2nd Edition of the National Guidelines on Nutrition Care, Support, and Treatment (NCST) for Adolescents and Adults in 2014. In 2017, the guidelines were updated to include lessons learned and align with the 2nd Edition (2016) of the Guidelines for Community-Based Management of Acute Malnutrition (CMAM) and the 3rd Edition (2016) of the Malawi Guidelines for Clinical Management of HIV in Children and Adults. NCST services provide a comprehensive set of nutrition interventions aimed at preventing and managing undernutrition and overnutrition in adolescents and adults at various service delivery points in health facilities and communities. In addition, NCST services promote the linkage and referral of clients between the health facility and community-based health, nutrition, economic strengthening, livelihoods, and food security interventions. This National NCST Operational Plan 2018-2022 outlines an overarching implementation framework for improving access and coverage of quality nutrition services for adolescent (15-18 years) and adult (19 years and older) people living with HIV (PLHIV) and TB clients in Malawi. The operational plan was developed through a consultative process with local and external technical experts. Under the leadership of the MOH, all nutrition partners will be instrumental in supporting the implementation of the outlined priority actions over the five-year period of this plan. The National NCST Operational Plan 2018–2022 will be implemented alongside the National Multi-Sector Nutrition Policy 2017–2021, the National Multi-Sector Nutrition Strategic Plan 2017–2021, the Health Sector Strategic Plan II 2017-2022 and the National HIV Strategic Plan 2015-2020. It is envisaged that these concerted efforts will contribute to improvements in national nutrition and health outcomes. Dr. Charles Mwansambo CHIEF OF HEALTH SERVICES Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 iii Acknowledgments The National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018-2022 was developed with financial and technical support from the U.S. Agency for International Development (USAID) through the Food and Nutrition Technical Assistance III Project (FANTA), implemented by FHI 360, and the World Food Programme (WFP)/Malawi. The Government of Malawi (GOM) would further like to express its sincere gratitude to all those who contributed in different capacities to the development and production of these guidelines. Dr George Chithope-Mwale, Director for Clinical Services, Ministry of Health (MOH) and Mr. Felix Phiri Director for Nutrition, Department of Nutrition, HIV and AIDS (DNHA) are recognised in a special way for their policy guidance. The Government is also highly indebted to Janet Guta, Deputy Director for Nutrition, MOH; Blessings Muwalo, DNHA; Frank Msiska, MOH; Alice Nkoroi, FANTA; Stanley Mwase, FANTA Consultant; Tina Lloren FANTA; and Violet Orchardson, USAID for their leadership and technical guidance during the whole process of drafting and producing the final version of these national guidelines. The following people were consulted and provided technical guidance in the development and finalisation of this operational plan: Dr. Rose Nyirenda MOH/HIV Department Emmanuel Mkandawire Chitipa DHO Nozza Mpesi Chikwawa DHO Ndondwa Msaka UNAIDS Kuzani Mbendera MOH/TB Unit Mayamiko Makondi Mulanje DHO Robertson Saizi Thyolo DHO Isaac Ahemesah UNAIDS Nancy Masache MOH/Reproductive Health George Nundwe Mzimba North DHO Davie Panyani Nkhatabay DHO Emma Chimzukira WFP Feston Kaupa Central Medical Stores Nelson Mwango Phalombe DHO Cassius Mkandawire Mchinji DHO Trust Mlambo WFP Lisungu Kamkondo Lilongwe DHO Edward Chitete Blantyre DHO Kondwani Mhango Mzimba DHO Kassa Mohhamed DFID Dorothy Mphaya Chiradzulu DHO Jason Chigamba Balaka DHO Kalima Chikafa Nsanje DHO Urunji Mezuwa Nkhotakota DHO Kingsley Chizeze Salima DHO Victor Munkhuwa Dowa DHO Getrude Maida Mangochi DHO Gladys Manyenje Kasungu DHO Langani Nyirenda Ntchisi DHO Khumbo Mkandawire Machinga DHO Halmiton Gondwe Karonga DHO Arnold Kayira Machinga DHO Martins Mkandawire Dedza DHO Emma Kapawe Mwanza DHO Sekanabo Kapira Neno DHO Maggie Chiwaula Zomba DHO Arthur Bunyani Zomba Central Hospital George Mtengowadula Ntcheu DHO Amanda Yourchuck FANTA Phindile Lupafya FANTA Letcher M. Munyenyembe Rumphi DHO Molly Kumwenda Catholic Relief Services Linda Dziweni Sato Baylor University Susan Mhango Baylor University William Mkandawire Partners in Hope EQUIP-Malawi Project Savel Kafwafwa Partners in Hope EQUIP- Malawi Project Chiukepo Longwe Partners in Hope EQUIP-Malawi Project Happy Botha Nkhoma - Peanut Butter and Jesus Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 iv Contents 1 Introduction .................................................................................................................................. 1 1.1 Background ............................................................................................................................ 1 1.2 Rationale for the Operational Plan ......................................................................................... 1 1.3 Scope of the Operational Plan ................................................................................................ 2 1.4 Goal ........................................................................................................................................ 2 1.5 Objectives .............................................................................................................................. 2 1.6 Guiding Principles ................................................................................................................. 2 2 Process of Developing the Operational Plan .............................................................................. 4 2.1 Situational Analysis of NCST Service Delivery .................................................................... 4 2.2 Development of the Operational Plan .................................................................................... 4 2.3 Costing the Operational Plan ................................................................................................. 4 3 Operational Plan Strategic Action Areas ................................................................................... 5 3.1 Improve Availability and Access to NCST Supplies and Equipment .................................... 5 3.2 Increase Competence and Responsiveness of NCST Workforce........................................... 7 3.3 Increase Quality and Geographical Coverage of NCST Service Delivery ............................ 9 3.4 Improve NCST Monitoring, Evaluation, and Information Management ............................. 10 3.5 Strengthen Leadership and Governance of NCST Services ................................................ 11 3.6 Increase Resource Mobilisation and Financing of NCST Services ..................................... 12 3.7 Intensifying NCST Services to Respond to Emergency and Humanitarian Situations ........ 13 4 National NCST Monitoring and Evaluation Plan ................................................................... 14 5 Summary of the National NCST Costs..................................................................................... 25 5.1. Total Cost of Implementing NCST by Strategic Action Area ............................................. 25 5.2. Cost of Treatment per Severely and Moderately Undernourished Adolescent or Adult ..... 26 6 Guide for Developing District Plan of Action .......................................................................... 28 6.1. Facility Level NCST Resource Mapping .............................................................................. 28 6.2. Stakeholder Mapping ............................................................................................................ 28 6.3. Costing of District Operational Plan ..................................................................................... 28 6.4. District Operational Plan ...................................................................................................... 28 7 References ................................................................................................................................... 30 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 v Abbreviations and Acronyms ABC Activity-based Costing CMAM Community-based Management of Acute Malnutrition CMED Central Monitoring and Evaluation Division CSB+ Corn Soya Blend Plus DHS Demographic and Health Survey DHIS-2 District Health Information Software – Version 2 DHMT District Health Management Teams DNHA Department of Nutrition, HIV and AIDS DIP District Implementation Plan FANTA Food and Nutrition Technical Assistance III Project HMIS Health Management Information System HSA Health Surveillance Assistant HSSP II Health Sector Strategic Plan II 2017-2022 LOE Level of Effort MAM Moderate Acute Malnutrition MICS Multiple Indicator Cluster Survey MUAC Mid-Upper Arm Circumference M&E Monitoring and Evaluation NCST Nutrition Care Support and Treatment NECS Nutrition Education and Communication Strategy NGO Non-governmental Organization MOH Ministry of Health OP Operational Plan P&C Planning and Costing PLW Pregnant and Lactating Women RUTF Ready-to-Use Therapeutic Food SAM Severe Acute Malnutrition SFP Supplementary Feeding Programme SUN Scaling Up Nutrition TNP Targeted Nutrition Program TOT Training of Trainers TOR Terms of Reference USAID United States Agency for International Development US$ U.S. dollar WFP World Food Programme WHO World Health Organization Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 1 1 Introduction 1.1 Background Malnutrition remains a major public health problem in Malawi and is compounded by the high prevalence of infectious diseases, such as HIV and tuberculosis (TB). HIV infection causes progressive destruction of the immune system and predisposes people to opportunistic infections and malnutrition. Infection also increases nutritional needs while at the same time increasing nutrient losses and reducing intake and absorption. The subsequent deterioration of nutritional status affects the immune system and continues the cycle of disease progression and further worsening of nutrition status (Katona 2008). According to a World Health Organisation (WHO) technical consultation on nutrient requirements for people living with HIV (PLHIV), energy requirements increase by 10 percent to maintain body weight and physical activity in asymptomatic HIV-infected adults and for growth in asymptomatic children. During the symptomatic stage, however, the energy requirements increase by approximately 20 to 30 percent to maintain the adult body weight and by 50 to 100 percent over normal requirements in children to prevent weight loss. Adequate nutrition is therefore critical to maximise the chances of slowing disease progression, especially as nutrition builds and maintains optimal immune function (WHO, Geneva 2003). The 2015-2016 Malawi Demographic and Health Survey estimated the prevalence of HIV among adolescents and adults 15 to 64 years at 8.8 percent (National Statistics Office, Malawi and ICF 2017). The survey showed that there are variations in the prevalence among women and men (10.8 percent in women and 6.4 percent in men), and across the three geographic regions of the country (5.1 percent in the North, 5.6 percent in the Central and 12.8 percent in the South). The prevalence is also twice as high in urban areas as compared to rural areas (14.6 and 7.4 percent, respectively). The Government of Malawi (GOM) recognises the important role that food and nutrition play in the care and treatment of infectious diseases and it is therefore committed to delivering effective food and nutrition interventions to those in need. 1.2 Rationale for the Operational Plan Recognising the critical role that nutrition plays in the care and treatment of infectious diseases, such as HIV and TB, the Ministry of Health (MOH) developed the National Guidelines on Nutrition Care, Support, and Treatment (NCST) for Adolescents and Adults. The NCST guidelines instruct service providers on how to improve the quality of nutrition services through the integration of a set of client- centred, priority nutrition interventions as part of routine health service delivery. As of September 2017, NCST services were provided in 211 out of total 726 health facilities across the country, which represents a 29 percent geographical coverage of service delivery. The absence of a costed national NCST operational plan has hampered efforts to advocate and mobilise resources for the scale-up of services to additional facilities and districts. The MOH has therefore developed this 5-year national NCST operational plan to guide the government and its partners to effectively plan and implement activities; accelerate the institutionalization and integration of service delivery within the health system; and provide a monitoring and evaluation (M&E) framework for implementation over the next five years. The operational plan is grounded in evidence from past achievements, lessons learned, and analysis of implementation gaps. It is aligned with the National Multi-Sector Nutrition Policy 2017- 2021 and the Health Sector Strategic Plan II (HSSP II) 2017-2022. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 2 1.3 Scope of the Operational Plan The NCST operational plan guides overall operations at the national, district, and facility levels and sets priorities for the next five years. The plan is designed to resolve existing challenges identified through a situational analysis and consultation with stakeholders. The plan recognises the practical realities of delivering nutrition services to adolescent and adult PLHIV and TB clients in Malawi. It takes into consideration issues of coordination, supply chain management, financing, governance, sustainability, and advocacy. It also emphasises the use of measurable indicators with set targets to determine progress and ensures that those most in need of services have access. Lastly, the operational plan outlines the costs needed to implement each of the prioritised actions. 1.4 Goal To increase access and coverage of quality nutrition services for adolescent (15-18 years) and adult (19 years and older) PLHIV and TB clients as well as other patients presenting at health facilities with various forms of illness. 1.5 Objectives The following seven objectives will help to increase access and coverage of quality nutrition services to adolescents and adults. Each of the objectives presented below has a corresponding strategic action area outlined in section 3 and an M&E plan detailed in section 4 of the operational plan. 1. Improve availability and access to NCST supplies and equipment 2. Increase competence and responsiveness of NCST workforce 3. Increase the quality and geographical coverage of NCST service delivery 4. Improve monitoring, evaluation, and information management 5. Strengthen leadership and governance of NCST services 6. Increase resource mobilization and financing of NCST services 7. Intensify NCST services to respond to emergency and humanitarian situations 1.6 Guiding Principles The implementation of the National NCST Operational Plan 2018–2022 will be guided by a set of principles that are relevant to all strategic action areas. These principles are:  Equity: NCST services shall be provided to all vulnerable adolescents and adults in need regardless of gender, class, caste, ethnicity, or sexual orientation. Service delivery shall ensure adequate and effective coverage in poor and hard to-reach locations.  Gender equality and empowerment: The design and implementation of NCST services shall be non-discriminatory in addressing the nutritional needs of girls, boys, women, and men. The design and implementation of services shall have a gender lens and shall promote male involvement and female empowerment for improved nutritional outcomes.  Health systems strengthening: NCST services will be provided in an integrated manner that links facility and community-based health and nutrition services along a continuum of care. The integrated health systems strengthening approach will involve human resources, health financing, governance, health information systems, supply chains, and service delivery.  Effective coordination and partnerships: All NCST activities pertaining to policy and coordination will be coordinated through the Department of Nutrition, HIV and AIDS (DNHA) whilst the MOH Nutrition Unit shall facilitate program implementation and scale up. Effective Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 3 inter- and multi-sectoral linkages will be created not just within health but also with other sectors, such as education, health, agriculture, and social welfare. The government will also endeavour to build and strengthen partnerships with multiple stakeholders, including the private sector and development partners.  Evidenced-based interventions: NCST service delivery will be informed by scientifically tested strategies and best practices that are most likely to lead to optimal outcomes.  Community empowerment and participation: Partnering with and empowering communities with knowledge and skills to address undernutrition and overnutrition, particularly within the context of infectious diseases, will result in better outcomes and engender community acceptance and ownership of NCST services.  Sustainability: NCST service delivery is designed to be sustainable. The government, health institutions, and the domestic private sector will be pro-actively engaged in ensuring the sustainability of service delivery.  Emergency preparedness and response. During emergency and humanitarian situations, delivery of NCST services will be integrated within the humanitarian response plans and efforts so that services are intensified to meet the nutrition needs of the affected populations through early case identification, referral, and provision of quality, life-saving treatment, care, and support. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 4 2 Process of Developing the Operational Plan This National NCST Operational Plan 2018–2022 was developed through a participatory process involving national-, zonal-, district-, and facility-level stakeholders. To develop the operational plan, three main steps were undertaken: a situational analysis of NCST service delivery, development of the operational plan, and costing of the operational plan. Each of the three steps is described below. 2.1 Situational Analysis of NCST Service Delivery The initial step in developing the NCST operational plan involved conducting a situational analysis that included document review, key informant interviews and consultations with facility-based service providers as well as district and national level service providers and managers. The overall goal of the situational analysis was to identify and document strengths, bottlenecks, opportunities, and lessons learned from the initial phase of NCST implementation. 2.2 Development of the Operational Plan Following the situational analysis, recommendations were synthesised and used to develop priority strategic actions for implementation over the next five years, organised under the seven strategic action areas. Six of the seven prioritised strategic action areas are founded on the WHO health system strengthening framework; it is envisioned that implementation of the actions will lead to an improvement in quality nutrition service delivery to adolescents and adults, and also contribute to strengthening the broader health system. 2.3 Costing the Operational Plan Finally, the Nutrition Assessment, Counselling, and Support (NACS) Planning and Costing (P&C) Tool developed by FANTA was used to cost the operational plan. The Microsoft Excel-based NACS P&C Tool assists program managers and implementers responsible for designing, financing, and managing NACS (referred to as NCST in Malawi) at national and sub-national levels with estimating the human, material, and financial resources to establish and maintain NACS services. Estimates of inputs and costs are generated using the activity-based costing approach (Baker 1998) in which NCST services were divided into seven activity categories (service delivery, training, supervision, commodities, logistics, start-up governance, and routine governance). In the costing step, a series of activities were undertaken including: collection and analysis of programmatic and epidemiological data; stakeholder participation to reach consensus on the costs and assumptions used; and, training of national, zonal, and district nutrition managers on the costing process. Several assumptions were made, including scope and scale of health facilities delivering NCST services; epidemiological assumptions including estimated annual caseload of clients who are severely and moderately undernourished, normal nutritional status, overweight and obese; and programmatic assumptions including the number of years NCST will be implemented; geographical scope; distances; prices of commodities and equipment; and roles and responsibilities of providers at the different levels of the health system. Stakeholders agreed that costing should be done in U.S. dollars due to the current instability of the Malawi Kwacha. Costs presented cover the direct cost of implementing NCST at the facility, district, zonal, and national levels. They do not include the cost of partner staff level of effort needed to support service delivery. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 5 3 Operational Plan Strategic Action Areas This section describes the prioritised seven strategic action areas which are: improve availability and access to NCST commodities; increase competence and responsiveness of NCST workforce; improve quality and geographical access to NCST service delivery; improve monitoring, evaluation and information management; strengthen leadership and governance of NCST services; increase resource mobilisation and financing of NCST services; and intensify NCST services to respond to emergency and humanitarian situations. Under each of the strategic action areas, key actions and their cost estimates are presented. It is envisioned that district health management teams (DHMTs) will adapt and prioritize the key activities to be included in the district implementation plans based on their district-specific needs. 3.1 Improve Availability and Access to NCST Supplies and Equipment An effective and efficient NCST commodity management system is essential for quality of service delivery. Health facilities providing NCST services should have a consistent supply of the necessary equipment, supplies, and food commodities such as ready-to-use therapeutic food (RUTF), supplementary food including corn soya blend plus (CSB+), and vegetable oil. In addition, equipment and supplies such as weighing scales, height measuring equipment, mid-upper arm circumference (MUAC) tapes, technical reference materials, and job aids should be available for service delivery. According to the situational analysis, the majority of health facilities delivering NCST services reported having the necessary equipment, though widespread stock outs of RUTF, CSB+, and vegetable oil were reported. Therapeutic and supplementary food commodities have been incorporated into the MOH essential drugs and supplies list, allowing for procurement and distribution by government departments and agencies; however, the commodities are not currently prioritised in planning or budgetary allocation. All therapeutic and supplementary food commodities are procured and distributed by partners. There are also challenges with the capacity of the Central Medical Stores (CMS) to procure and distribute therapeutic and supplementary food commodities along the supply chain. There is local capacity to produce RUTF and CSB+ that can help meet the increased national demand to support NCST and community-based management of acute malnutrition (CMAM) service delivery. However, local therapeutic and supplementary food producers face challenges including the long turnaround time for quality control approval and the lack of a local, internationally certified laboratory to conduct quality control checks. In addition, there is little harmonisation and integration of the RUTF supply chain management systems, with different stakeholders involved in procuring and distributing NCST and CMAM commodities and running parallel RUTF pipelines. Also, government service providers, pharmacists, and managers are not empowered to forecast their commodity needs at the various levels as this is usually done by partner organisations. Based on the identified challenges and in line with the recommendations set out in the national NCST guidelines, this operational plan aims to establish and strengthen systems that will improve availability and access to NCST supplies and equipment. Prioritised actions towards achieving this goal are listed in Table 3.1. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 6 Table 3.1: Prioritised Actions to Improve Availability and Access to NCST Supplies and Equipment 1. Coordinate NCST with CMAM therapeutic and supplementary food commodity management 2. Procure therapeutic food commodities for adolescent and adult PLHIV and TB clients 3. Procure supplementary food commodities for adolescent and adult PLHIV and TB clients 4. Procure NCST supplies and equipment 5. Conduct annual planning and quantification of NCST supplies and equipment with all stakeholders 6. Train facility-based service providers, pharmacists and managers on NCST supply chain management 7. Establish sufficient and safe storage of therapeutic and supplementary food commodities at central, district and facility levels 8. Improve efficiency of delivery of therapeutic and supplementary food commodities by ensuring last mile delivery to the beneficiary Table 3.2: Cost of Prioritised Actions: Supplies and Equipment Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 1 Coordination meetings for NCST and CMAM commodity management 2,316 2,316 2,316 2,316 2,316 Action 2 Therapeutic food commodities – adolescents (15-18) 8,364 11,472 13,953 13,275 14,019 Therapeutic food commodities – adults (19 years and above) 2,379,678 3,265,568 3,973,134 3,772,690 3,983,402 Action 3 Supplementary food commodities – adolescents (15- 18) 17,288 23,720 28,856 23,907 25,245 Supplementary food commodities – adults (19 years and above) 4,918,187 6,749,089 8,211,427 6,801,766 7,181,660 Supplementary food commodities – pregnant women and lactating women (up to 6 months post-partum)* 869,887 1,193,717 1,452,362 1,206,688 1,274,086 Action 4 NCST supplies and equipment 1,430,328 1,504,031 1,756,060 2,014,738 1,935,192 Action 5 Annual national planning and quantification workshop 7,590 7,590 7,590 7,590 7,590 Action 6 Logistics management training for facility-based service providers and pharmacists 606,998 301,398 261,173 207,641 167,187 Logistics management training for managers 92,458 92,458 92,458 92,458 92,458 Action 7 Storage of therapeutic food—cost of renting space 6,952 9,540 11,607 11,021 11,637 Storage of supplementary food—cost of renting space 71,647 98,319 119,622 99,223 104,765 Action 8 Transport of therapeutic food 240,204 329,624 401,044 380,814 402,084 Transport of supplementary food 2,185,810 2,999,522 3,649,436 3,026,420 3,195,453 Total Cost 12,837,707 16,588,364 19,981,038 17,660,547 18,397,094 * Note that supplementary food commodities for pregnant women and lactating women (up to 6 months post- partum) are also planned and costed for in the National CMAM Operational Plan 2017-2021. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 7 3.2 Increase Competence and Responsiveness of NCST Workforce A responsive, sufficient, competent and productive workforce that is equitably distributed and given necessary resources is critical to obtaining optimal health and nutrition outcomes. Achieving this goal requires addressing multiple factors: availability of adequate numbers of well-trained and equitably distributed health care providers, such as medical officers, clinical officers, medical assistants, nurses/midwives, health surveillance assistants (HSAs), nutritionists, and dieticians; and availability of treatment protocols and technical reference materials. The situational analysis revealed several challenges concerning human resources responsible for delivering NCST services. Most of the districts and health facilities visited had a limited number of service providers trained in NCST. Health facilities supported by implementing partners were more likely to receive training and frequent mentorship and supervision compared to those without partner support. Lack of trained service providers, limited mentoring and supervision, and the high staff attrition were considered to be the main limiting factors to quality NCST service delivery. District managers also indicated lack of supervision tools, financial resources, and inadequate transport as the major deterrent to conducting frequent mentoring and supervision to health facilities and communities. The prioritised activities listed in Table 3.3 aim at strengthening the competence and responsiveness of service providers in delivering NCST services. The activities also include continued mentoring and supportive supervision to reinforce knowledge and skills acquired through pre-service and in-service training. Table 3.3: Prioritised Actions to Increase the Competence and Responsiveness of NCST Workforce 1. Review the current pre-service training curricula for health professionals (doctors, nurses, clinicians, and HSAs) to understand gaps and recommend areas to be updated 2. Provide technical updates to the pre-service training curricula for doctors, nurses, clinicians, and HSAs to include NCST theory and practice 3. Conduct NCST training for pre-service tutors and lecturers teaching in the medical, nursing and HSA training institutions 4. Conduct NCST in-service training for service providers at the health facilities 5. Conduct NCST training for national, zonal, and district coaches and managers 6. Train National Association for People Living with HIV/AIDS in Malawi (NAPHAM) national and district caretakers on NCST 7. Train community-based support group leaders and facilitators on NCST 8. Document NCST district, facility, and community-based training information in TrainSMART 9. Conduct mentorship and supportive supervision visits for NCST 10. Hold quarterly district coordination meetings with support group leaders and facilitators Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 8 Table 3.4: Cost of Prioritised Actions: Competence and Responsiveness of NCST Workforce Item Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 1 Review of the pre-service training curricula for health professionals* 22,953 -- -- -- 22,953 Action 2 NCST technical update workshops with medical, nursing, HSAs and other health professional training schools* 6,995 -- 6,995 -- 6,995 Action 3 NCST training for lecturers and tutors in medical, nursing, HSA, and other health professional training schools 30,655 30,655 30,655 30,655 30,655 Actions 4-7 NCST in-service training for service providers at the health facilities 790,613 1,013,284 1,177,407 1,251,082 1,262,615 NCST training for district coaches and managers 166,989 159,531 159,531 159,531 159,531 NCST training for national and zonal coaches and managers 28,024 13,010 28,024 13,010 28,024 NCST training for NAPHAM national and district care takers 37,031 -- -- -- -- NCST training for community-based support group leaders and facilitators 141,577 141,577 141,577 141,577 141,577 Action 8 No additional cost required. Included in national level routine governance and training costs. Action 9 Mentoring and supportive supervision from district to facilities 35,502 44,317 51,123 53,710 53,553 Mentoring and supervision from national to the district level 4,515 3,810 3,810 3,810 3,810 Mentoring and supervision for community-based support groups 120,269 120,269 120,269 120,269 120,269 Action 10 Quarterly district coordination meetings with community-based support group leaders and facilitators 44,791 44,791 44,791 44,791 44,791 Total Cost 1,429,914 1,571,244 1,764,182 1,818,435 1,874,773 * Note that costs for the nutrition pre-service technical update are also included in the CMAM Operational Plan. Total costs for the pre-service update should be shared across CMAM and NCST. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 9 3.3 Increase Quality and Geographical Coverage of NCST Service Delivery To ensure universal provision of high quality NCST services to adolescent and adult clients, it is essential that services are safe, accessible and patient-centered. In Malawi, NCST services are primarily designed to be integrated within HIV and TB care and treatment. Over the past four years, the MOH and partners have focused on improving quality of nutrition services through application of modern quality assurance (QA) and quality improvement (QI) methods. This has resulted in improved use of data for programming and decision making; improved patient care and outcomes; better team work among service providers; and integration of nutrition services at ART, ANC/PMTCT and TB service delivery points. While the application of QI and QA methods at facility level has contributed to successful implementation of NCST, there is limited referral and linkage of clients to community-based interventions including livelihoods, food security, economic strengthening, and psychosocial support. Additionally, the geographic coverage of NCST services is limited and the pace of scale up is slow. By September 2017, NCST services were implemented in a total of 211 out of 726 health facilities, in 21 out of 29 districts of Malawi. Table 3.5 shows a summary of current NCST implementation and the plan for scaling up service delivery over the next five years: Table 3.5: NCST Scale-up Plan Year 2018 2019 2020 2021 2022 No. Health Facilities 403 547 652 707 726 No. of Districts 29 29 29 29 29 The operational plan has prioritised the implementation of actions listed in Table 3.6 to increase the quality and geographic coverage of NCST service delivery. Table 3.6: Prioritised Actions to Increase the Quality and Geographic Coverage of NCST Service Delivery 1. Scale-up NCST to 726 health facilities within 29 districts of Malawi 2. Establish district and facility QI teams 3. Mentor and coach district and facility QI teams on a quarterly basis 4. Conduct QI learning sessions and forums for implementing facilities every six months 5. Link NCST clients with social protection, livelihood, food security & economic strengthening interventions Table 3.7: Cost of Prioritised Actions: Quality and Geographic Coverage of Service Delivery Item Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 1 No additional cost required. The cost of scaling up NCST is captured in all strategic action areas Action 2 No additional cost required. QI training is part of the standard 10 day NCST training. See section 3.2. Action 3 No additional cost required. The cost of quarterly QI mentoring and coaching is already accounted for in the cost of mentoring and supervision. See Action 9 section 3.2. Action 4 QI learning sessions 355,145 481,885 574,300 622,708 639,430 Action 5 No additional cost required. Cost is part of staff LOE for time spent linking clients with social protection, livelihood, food security, and economic strengthening interventions Total Cost 355,145 481,885 574,300 622,708 639,430 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 10 3.4 Improve NCST Monitoring, Evaluation, and Information Management Timely, accurate, and reliable NCST data and information is vital for programming and decision making. NCST data and indicators are reported and managed through the MOH District Health Information System – Version 2 (DHIS-2) software. The situational analysis indicated that NCST data transmission from facility to district, zonal and national levels is untimely. The data quality is also poor with many facilities having inaccurate and inconsistent data. Over the past year, the MOH and partners invested in improving the quality of data capture and reporting at the facility and district level through the institutionalization of monthly and quarterly data quality assessments and audits. These data quality assurance efforts targeted districts in South East and South West Zones of Malawi. For consistent availability of quality NCST data, a robust knowledge management system, with significant investment in routine data quality assurance, needs to be put in place and supported across all health facilities in the country. This operational plan aims to improve the monitoring, evaluation and information management of NCST by implementing actions listed in Table 3.8. Table 3.8: Prioritised Actions to Improve NCST Monitoring, Evaluation, and Information Management 1. Identify operational research needs to address NCST knowledge and implementation gaps 2. Hold annual national program learning and knowledge sharing conference 3. Conduct annual national review of NCST operational plan 4. Conduct midterm and end-line evaluations of the NCST operational plan implementation 5. Conduct quarterly data quality assessments & audits (DQA) with implementing facilities and districts 6. Establish the use of mobile DHIS-2 in NCST implementing facilities 7. Provide logistical and technical support (trouble shooting) to districts and facilities in the use of DHIS-2 Table 3.9: Cost of Prioritised Actions: Monitoring, Evaluation and Information Management Item Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 1 Meeting to identify operational research needs 7,590 -- -- -- -- Action 2 Annual learning and knowledge sharing conference 21,006 21,006 21,006 21,006 21,006 Action 3 Annual national review of the NCST OP 24,914 24,914 24,914 24,914 24,914 Action 4 Midterm evaluation of NCST operational plan -- -- 38,514 -- -- Endline evaluation of CMAM operational plan -- -- -- -- 38,514 Action 5 Quarterly facility & district DQA 426,116 426,116 426,116 426,116 426,116 Action 6 Establish the use of mobile DHIS-2 at facility level 50,000 60,000 65,000 70,000 75,000 Action 7 There is no budget included for logistical support. Cost of internet access and other logistical support to operation of DHIS-2 is provided by the Central Monitoring and Evaluation Division (CMED). Total 529,626 532,036 575,550 542,036 585,550 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 11 3.5 Strengthen Leadership and Governance of NCST Services The National Multi-Sector Nutrition Policy 2017 -2021 (DNHA 2017) and the Health Sector Strategic Plan (HSSP) II (MOH 2017) create the enabling environment for NCST service delivery. The DNHA is responsible for the coordination of NCST service delivery, while the nutrition unit of the MOH is responsible for technical oversight of NCST activities at the national and sub-national levels. At the district level, NCST activities are managed by the DHMT and coordinated by the district nutritionists/coordinators in collaboration with the ART, TB, ANC/PMTCT, HMIS and Health Promotion coordinators. At health facility level, quality improvement teams under the leadership of the health facility in-charge ensure delivery of NCST services to PLHIV and TB clients. There are three main nutrition coordination mechanisms through which NCST activities are discussed: the National Nutrition Committee (NNC), the Targeted Nutrition Program (TNP) technical working group and the Emergency Nutrition Cluster. NCST is not well-defined in non-nutrition coordination mechanisms such as HIV, TB, agriculture, gender, and social protection. To ensure effective integration, it is essential that NCST is prominent and coordinated in other sector plans. This operational plan has prioritised actions listed on Table 3.10 to strengthen leadership and governance of NCST services. Table 3.10: Prioritised Actions to Strengthen Leadership and Governance of NCST Services 1. Update NCST guidelines and technical tools to align with new evidence including CMAM, TB, and HIV care and treatment guidelines 2. Integrate implementation of NCST with other health and non-health services including HIV, TB, reproductive health, PMTCT, health promotion, agriculture, food security and social protection 3. Strengthen coordination of NCST through the TNP and other nutrition coordination mechanisms at national, district and community levels 4. Develop quarterly NCST policy and technical briefs to share data, best practices, and lessons learned 5. Provide financial and logistical support for the NCST focal persons at national and district levels Table 3.11: Cost of Prioritised Actions: Leadership and Governance Item Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 1 Update of national NCST guidelines 25,138 -- -- 25,138 -- Actions 2-3 Quarterly TNP technical working group meetings 3,931 3,931 3,931 3,931 3,931 Action 4 Development and printing of quarterly NCST policy and technical briefs 22,000 22,000 22,000 22,000 22,000 Action 5 These costs are captured in other activity budgets (e.g., training, supportive supervision, mentoring) Total 51,069 25,931 25,931 51,069 25,931 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 12 3.6 Increase Resource Mobilisation and Financing of NCST Services NCST is primarily funded through external donor and non-government resources. The GOM provides the infrastructure used in delivering services and pays salaries for majority of the NCST workforce. Partners and donors including USAID/PEPFAR, DFID, Irish Aid, GIZ, and other private donors finance NCST equipment and supplies, in-service and pre-service training, and service delivery including quality improvement and development of technical reference materials. This funding is usually short- term, ranging between 1-3 years. There is potential for mobilising additional resources and funding from the government and other donors such as the World Bank, European Union and the Global Fund. This operational plan has prioritised actions listed on table 3.12 to increase resource mobilisation and financing of NCST services. Table 3.12: Prioritised Actions to Increase Resource Mobilisation and Financing of NCST 1. Conduct a funding gap analysis using the finalised National NCST Operational Plan 2018-2022 2. Conduct advocacy and resource mobilisation campaigns for increased awareness of NCST among national level policymakers 3. Advocate for prioritisation and allocation of funding for NCST by the government 4. Advocate for increased NCST funding from development partners Table 3.13: Cost of Prioritised Actions: Resource Mobilisation and Financing Item Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Actions 1-4 Advocacy campaigns (3 per year) 31,521 31,521 31,521 31,521 31,521 Total 31,521 31,521 31,521 31,521 31,521 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 13 3.7 Intensifying NCST Services to Respond to Emergency and Humanitarian Situations Climate change has had an impact on Malawi’s weather patterns, affecting agricultural productivity, household food security, and the general resilience of households to shocks. The operational plan includes estimated expenses that will be required beyond regular NCST operating costs to respond to emergencies and associated increases in NCST caseloads. To estimate additional supply requirements during an emergency, we estimated an increased prevalence of 3.0% for severe undernutrition and 12.0% for moderate undernutrition among adolescent and adult PLHIV and TB clients in Malawi. The estimates are specific to the Malawi context and taken from routine MOH data on the highest prevalence levels recorded during the most recent humanitarian crisis experienced in 2015/2016. Table 3.14: Prioritised Actions to Intensify NCST Services to Respond to Emergency and Humanitarian Situations 1. Intensify case finding through community-based groups 2. Advocate for increased resources for undernourished adolescent and adult clients 3. Procure additional therapeutic food supplies and equipment to meet the increased severe undernourished caseload 4. Procure additional supplementary food supplies and equipment to meet the increased moderate undernourished caseload 5. Conduct refresher trainings of service providers and community-based groups on NCST 6. Intensify the frequency of government and NCST partner coordination meetings 7. Intensify real-time monitoring and reporting of NCST service delivery through DHIS-2 Table 3.15: Cost of Prioritised Actions: Illustrative Annual Emergency Budget Item Annual Budget (US$) Action 1 NCST training for NAPHAM national and district care takers 37,031 Mentoring and supervision for community-based groups 120,269 Quarterly district coordination meetings with support group leaders and facilitators 44,791 Action 2 Advocacy meetings for resource mobilisation 1,966 Actions 3-4 Emergency therapeutic food, storage, and transport 2,714,254 Emergency supplementary food, storage, and transport 9,030,357 Action 5 Refresher training of NCST service providers 1,262,615 Refresher training of NCST community-based groups leaders and facilitators 141,577 Action 6 Monthly government and NCST partner coordination meetings 11,794 Action 7 Intensified real-time monitoring and reporting data through DHIS-2 60,000 Total 13,424,654 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 14 4 National NCST Monitoring and Evaluation Plan Effective and efficient implementation of the NCST operational plan depends on accurately tracking progress and performance, evaluating impact, and ensuring accountability at all operational levels. To ensure that the goal, outcomes, and objectives of the operational plan are achieved, indicators and annual targets have been identified for each prioritised activity. These indicators are included in the M&E framework presented in the tables below. Data for the indicators detailed below should be collected per the schedules indicated in the tables and complied by MOH on an annual basis. Each district should consolidate its NCST data, which will then be aggregated at the national level. National and district level stakeholders should use this data to review progress towards operational plan objectives and targets on an annual basis. In addition, a midterm (Year 3) and end-line (Year 5) evaluation of the operation plan shall be conducted. Guidance to districts on NCST data collection is provided in Section 6 of this plan. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 15 Table 4.1: National NCST Monitoring and Evaluation Plan: Objective 1 Objective 1: Improve availability and access to NCST supplies and equipment Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Annual Targets Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Coordinate NCST and CMAM therapeutic and supplementary food commodity management Number of NCST and CMAM commodity management coordination meetings conducted Measure of the number of meetings conducted, including number of people who participate in the NCST and CMAM commodity management coordination meetings. Minutes of Meetings Annually 10 2 2 2 2 2 11,580 MOH Nutrition partners 2. Procure therapeutic food commodities for adolescent and adult PLHIV and TB clients Percentage of therapeutic food commodities procured annually Measure of the quantity of NCST therapeutic food commodities procured compared to the national need. See Annexes 1 for the list of essential supplies and equipment. CMS, MOH, WFP and NGO record of procured commodities Quarterly 100% 100% 100% 100% 100% 100% 17,435,555 MOH CMS, and nutrition partners 3. Procure supplementary food commodities for adolescent and adult PLHIV and TB clients Percentage of supplementary food commodities procured annually Measure of the quantity of NCST supplementary food commodities procured compared to the national need. See Annexes 1 for the list of essential supplies and equipment. CMS, MOH, WFP and NGO record of procured commodities Quarterly 100% 100% 100% 100% 100% 100% 39,977,885 MOH CMS, and nutrition partners 4. Procure NCST supplies and equipment Percentage of essential NCST supplies and equipment procured annually Measure of the quantity of NCST supplies and equipment procured compared to the national need. See Annexes 1 for the list of essential supplies and equipment. CMS, MOH, WFP and NGO record of procured commodities Quarterly 100% 100% 100% 100% 100% 100% 8,640,349 MOH CMS, and nutrition partners 5. Conduct annual national planning and quantification of NCST supplies and equipment with all stakeholders Annual quantification workshops held within each MOH fiscal year, and annual NCST supplies and equipment report produced following the workshop. Measures the number of annual quantification workshops conducted, and availability of annual NCST supplies and equipment quantification report prepared in consultation with all stakeholders (MOH, national, and district representatives, NCST partners, RUTF and CSB++/CSB+ manufacturers). See Annexes 3 and 4 for the list of supplies and equipment to be quantified annually. Annual NCST supplies and equipment quantification report Annually 5 1 1 1 1 1 37,950 MOH CMS, and nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 16 Objective 1: Improve availability and access to NCST supplies and equipment Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Annual Targets Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 6. Train managers and service providers on NCST supplies and logistics management Number of service providers trained on NCST supplies and logistics management Measure of the number of facility-based service providers trained on NCST supplies and logistics management, disaggregated by sex MOH and partner training records Annually 2,314 1,209 444 343 209 109 1,544,397 MOH Nutrition partners Number of managers trained on NCST supplies and logistics management Measure of the number of district-, zonal-, and national-level managers trained on NCST supplies and logistics management, disaggregated by sex MOH training records Annually 725 145 145 145 145 145 462,290 MOH Nutrition partners 7. Establish sufficient and safe storage facilities at central, district, and facility levels Percentage of health facilities and districts with adequate storage space for therapeutic and supplementary food supplies Measure of health facilities and districts with sufficient storage space to accommodate at least 2-month supply of therapeutic and supplementary food for estimated caseload MOH national and district records Quarterly 100% 50% 100% 100% 100% 100% 544,333 MOH Nutrition partners 8. Improve efficiency of delivery of therapeutic and supplementary food commodities by ensuring last mile delivery to the beneficiary Percentage of severely and moderately undernourished clients who receive therapeutic and supplementary food Proportion of clients who receive nutrition assessment and classified as severely and moderately undernourished, who receive therapeutic and supplementary food commodities during the reporting period. MOH – DHIS-2, NCST reports Quarterly 100% 100% 100% 100% 100% 100% 16,810,411 MOH CMS and Nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 17 Table 4.2: National NCST Monitoring and Evaluation Plan: Objective 2 Objective 2: Increase competence and responsiveness of NCST workforce Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Review the current pre-service training curricula for health professionals to understand gaps and recommend areas for update Assessment conducted Measures the number of assessments conducted Assessment report Year 1 (baseline) and Year 5 (post- interventio n) 2 1 -- -- -- 1 45,906 MOH Universities , Training Institutions and other partners 2. Provide technical update to the pre-service training curricula for nurses, clinicians and HSAs to include NCST theory and practice Number of pre-service training curricula updated Measure of the pre-service training curricula that have been updated for frontline workers (medical officers, clinical officers, medical assistants, nurses/midwives, HSAs) Pre-service training curricula Bi-annually 5 frontline workers curricula 5 -- 5 -- 5 20,985 MOH Universities , Training Institutions and other partners 3. Conduct NCST training for tutors and lecturers teaching in medical and nursing training institutions Number of tutors and lectures trained per year Measure of the number of tutors and lecturers trained on NCST, disaggregated by sex MOH and partner training records Annually 150 30 30 30 30 30 153,275 MOH Universities and training institutions 4. Conduct NCST training for all service providers Number trained on NCST Measure of the number of facility-based service providers trained on NCST, disaggregated by sex MOH and partner training records - TrainSMART Quarterly 9,620 1,401 1,785 2,061 2,176 2,197 5,495,001 MOH Nutrition partners 5. Conduct NCST training for national, zonal, and district coaches and managers Number of coaches and managers trained on NCST Measure of the number of national, zonal and district coaches and managers trained on NCST, disaggregated by sex MOH and partner training records – TrainSMART Annually 805 165 155 165 155 165 915,205 MOH Nutrition partners 6. Train National Association for People Living with HIV/AIDS in Malawi (NAPHAM) national and district caretakers on NCST Number of national and district caretakers trained on NCST Measure of the number of national and district caretakers trained on NCST, disaggregated by sex MOH and partner training records – TrainSMART Annually 100 100 -- -- -- -- 37,031 MOH Nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 18 Objective 2: Increase competence and responsiveness of NCST workforce Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 7. Train community-based support group leaders and facilitators Number of support group leaders and facilitators trained on NCST Measure of the number of support group leaders and facilitators trained on NCST, disaggregated by sex MOH and partner training records – TrainSMART Annually 7,250 1,450 1,450 1,450 1,450 1,450 707,885 MOH Nutrition partners 8. Conduct mentorship and supportive supervision visits Number of mentorship and supportive supervision visits A measure of the number of mentorship and supportive supervision visits conducted to each facility and community using the NCST standard guide/tool MOH and partner records Quarterly 12,140 1,612 2,188 2,608 2,828 2,904 859,305 MOH Nutrition partners 9. Hold quarterly district coordination meetings with support group leaders and facilitators Number of coordination meetings conducted with support group leaders and facilitators A measure of the number of district level meetings conducted with PLHIV support group leaders and facilitators MOH and partner records Quarterly 580 116 116 116 116 116 223,955 MOH NAPHAM and nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 19 Table 4.3: National NCST Monitoring and Evaluation Plan: Objective 3 Objective 3: Increase Quality and Geographical Coverage of NCST Service Delivery Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Scale-up NCST to 726 health facilities within 29 districts of Malawi Number of health facilities delivering NCST services Measure of the number of health facilities delivering NCST services at ART, ANC/PMTCT, TB or OPD service delivery points MOH and partner records Annually 726 health facilities in 29 districts 403 547 652 707 726 No additional cost required MOH Nutrition partners 2. Establish district and facility QI teams Number of NCST implementing facilities with established QI teams Measure of the number of NCST implementing facilities with established QI teams with a plan of action and meeting at least once every month to review data and progress of implementation MOH and partner records including QI plans and documentati on journals Quarterly 726 403 547 652 707 726 No additional cost required MOH Nutrition partners 3. Mentor and coach district and facility QI teams on a quarterly basis. Number of mentorship and coaching visits per year A measure of the number of mentorship and coaching visits conducted using the standard QI guide/tools at the district and facility level MOH and partner records Quarterly 12,140 1,612 2,188 2,608 2,828 2,904 No additional cost required MOH Nutrition partners 4. Conduct QI learning sessions and forums for implementing facilities every six months. Number of QI learning sessions per year A measure of the number of QI learning sessions per year MOH and partner records Annually 6,070 806 1,094 1,304 1,414 1,452 2,673,468 MOH Nutrition partners 5. Link NCST clients with social protection, livelihood, food security and economic strengthening Percentage of NCST clients who are linked to social protection, livelihood, food security and economic strengthening A measure of the number of clients who received nutrition assessment and classification and were referred for social protection, livelihood, food security and economic strengthening. MOH records, DHIS-2 Quarterly No additional cost required MOH Nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 20 Table 4.4: National NCST Monitoring and Evaluation Plan: Objective 4 Objective 4: Improve monitoring, evaluation, and information management Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Identify operational research questions that address NCST knowledge and implementation gaps Operational research questions identified Meeting held with stakeholders to identify and document NCST operations research questions Operational research meeting report Year 1 1 1 -- -- -- -- 7,590 MOH Universities and partners 2. Hold annual program learning and knowledge sharing conference NCST dissemination conference held A measure of the number of annual NCST conferences conducted Conference report Annually 5 1 1 1 1 1 105,030 MOH Nutrition partners 3. Conduct annual national review of implementation of the NCST operational plan NCST operational plan annual review meeting held A measure of the number of annual NCST review meetings conducted annually Annual meeting report/brief Annually 5 1 1 1 1 1 124,570 MOH Nutrition partners 4. Conduct midterm and endline evaluations of implementing NCST operational plan Midterm evaluation conducted Midterm evaluation conducted Midterm report Year 3 Midterm evaluation -- -- 1 -- -- 38,514 MOH Nutrition partners Endline evaluation conducted Endline evaluation conducted Endline report Year 5 Endline evaluation -- -- -- -- 1 38,514 MOH Nutrition partners 5. Conduct quarterly DQA with implementing districts and facilities Number of DQA conducted A measure of the number of DQA exercises conducted, disaggregated by district and facility MOH and partner records Quarterly 580 116 116 116 116 116 2,130,58 0 MOH Nutrition partners 6. Establish the use of mobile DHIS-2 in NCST implementing facilities Number of facilities and districts using mobile DHIS-2 Mobile DHIS-2 implemented MOH records Quarterly 726 403 547 652 707 726 320,000 MOH Nutrition partners 7. Provide logistical and technical support to districts and facilities in the use of DHIS-2 Percentage of districts with reliable internet access Reliable: without outages of more than 1 week within the quarter DHOs, CMED Quarterly 100% 100% 100% 100% 100% 100% No addition al cost required MOH Nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 21 Table 4.5: National NCST Monitoring and Evaluation Plan: Objective 5 Objective 5: Strengthen the leadership and governance of NCST services Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Update the national NCST guidelines and tools to align with new evidence including CMAM, TB, HIV care and treatment guidelines National NCST guidelines updated National NCST guidelines that are aligned with CMAM, TB and HIV care and treatment MOH and partner records Year 1 and Year 4 Guidelines reviewed and updated in years 1 and 4 1 -- -- 1 -- 50,276 MOH Nutrition partners 2. Integrate implementation of NCST with other health and non-health services including HIV, TB, reproductive health, PMTCT, health promotion, agriculture, food security and social protection. Percentage of health facilities that implement NCST integrated with health and non-health services and interventions A measure of the number of health facilities that integrate NCST service delivery with health and non-health services and interventions such as; HIV, TB, reproductive health, PMTCT, health promotion, agriculture, food security and social protection. MOH records Annually 100% 100% 100% 100% 100% 100% 19,655 MOH Nutrition partners 3. Strengthen coordination of NCST through the TNP and other coordination mechanisms at the national, district and community levels Number of TNP technical working group meetings held per year A measure of the number of TNP technical working group meetings held annually Meeting minutes Annually 20 4 4 4 4 4 MOH Nutrition partners 4. Develop quarterly NCST policy and technical briefs to share data, best practices, and lessons learnt Number of quarterly NCST policy and technical briefs produced and delivered Measures the number of NCST briefs developed and disseminated to policymakers and implementers on a quarterly basis MOH records Annually 20 4 4 4 4 4 110,000 MOH Nutrition partners 5. Provide financial and logistical support for the NCST focal person at national and district levels Percentage of national and district level NCST focal persons supported Measure of the number of national and district level NCST focal persons supported out of the total number of focal persons MOH records Annually 100% 100% 100% 100% 100% 100% No additional cost required MOH Nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 22 Table 4.6: National NCST Monitoring and Evaluation Plan: Objective 6 Objective 6: Increase Resource Mobilisation and Financing of NCST Services Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Conduct a funding gap analysis using the finalised operational plan Annual NCST funding gap analysis Measure of the existence of a document providing a funding gap analysis on an annual basis NCST funding gap analysis report Annually 5 1 1 1 1 1 157,605 MOH Nutrition partners 2. Conduct advocacy and resource mobilisation campaigns to increase awareness of NCST among national level policy makers Number of advocacy campaigns conducted per year A measure of the number of advocacy campaigns conducted and attended by policymakers and development partners annually MOH and partner records Annually 5 1 1 1 1 1 MOH Nutrition partners 3. Advocate for prioritisation and allocation of funding for NCST by the government Percentage increase in funding allocation by government per year Measure of the percentage increase in NCST funding allocated by the government Government (MOH) budget Annually 0.05% 0.04% 0.04% 0.05% 0.05% 0.05% MOH DNHA and Nutrition partners 4. Advocate for increased NCST funding from development partners Percentage increase in funding allocation by development partners per year Measure of the percentage increase in NCST funding allocated by the development partners Government (MOH) and development partner budgets Annually X% MOH Nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 23 Table 4.7: National NCST Monitoring and Evaluation Plan: Objective 7 Objective 7: Intensify NCST Services to Respond to Emergency and Humanitarian Situations Priority Action Indicator Indicator Definition Means of Verification Frequency Total Annual Target Quarterly Targets Cost ($) Lead Agency Supporting Agency Q1 Q2 Q3 Q4 1. Intensify case finding through community- based groups Number of support NAPHAM national and district caretakers trained Measure of the number of NAPHAM national and district care takers trained on NCST, disaggregated by sex MOH and partner training records – TrainSMART Quarterly 100 1 -- -- -- 37,031 MOH NAPHAM and nutrition partners Number of mentorship and supportive supervision visits conducted A measure of the number of mentorship and supportive supervision visits conducted using the NCST standard guide/tool at the community level MOH and partner records Quarterly 120,269 MOH NAPHAM and nutrition partners Number of coordination meetings conducted with support group leaders and facilitators A measure of the number of meetings conducted with PLHIV support group leaders and facilitators MOH and partner records Quarterly 116 29 29 29 29 44,791 MOH NAPHAM and nutrition partners 2. Advocate for increased resources for undernourished adolescent and adult clients Number of advocacy campaigns conducted A measure of the number of advocacy campaigns conducted and attended by policymakers and development partners MOH and partner records Quarters 1 and 2 2 1 1 -- -- 1,966 MOH Nutrition partners 3. Procure additional therapeutic food supplies and equipment to meet the increased severe undernourished caseload Percentage of additional therapeutic food supplies and equipment procured Measure of the quantity of additional therapeutic food supplies and equipment procured compared to the national need. See Annexes 1 for the list of essential supplies and equipment. CMS, MOH, WFP and NGO record of procured commodities Quarterly 100% 100% 100% 100% 100% 2,714,25 4 MOH Nutrition partners 4. Procure additional supplementary food supplies and equipment to meet the increased moderate undernourished caseload Percentage of additional supplementary food supplies and equipment procured Measure of additional supplementary food supplies and equipment procured compared to the national need. See Annexes 1 for the list of essential supplies and equipment. CMS, MOH, WFP and NGO record of procured commodities Quarterly 100% 100% 100% 100% 100% 9,030,35 7 MOH Nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 24 Objective 7: Intensify NCST Services to Respond to Emergency and Humanitarian Situations Priority Action Indicator Indicator Definition Means of Verification Frequency Total Annual Target Quarterly Targets Cost ($) Lead Agency Supporting Agency Q1 Q2 Q3 Q4 5. Conduct refresher trainings of service providers and community-based groups on NCST Number of service providers trained on NCST Measure of the number of facility-based service providers trained on NCST, disaggregated by sex MOH and partner training records - TrainSMART Quarterly 2,197 2,197 -- -- -- 1,262,61 5 MOH Nutrition partners Number of community group leaders and facilitators trained Measure of the number of community-based group leaders and facilitators trained on NCST, disaggregated by sex MOH and partner training records - TrainSMART Quarterly 1,450 1,450 -- -- -- 141,577 MOH Nutrition partners 6. Intensify the frequency of government and NCST partner coordination meetings Number of government- partner coordination meetings held A measure of the number of government- partner coordination meetings held Meeting minutes Monthly 12 3 3 3 3 11,794 MOH Nutrition partners 7. Intensify real-time monitoring and reporting of NCST service delivery through DHIS-2 Number of facilities and districts using mobile DHIS-2 Mobile DHIS-2 implemented MOH records Quarterly 726 726 -- -- -- 60,000 MOH Nutrition partners Percentage of districts with reliable internet access Reliable: without outages of more than 1 week within the quarter DHOs, CMED Quarterly 100% 100% 100% 100% 100% MOH Nutrition partners Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 25 5 Summary of the National NCST Costs 5.1. Total Cost of Implementing NCST by Strategic Action Area The total cost of the operational plan’s prioritised actions is presented in Table 5.1, summarised by strategic action area. Note that Strategic Action Area 7, strengthen emergency preparedness and response, is not included in the costs below, as these are not part of routine NCST operational costs. Table 5.1: Total Cost of NCST by Objective Year 1 Year 2 Year 3 Year 4 Year 5 Improve Availability and Access to NCST Supplies and Equipment 12,837,707 16,588,364 19,981,038 17,660,547 18,397,094 Increase the competence and responsiveness of NCST workforce 1,429,914 1,571,244 1,764,182 1,818,435 1,874,773 increase the quality and geographic coverage of NCST Service Delivery 355,145 481,885 574,300 622,708 639,430 Improve NCST Monitoring, Evaluation, and Information Management 529,626 532,036 575,550 542,036 585,550 Strengthen Leadership and Governance of NCST Services 51,069 25,931 25,931 51,069 25,931 Increase Resource Mobilisation and Financing of NCST 31,521 31,521 31,521 31,521 31,521 Total 15,234,982 19,230,981 22,952,522 20,726,316 21,554,299 Figure 1: Percentage of Total Cost for Each Strategic Action Area Supplies and Equipment, 86% Workforce, 8% Coverage, 3% M&E, 3% Leadership and Governance, 0.2% Financing, 0.2% Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 26 5.2. Cost of Treatment per Severely and Moderately Undernourished Adolescent or Adult Figure 2, 3 and 4 below shows the cost of treating an individual severely and moderately undernourished adolescent, adult or pregnant and lactating woman (up-to 6 months postpartum). These costs include: - Human resource time and space at the facility level - Therapeutic and supplementary food supplies - Medicines and other equipment - Storage and transport of food supplies Note: The cost of treatment of an individual severely or moderately undernourished adolescent, adult or pregnant and lactating woman (up-to 6 months postpartum) does not include health systems strengthening costs such as: workforce development; monitoring, evaluation, and information management; leadership and governance; and resource mobilisation. Figure 2: Average Cost of Treating a Severely Undernourished Adolescent or Adult $66.13 $64.79 $64.17 $63.64 $63.52 $62.00 $62.50 $63.00 $63.50 $64.00 $64.50 $65.00 $65.50 $66.00 $66.50 Year 1 Year 2 Year 3 Year 4 Year 5 Note: The red line is the average cost of treatment per person for the 5-year period, which is $64.45 Table 5.2: Total Treatment Cost and National Caseload of Severely Undernourished Adolescents and Adults Year 1 Year 2 Year 3 Year 4 Year 5 Total treatment cost for Severe Undernutrition $2,659,507 $3,645,341 $4,434,559 $4,211,109 $4,444,816 Targeted number of Severely Undernourished Adolescent and Adults $40,215 $56,261 $69,105 $66,168 $69,975 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 27 Figure 3: Average Cost of Treating a Moderately Undernourished Adolescent or Adult $40.16 $39.31 $38.93 $39.32 $39.23 $38.20 $38.40 $38.60 $38.80 $39.00 $39.20 $39.40 $39.60 $39.80 $40.00 $40.20 $40.40 Year 1 Year 2 Year 3 Year 4 Year 5 Note: The red line is the average cost of treatment per person for the 5-year period, which is $39.39 Tabl.5.3: Total Treatment Cost and National Caseload of Moderately Undernourished Adolescents and Adults Year 1 Year 2 Year 3 Year 4 Year 5 Total treatment cost for Moderate Undernutrition $6,920,737 $9,479,036 $11,530,175 $9,538,503 $10,065,770 Targeted number of Moderately Undernourished Adolescent and Adults 172,347 241,118 296,160 242,612 256,570 Figure 4: Average Cost of Treating an Undernourished Pregnant and Lactating Woman (up-to 6 month postpartum) $39.98 $38.74 $38.32 $37.96 $37.76 $36.50 $37.00 $37.50 $38.00 $38.50 $39.00 $39.50 $40.00 $40.50 Year 1 Year 2 Year 3 Year 4 Year 5 Note: The red line is the average cost of treatment per person for the 5-year period, which is $38.55 Year 1 Year 2 Year 3 Year 4 Year 5 Total treatment cost for Undernutrition $1,378,805 $1,869,076 $2,270,618 $1,901,413 $2,000,439 Targeted number of Undernourished pregnant and lactating women (up-to 6 month postpartum) 34,484 48,244 59,257 50,096 52,978 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 28 6 Guide for Developing District Plan of Action Following the launch of the national NCST operational plan, all DHMTs teams will be required to draft and implement specific annual action plans that will be integrated within their district implementation plans. The plans will be revised on a yearly basis. The following components should be included in developing the annual action plan. 6.1. Facility Level NCST Resource Mapping This section should document health facilities that provide NCST services; those that do not provide services; service delivery points where NCST is provided including ART, ANC/PMTCT, TB and OPD; and proportion of clients who receive nutrition assessment and classification, nutrition counselling, and therapeutic and supplementary food support. The analysis should also highlight QI activities including functionality of QI teams and progress made in achieving set QI targets. Finally, the section should summarise resources available to effectively deliver NCST services, including:  Proportion of staff trained on all 6 NCST training modules in the past 2 years  NCST stock-out history over the last 3 months  Space available for storage of therapeutic and supplementary food supplies  Availability of NCST monitoring and reporting tools, job aids, guidelines, and protocols  Availability and functionality of NCST equipment (see Annex 1 for a list of essential supplies and equipment) Additionally, the resource mapping should highlight the number of community-based peer support groups in the district and those actively implementing nutrition interventions such as assessment, counselling, and referral of clients. 6.2. Stakeholder Mapping This section should provide an updated list of all NCST stakeholders, including NGOs in the district and their role in NCST. The list should provide a corresponding documentation of the NCST resources that the stakeholders are contributing to NCST service delivery. 6.3. Costing of District Operational Plan Each district should use the NCST operational plan to review the annual costs generated through the national costing exercise and review costing assumptions used to ensure that they are still valid. The DHMT should then update the annual projected costs for their districts and include them in the district implementation plan. 6.4. District Operational Plan The annual district plan should be presented in table format and include activities aligned to the national strategic action areas: 1) improving availability and access to NCST supplies and equipment; 2) increasing competence and responsiveness of NCST workforce; 3) increasing the quality and geographical coverage of NCST service delivery; 4) improving monitoring, evaluation, and information management; 5) strengthening leadership and governance of NCST services; 6) increasing resource mobilization and financing of NCST services; and 7) intensifying NCST services to respond to emergency and humanitarian situations. Table 6.1 shows a template for developing a district NCST operational plan. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 29 Table 6.1: Example of District CMAM Operational Plan Activity Indicator Indicator Definition Means of verification Frequency Annual District Target Timeframe Cost ($) Lead Agency Supporting Agency Q1 Q2 Q3 Q4 Objective 1: Improve availability and access to NCST supplies and equipment 1. 2. Objective 2: Increase the competence and responsiveness of NCST workforce 1. 2. Objective 3: Increase quality and geographical coverage of NCST service delivery 1. 2. Objective 4: Improve monitoring, evaluation, and information management 1. 2. Objective 5: Strengthen leadership and governance of NCST services 1. 2. Objective 6: Increase resource mobilization and financing of NCST services 1. 2. Objective 7: Intensify NCST services to respond to emergency and humanitarian situations 1. 2. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 30 7 References Baker, J. 1998. Activity-Based Costing and Activity-Based Management for Health Care. Dallas, Texas: Aspen Publishers. DNHA. 2017. National Multi-Sector Nutrition Policy 2017-2021. Policy , Lilongwe, Malawi: DNHA. Katona, P. and Katona-Apte, J. 2008. “The Interaction between Nutrition and Infection.” Clinical Infectious Diseases (Clinical Infectious Diseases) 46, 1582-1588. MOH. 2017. Health Sector Strategic Plan II 2017-2022. Towards Universal Health Coverage. Strategic Plan, Lilongwe, Malawi: MOH. National Statistics Office, Malawi and ICF. 2017. Malawi Demographic and Health Survey 2015-16. Zomba, Malawi: NSO and ICF. WHO, Geneva. 2003. Nutrient Requirements for People Living with HIV/AIDS. Geneva: WHO. Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 31 Annex 1: NCST Equipment, Supplies, and Materials Item Minimum per health facility 1. Equipment and nutrition supplies Height board (measures up to 0.1 cm) 4 (one at each contact point) Tape stuck to the wall, for height measure (measures up to 0.1 cm) 4 (if height board is not available) Adolescent/adult MUAC tape (measures to nearest 1 mm or 0.1 cm) 8 (two at each contact point) Adolescent/adult weighing scale (measures up to 100 g/0.1 kg) 4 (one at each contact point) RUTF 2 months’ supplies for the total number of severely undernourished clients Supplementary food, e.g., CSB+ (likuni phala), Vitameal, vegetable oil 2 months’ supply for the total number of severely and moderately undernourished clients Iron/folic acid supplements 2 months’ supply for the total pregnant and lactating women 2. Technical reference materials NCST/Nutrition Register for Adolescent and Adults 1 at each contact point providing NCST services NCST/Nutrition Client Management Forms 1 booklet with 100 forms NCST report forms 1 booklet with 50 sheets NCST District Mentoring and Coaching Checklists at least 3 checklists NCST Competencies, Standards, and Verification Criteria Checklist 1 NCST guidelines At least 1 copy NCST job aids At least 1 set BMI reference charts or BMI wheels At least 4 charts or BMI wheels BMI-for-age reference charts or wheels Nutrition counselling materials for adolescents, adults, and pregnant and lactating women 4 (one at each contact point) Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 32 Annex 2: Detailed Budgets: Supplies and Equipment Table 7.1: Action 1: Coordination meetings for NCST and CMAM commodity management Year 1 Year 2 Year 3 Year 4 Year 5 Venue 166 166 166 166 166 Lunch/refreshments 1,750 1,750 1,750 1,750 1,750 Stationary 400 400 400 400 400 Table 7.2: Action 2: Therapeutic food commodities - adolescents (15-18) Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost RUTF kg 3.26 2,566 8,364 3,518 11,472 4,278 13,953 4,071 13,275 4,300 14,019 Table 7.3: Action 2: Therapeutic food commodities - adults Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost RUTF kg 3.26 729,963 2,379,678 1,001,709 3,265,568 1,218,752 3,973,134 1,157,267 3,772,690 1,221,902 3,983,402 Table 7.4: Action 3: Supplementary food commodities - adolescents (15-18) Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost CSB+ kg 0.72 20,718 14,917 28,426 20,467 34,582 24,899 28,739 20,692 30,346 21,850 Vegetable Oil Litre 1.19 1,992 2,371 2,733 3,253 3,326 3,957 2,704 3,215 2,854 3,395 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 33 Table 7.5: Action 3: Supplementary food commodities - adults Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost CSB+ kg 0.72 5,894,117 4,243,764 8,088,328 5,823,597 9,840,846 7,085,408 8,176,377 5,886,990 8,633,046 6,215,791 Vegetable Oil Litre 1.19 566,742 674,423 777,721 925,492 946,237 1,126,019 768,722 914,776 811,657 965,869 Table 7.6: Action 3: Supplementary food commodities - PLW Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost CSB+ kg 0.72 959,551 690,877 1,316,764 948,068 1,602,066 1,153,487 1,331,072 958,370 1,405,416 1,011,898 Vegetable Oil Litre 1.19 106,617 126,874 146,307 174,105 178,009 211,829 147,894 175,997 156,155 185,827 Iron and folic acid Package 1.63 31,985 52,136 43,892 71,544 53,402 87,046 44,369 72,321 46,847 76,361 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 34 Table 7.7: Action 4: Other supplies and equipment Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Equipment Adult height boards each 100.00 2,149 214,933 769 76,800 561 56,000 294 29,333 102 10,133 Adult MUAC tapes each 0.50 4,299 2,149 5,836 2,917 6,955 3,477 7,541 3,771 7,745 3,872 Adult scales each 100.00 2,149 214,933 769 76,800 561 56,000 2,442 244,267 871 86,933 Blood glucose test strips each 0.44 14,466 6,365 19,898 8,754 24,202 10,648 26,809 11,794 28,306 12,452 BMI wheels each 3.00 2,149 6,448 2,916 8,752 3,477 10,432 3,771 11,312 3,871 11,616 Food demonstration equipment set 10.00 363 3,627 141 1,296 102 945 420 4,122 159 1,467 Glucometer each 11.57 403 4,663 547 6,329 652 7,544 707 8,180 726 8,400 haemoglobin tests each 2.78 202,836 563,884 278,991 775,576 339,656 944,229 363,283 1,009,913 383,842 1,067,071 Health facility documentation packet set 102.00 1,209 361,460 1,691 512,678 2,078 632,103 2,321 659,735 2,454 703,442 Haemoglobin machines each 38.70 403 15,596 547 21,169 652 25,232 707 27,361 726 28,096 Pallets each 10.00 3,627 36,270 1,296 12,960 945 9,450 495 4,950 171 1,710 Table 7.8: Action 5: Annual national review and quantification workshop Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 5,124 5,124 5,124 5,124 5,124 Venue 166 166 166 166 166 Lunch/refreshments 1,400 1,400 1,400 1,400 1,400 Stationary 200 200 200 200 200 Printing 700 700 700 700 700 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 35 Table 7.9: Action 6: Logistics management training Training Type Year 1 Year 2 Year 3 Year 4 Year 5 Logistics management training for service providers Accommodation (B&B) for trainers 101,894 101,894 101,894 101,894 101,894 Transport for trainees 12,983 5,091 4,170 2,786 1,248 Refreshments for trainees 72,540 26,640 20,580 12,540 6,540 Per diem for trainees 353,995 130,003 100,430 61,195 31,915 Hall hire for training 21,626 21,626 21,626 21,626 21,626 Training materials sets 43,959 16,144 12,471 7,599 3,963 Logistics management training for managers Accommodation (B&B) for trainers 25,474 25,474 25,474 25,474 25,474 Transport for trainees 3,347 3,347 3,347 3,347 3,347 Refreshments for trainees 8,700 8,700 8,700 8,700 8,700 Per diem for trainees 42,456 42,456 42,456 42,456 42,456 Hall hire for training 7,209 7,209 7,209 7,209 7,209 Training materials sets 5,272 5,272 5,272 5,272 5,272 Table 7.10: Action 7: Storage of therapeutic and supplementary food commodities Year 1 Year 2 Year 3 Year 4 Year 5 Storage of therapeutic foods RUTF 6,952 9,540 11,607 11,021 11,637 Storage of supplementary foods CSB+ 65,238 89,524 108,921 90,498 95,553 Vegetable oil 6,409 8,795 10,701 8,724 9,212 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 36 Table 7.11: Action 8: Transport of therapeutic and supplementary food commodities Year 1 Year 2 Year 3 Year 4 Year 5 Transport of therapeutic foods RUTF 240,204 329,624 401,044 380,814 402,084 Transport of supplementary foods CSB+ 1,964,356 2,695,628 3,279,694 2,724,966 2,877,162 Vegetable oil 221,454 303,894 369,742 301,454 318,291 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 37 Annex 3: Detailed Budgets: Competence and Responsiveness of NCST Workforce Table 7.12: Action 1: Review of the pre-service training curricula for health professionals Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 5,124 -- -- -- 5,124 Venue 829 -- -- -- 829 Lunch/refreshments 1,400 -- -- -- 1,400 Stationary 400 -- -- -- 400 Printing 1,200 -- -- -- 1,200 International Consultant 9,000 -- -- -- 9,000 National consultant 5,000 -- -- -- 5,000 Accommodation for data collection 3,587 -- -- -- 3,587 Per diem for data collection 2,310 -- -- -- 2,310 Table 7.13: Action 2: NCST Technical update workshops Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 5,124 -- 5,124 -- 5,124 Venue 166 -- 166 -- 166 Lunch/refreshments 1,400 -- 1,400 -- 1,400 Stationary 200 -- 200 -- 200 Printing 105 -- 105 -- 105 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 38 Table 7.14: Action 3: NCST training for lecturers and tutors Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation for trainers 2,196 2,196 2,196 2,196 2,196 Transport 3,421 3,421 3,421 3,421 3,421 Lunch/refreshments 5,000 5,000 5,000 5,000 5,000 Per diem for trainees 18,300 18,300 18,300 18,300 18,300 Venue 829 829 829 829 829 Training materials 909 909 909 909 909 Table 7.15: Actions 4-7 NCST training Training Type Year 1 Year 2 Year 3 Year 4 Year 5 NCST training for service providers Facilitator Guides 9,954 14,742 19,502 23,151 23,408 Per diem 512,766 653,310 754,326 796,416 804,102 Refreshments 176,600 227,058 264,686 282,225 284,674 Trainee materials 50,940 64,903 74,938 79,119 79,883 Transport for trainers and trainees 10,109 13,036 15,410 16,623 16,710 Venue 30,244 40,235 48,545 53,548 53,838 NCST training for district coaches and managers Facilitator Guides 1,606 1,606 1,606 1,606 1,606 Per diem 106,140 106,140 106,140 106,140 106,140 Refreshments 42,750 42,750 42,750 42,750 42,750 Trainee materials 5,272 5,272 5,272 5,272 5,272 Transport for trainers and trainees 2,106 2,106 2,106 2,106 2,106 Venue 9,115 1,657 1,657 1,657 1,657 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 39 NCST training for national and zonal coaches Facilitator Guides 642 642 642 642 642 Per diem 14,640 7,320 14,640 7,320 14,640 Refreshments 5,250 2,063 5,250 2,063 5,250 Trainee materials 3,959 727 3,959 727 3,959 Transport for trainers and trainees 1,047 601 1,047 601 1,047 Venue 2,486 1,657 2,486 1,657 2,486 NCST training for NAPHAM national and district care takers Accommodation for trainers 659 -- -- -- -- Transport 4,528 -- -- -- -- Lunch/refreshments 6,000 -- -- -- -- Per diem for trainees 21,960 -- -- -- -- Venue 249 -- -- -- -- Training materials 3,636 -- -- -- -- NCST training for community-based support group members Accommodation for trainers 659 -- 659 -- 659 Transport for trainers 947 -- 947 -- 947 Lunch/refreshments 87,000 -- 87,000 -- 87,000 Venue 249 -- 249 -- 249 Training materials 52,722 -- 52,722 -- 52,722 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 40 Table 7.16: Action 9: Mentoring and supportive supervision Supervision Type Year 1 Year 2 Year 3 Year 4 Year 5 Mentoring and supportive supervision from district to facilities Lunch allowance 6,894 8,567 9,823 10,264 10,263 Supervisory checklists 16,607 20,600 23,446 24,444 24,477 Transport 12,001 15,150 17,854 19,002 18,813 Mentoring and supervision from national to the district level Per diems for overnights 3,294 2,708 2,708 2,708 2,708 Supervisory checklists and documentation 189 189 189 189 189 Lunch allowance for day trips 29 29 29 29 29 Transport 1,003 884 884 884 884 Mentoring and supervision for community-based groups Transport 101,059 101,059 101,059 101,059 101,059 Lunch allowance 19,210 19,210 19,210 19,210 19,210 Table 7.17: Action 10: Quarterly district coordination meetings with support group leaders and facilitators Year 1 Year 2 Year 3 Year 4 Year 5 Transport 15,791 15,791 15,791 15,791 15,791 Lunch/Refreshments 29,000 29,000 29,000 29,000 29,000 Stationary 5,800 5,800 5,800 5,800 5,800 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 41 Annex 4: Detailed Budgets: Quality and Geographic Coverage of Service Delivery Table 7.18: Action 4: QI Learning Sessions Year 1 Year 2 Year 3 Year 4 Year 5 Transport 701 952 1,134 1,230 1,263 Per diem 353,995 480,485 572,717 621,029 637,718 Venue 249 249 249 249 249 Stationary 200 200 200 200 200 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 42 Annex 5: Detailed Budgets: Monitoring, Evaluation and Information Management Table 7.19: Action 1: Meeting to identify operational research needs Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 5,124 -- -- -- -- Venue 166 -- -- -- -- Lunch/refreshments 1,400 -- -- -- -- Stationary 200 -- -- -- -- Printing 700 -- -- -- -- Table 7.20: Action 2: Annual learning & knowledge sharing conference Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 14,640 14,640 14,640 14,640 14,640 Venue 166 166 166 166 166 Lunch/refreshments 4,000 4,000 4,000 4,000 4,000 Stationary 200 200 200 200 200 Printing 2,000 2,000 2,000 2,000 2,000 Table 7.21: Action 3: Annual national review of the NCST Operational Plan Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 18,300 18,300 18,300 18,300 18,300 Venue 414 414 414 414 414 Lunch/refreshments 5,000 5,000 5,000 5,000 5,000 Stationary 200 200 200 200 200 Printing 1,000 1,000 1,000 1,000 1,000 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 43 Table 7.22: Action 4: Midterm and endline evaluations of NCST Operational Plan Year 1 Year 2 Year 3 Year 4 Year 5 Midterm evaluation Accommodation -- -- 18,300 -- -- Venue -- -- 414 -- -- Lunch/refreshments -- -- 5,000 -- -- Stationary -- -- 200 -- -- Printing -- -- 600 -- -- International consultant -- -- 9,000 -- -- National consultant -- -- 5,000 -- -- Endline evaluation Accommodation -- -- -- -- 18,300 Venue -- -- -- -- 414 Lunch/refreshments -- -- -- -- 5,000 Stationary -- -- -- -- 200 Printing -- -- -- -- 600 International consultant -- -- -- -- 9,000 National consultant -- -- -- -- 5,000 Table 7.23: Action 5: Quarterly facility and district DQA Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 308,904 308,904 308,904 308,904 308,904 Venue 9,612 9,612 9,612 9,612 9,612 Lunch/refreshments 84,400 84,400 84,400 84,400 84,400 Stationary 23,200 23,200 23,200 23,200 23,200 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 44 Table 7.24: Action 7: Establish the use of mobile DHIS-2 at facility level Year 1 Year 2 Year 3 Year 4 Year 5 Mobile DHIS-2 set up 50,000 60,000 65,000 70,000 75,000 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 45 Annex 6: Detailed Budgets: Leadership and Governance Table 7.25: Action 1: Update of national NCST Guidelines Year 1 Year 2 Year 3 Year 4 Year 5 Consultants International consultant 6,300 -- -- 6,300 -- National consultant 3,500 -- -- 3,500 -- Technical working group meetings Venue 249 -- -- 249 -- Lunch/refreshments 900 -- -- 900 -- Stationary 200 -- -- 200 -- Stakeholder consultation meeting Accommodation 5,124 -- -- 5,124 -- Venue 166 -- -- 166 -- Lunch/refreshments 1,400 -- -- 1,400 -- Stationary 200 -- -- 200 -- NCST guideline 105 -- -- 105 -- Stakeholder consensus meeting Accommodation 5,124 -- -- 5,124 -- Venue 166 -- -- 166 -- Lunch/refreshments 1,400 -- -- 1,400 -- Stationary 200 -- -- 200 -- NCST guideline 105 -- -- 105 -- Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 46 Table 7.26: Action 3: Quarterly TNP technical working group meetings Year 1 Year 2 Year 3 Year 4 Year 5 Venue 331 331 331 331 331 Lunch/refreshments 2,800 2,800 2,800 2,800 2,800 Stationary 800 800 800 800 800 Table 7.27: Action 4: Development and printing of quarterly NCST policy and technical briefs Year 1 Year 2 Year 3 Year 4 Year 5 Printing 20,000 20,000 20,000 20,000 20,000 Designer (consultant) 2,000 2,000 2,000 2,000 2,000 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 47 Annex 7: Detailed Budgets: Resource Mobilisation and Financing Table 7.28: Actions 1-4: Advocacy campaigns (3 per year) Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 26,352 26,352 26,352 26,352 26,352 Venue 249 249 249 249 249 Lunch/refreshments 3,600 3,600 3,600 3,600 3,600 Stationary 600 600 600 600 600 Printing 720 720 720 720 720 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 48 Annex 8: Detailed Budgets: Illustrative Annual Emergency Budget Table 7.29: Action 1: Intensify case finding through community-based groups Activity Annual cost NCST training for NAPHAM national and district care takers Accommodation for trainers 659 Transport 4,528 Lunch/refreshments 6,000 Per diem for trainees 21,960 Venue 249 Training materials 3,636 Mentoring and supervision for community-based groups Transport 101,059 Lunch allowance 19,210 Quarterly district coordination meetings with support group leaders and facilitators Transport 15,791 Lunch/Refreshments 29,000 Stationary 5,800 Table 7.30: Action 2: Advocacy meetings for resource mobilisation Activity Annual cost Lunch/refreshments 1,400 Venue 166 Stationary 400 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 49 Table 7.31: Action 3: Emergency therapeutic food commodities - adolescents (15-18) Item Unit Unit Cost Annual Requirement Annual Cost RUTF kg 0.72 2,643 8,615 Table 7.32: Action 3: Emergency therapeutic food commodities - adults Item Unit Unit Cost Annual Requirement Annual Cost RUTF kg 0.72 751,862 2,451,068 Table 7.33: Action 3: Storage and transport of emergency therapeutic food commodities Activity Annual Cost Transport of therapeutic foods RUTF 247,410 Storage of therapeutic foods RUTF 7,161 Table 7.34: Action 4: Emergency supplementary food commodities - adolescents (15-18) Item Unit Unit Cost Annual Requirement Annual Cost CSB+ kg 0.72 23,204 16,707 Vegetable Oil Litre 1.19 2,231 2,656 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 50 Table 7.35: Action 4: Emergency supplementary food commodities - adults Item Unit Unit Cost Annual Requirement Annual Cost CSB+ kg 0.72 6,601,411 4,753,016 Vegetable Oil Litre 1.19 634,751 755,354 Table 7.36: Action 4: Emergency supplementary food commodities - PLW Item Unit Unit Cost Annual Requirement Annual Cost CSB+ kg 0.72 1,074,697 773,782 Vegetable Oil Litre 1.19 119,411 142,099 Iron and folic acid Package 1.63 35,823 58,392 Table 7.37: Action 4: Storage and transport of emergency supplementary food commodities Activity Annual Cost Transport of supplementary foods CSB+ 2,200,079 Vegetable oil 248,028 Storage of supplementary foods CSB+ 73,067 Vegetable oil 7,178 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 51 Table 7.38: Action 5: Conduct refresher trainings of service providers and community-based groups on NCST Training Type Annual cost NCST training for service providers Facilitator Guides 23,408 Per diem 804,102 Refreshments 284,674 Trainee materials 79,883 Transport for trainers and trainees 16,710 Venue 53,838 NCST training for community-based support group members Accommodation for trainers 659 Transport for trainers 947 Lunch/refreshments 87,000 Venue 249 Training materials 52,722 Table 7.39: Action 6: Monthly government and NCST partner coordination meetings Activity Annual cost Lunch/refreshments 8,400 Venue 994 Stationary 2,400 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 52 Table 7.40: Action 7: Intensified real-time monitoring and reporting data through DHIS-2 Activity Annual cost Mobile DHIS-2 expansion 60,000 Malawi National Nutrition Care, Support, and Treatment (NCST) Operational Plan 2018–2022 53