Background

Globally, 22% of children under five years of age are stunted, 6.7% wasted, and 14.6% had low birth weight according to Global Nutrition Report 2021 [1]. Additionally, the state of Food Security and Nutrition in the World of 2021 report indicated that 29.9% of women of reproductive age suffered from anaemia while 42% of children under 5 years of age were affected. Overweight and obesity was found to be increasing rapidly nearly in every country in the world. Notably Sub-Saharan Africa and South Asia were identified as contributing the majority of the observed burden of malnutrition [2].

In Uganda, 29^% of children under 5 years are stunted, 11% underweight, 4% wasted and 53% anaemic while the prevalence of anaemia and chronic energy deficiency among women of reproductive age was 32% and 12% respectively as reported in the Uganda Demographic Health Survey 2016 [3]. Maternal malnutrition has detrimental effect on the mother and her offspring. Maternal consequences include; low pregnancy weight gain, increased infant and maternal morbidity and mortality, lethargy and reduced productivity. Infant consequences include; intrauterine growth retardation, low birth weight, pre-term birth and reduced intelligence quotient [4,5].

To address the situation in Uganda, the Ministry of Health (MoH) implemented various programs such as the Baby Friendly Health Facility Initiative (BFHI) [6], Infant and Young Child Feeding (IYCF) [7], Integrated Management of Acute Malnutrition (IMAM) [8], Vitamin A Supplementation and Deworming [9]. However, these programs have been implemented in a vertical manner targeting specific population segments, mainly children aged 0-59months. This limitation prompted the adoption of the Nutrition Assessment Counselling and Support (NACS) approach.

The NACS approach, initiated in 2009 in Uganda, aimed to integrate nutrition interventions into policies, programs and health service delivery for all segments of the population across the life cycle. It focused on a more holistic, simple, realistic and innovative ways of integrating and implementing preventive, supportive and curative nutrition services by involving all stakeholders and key sectors for more sustainability [10]. The process started with development of a comprehensive NACS training package with interventions to be provided to clients whenever they accessed health care in selected pilot districts. In these districts, health facilities were provided with; nutrition guidelines, job aides, nutrition supplies and logistics to enhance quality nutrition service delivery. The health workers were trained and empowered to; promote health facility-community linkage for continuum of care, monitor nutrition performance using data capture tools, utilise quality improvement approach to address the performance gaps, and work in partnership with stakeholders to increase coverage of nutrition services.

Regarding service delivery, the NACS intervention to package was provided to all the clients at every visit tailored to their needs. To mothers and their children, support was provided on optimal maternal nutrition practices which included iron/folic acid supplementation, counselling on a diversified diet and an extra meal, adequate consumption of iodine, deworming, prevention of malaria and counselling on the recommended antenatal visits.

Nutrition education and counselling emphasized optimal breastfeeding practices including early initiation of breastfeeding within the first hour of birth, exclusive breastfeeding for the first 6 months, continued breastfeeding for two years and beyond for non HIV exposed infants and one year for the HIV exposed infants who are confirmed negative on an HIV test. Mothers of older infants >6 months received nutrition education on optimal complementary feeding practices including frequency of meals, adequacy of the foods, thickness of the food, variety of the foods, active feeding, observation of personal, environmental and food hygiene at all processes of food preparation. Mothers/caretakers of sick children were counselled on continued breastfeeding and frequent feeding for infant >6 months [23]. The community system served as continuum of health and nutrition care providing livelihood and economic strengthening support as well as client follow up. The NACS approach aimed to integrate nutrition into health system but the extent of this integration at both the health facility and community levels has not been assessed.

The concept of integration is interpreted differently by various users in the health system and can be defined based on typology, breadth, processes, intensity and health system perspective [11,12]. Several models have been used to describe integrated care depending on the scale and these range from individual, group and disease specific and population based models [11–14]. These studies provide insights on the concept of integration but may not delve deeply into measurement methodologies of integration. For instance, Ellen Nolte et al. [11] and World Health Organization [12] focus on describing integration models while Ahgren et al. [13] and Jason Cheah [14] concentrate on theoretical framework for integration. This paper defines integration from the health system and intensity perspective as the extent to which NACS interventions are assimilated into the health system functions, whether partially or fully [15]. Although service integration has been cited as a strategy for strengthening health systems by reducing service fragmentation and improving access to diverse and interrelated healthcare, it faces challenges in poorly performing or under-resourced health systems. [12,16–19]. This study adapted an integrated nutrition service delivery conceptual framework S1 Fig mirroring the Chronic Care model which encompasses many processes and activities performed at the health facility and community level to improve the clinical nutrition outcomes of the beneficiaries.

Regarding benefits, several studies have shown that integrated health care is patient centered, cost effective, increase access to services and results into better health outcomes [14,20–22]. These studies differ in their emphasis on conceptualization and empirical evidence of integration. Atun et al. [15] focuses on the conceptual side while Oxman et al. [21] and Ryman et al. [22] leans towards exploring the practical advantages of integration. A thorough analysis would entail combining both theoretical frameworks and empirical evidence to fully understand the benefits of healthcare integration. Regarding the extent of integration, one study that assessed the level and trend of integration of acute malnutrition management in Niger found variations in integration across the health system functions. Governance and health information scored the highest while financing the lowest. The authors recommended adapting an indicator matrix aligned with national health, nutrition policies and development plans [16]. Deconinck et al. [16] in this study highlights integration process, level of integration and lessons learned. More detailed information on the methodology and deeper examination of the drivers to integration would enhance its impact. Findings from one health system performance assessment on IMAM/NACS conducted in Uganda in 2014 revealed a number of gaps in the health system building blocks. The same authors in this report acknowledged the fact that the assessment was not meant to be representative of the provision of NACS services in all Uganda, but provide examples of the strengths and gaps in the health system that affect implementation [23]. A systematic review assessing the impact of integrated health and nutrition programs’ impact on specific nutrition outcomes indicated that service delivery and health workforce were well integrated but governance, information systems, finance, supplies and technology were less integrated [24]. In comparison to the study by Deconinck et al. [16], Salam et al. [24] offers a broader perspective on integration across health system including nutrition specific and sensitive interventions as well as the enablers and barriers to integration. To gain a deeper understanding of the extent of integration, it is important to assess this concept by level of service delivery and beyond the confines of the health system. It is important to note that no single successful model of integration has been reported. Instead the effectiveness of integration varies according to the context and demands of a particular setting in which it occurs. This variation is evident in a systematic review that showed that integration had a positive impact on nutrition and non-nutrition outcomes with the model of integration adapting to the context and demands of a particular setting [25].

Despite a decade of NACS implementation in Uganda, there is paucity of information on the extent to which NACS has been integration in the health and community system functions. Furthermore, evidence is scarce on the drivers of integration.

Therefore, this study aimed to assess the extent of NACS integration within and beyond the health system and identify key drivers to this process. The study specifically examined the incorporation of NACS within the following domains: 1) healthcare facility levels, 2) health system building blocks and the community system. The findings of this study provides insights into level of assimilation, best practices and areas for improvement which can inform the scale up of NACS initiatives in Uganda.

Materials and methods

This study was approved by; the Higher Degrees, Research and Ethics Committee–Institutional Review Board, Makerere University School of Public Health (MaKSPH HDREC 24/01/2017), Uganda National Council of Science and Technology (SS 4251) and the Office of the President Uganda (ADM/194/212/01). A formal letter from the Ministry of Health was written to the Tororo District Health Officer to seek for permission to conduct the study. The Principal Investigator informed both the District Health Officer and the District Resident Commissioner about the study plan before its execution. Health workers and participating mothers were asked to sign informed consent form. The mothers who were unable to read and write provided their informed consent using their thumbprint.

Data collection tools and procedures

Study instruments.

The semi-structured questionnaire for this study was developed by adapting questions from studies on integration [28,29], benchmarking tools on policies and practices [30] and aligned to national health service standards, nutrition service delivery assessment tool [31,32]. This study used a health systems approach to assess the extent to which NACS activities have been assimilated in each of the health and community system functions and aligned to global and national definition. Governance and Leadership meant existence of strategic policy and legislative framework, effective oversight, provision of incentives and accountability [32]. Health financing meant availability of funding and the right financial incentives that enables individuals have access to effective public health and personal health care [33]. An effective health information system meant production, analysis, dissemination and use of reliable and timely information on the health system performance [34]. The health workforce meant availability of competent and dedicated staff [35]. An efficient service delivery meant physical presence of items required for service delivery for example the infrastructure, qualified staff and the way the governance task determined their use for an efficient system [36]. Health supplies and logistics meant availability or stock out of the nutrition commodities.

We used key informant and in-depth interview guides to collect information on the respective drivers of integration for each health system building block. The interview guides captured information on the experience, facilitating and inhibiting factors to integration.

Measuring the extent of NACS integration.

The extent of NACS integration was assessed using a facilitated panel discussion of 4–8 participants using a semi-structured questionnaire. Only one tool was filled per facility in which the participants reached consensus on the level of NACS assimilation using prescribed NACS constructs within the health and community systems as outlined in Table 1. The panelists were allocated reference numbers, equal opportunity and minimum time to share their views.

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Table 1. Constructs used to measure the extent of integration of NACS in the health system.

https://doi.org/10.1371/journal.pone.0289389.t001

The intensity of integration scores was measured on a scale of 1 to 5 as follows;

1. NACS activities are not integrated and not provided- (No integration)
2. NACS activities are partially integrated and provided by partners (Done by partners / Partial*)
3. NACS activities are partially provided by the Ministry of Health but not fully covering all the needs because of weak capacities–(Weak and not supported/ Partial**)
4. NACS activities are partially provided by Ministry of Health with some support from partners—(Some support from Partners / Partial***)
5. NACS activities are fully integrated and provided by Ministry of Health–(Full integration)

Results

Discussion

This study assessed the extent to which NACS elements were assimilated in the health system functions while also identifying the key factors driving the integration. The findings serve as valuable insights for the potential scale up of NACS in Uganda. The overall, integration scores for NACS across health facilities and health system building blocks and their implication for nutrition outcomes are discussed. Our deep dive at NACS integration at service delivery level revealed areas of weakness which further compromise nutrition outcomes. Further, this paper highlights the important role of community systems which are vital to the success of nutrition programs.

The findings showed that NACS was mostly integrated in the service delivery function with a mean score of 3.8. That is, the activities were provided by MoH with some support from partners. However, follow up care was weakest although lower health facilities tended to perform slightly better than the higher level facilities. This could be justified by the fact that they tend to be closer to communities. Similar to several studies, integration in the service delivery function scored highest because most programs are able to offer integrated services through the existing delivery mechanisms [24,25,28]. Consequently, community support systems such as integrated community outreaches, follow up and referral mechanisms, program specific community resource persons and frequent supervision need to be strengthened for better nutrition outcomes. This is supported by Emma Sacks et al.[37] who advocate for an expansion beyond the WHO building blocks and the allocation of technical and financial resources to community health to enable provision of primary health care for all.

The integration of NACS in the governance and leadership block was partial with a mean score of 3. This means that the NACS activities are being integrated but are compromised by weak capacities in terms of availability of the necessary protocols, planning, budgets and co-ordination which should be provided by the district health office and Ministry of Health. On the other hand, good leadership was the driving factor for the integration of nutrition interventions into health policies, plans, stakeholder coordination and ensuring sustainability of the interventions. These findings are comparable to several studies that suggest multi-sectoral coordination, leadership and planning as enablers to integration [20,24,38]. Unfortunately, this assessment did not cover the national level structures and processes so as to complete the loop from national level planning to implementation and may therefore be unable to elucidate why these gaps persist.

Across the 3 health facility levels, integration scored second lowest on health system financing with a mean score of 2.2. This may be an indicator that the financing of nutrition interventions heavily depends on donor support. The lack of pooled budgets and health workplans reflecting nutrition activities highlights the lack of investment in nutrition ultimately constraining nutrition service delivery. Although partner support was highlighted out as one of the drivers to integration, it was noted that there was no transparency, co-ordination of partner funding, commonly agreed upon funding allocation and poor integration in the district planning cycles. Although partner support facilitated integration, it was observed that this support might be unsustainable. Several studies have revealed similar challenges of sustainability of interventions due to donor driven projects [39–42]. This implies that sustained implementation of nutrition interventions requires reasonable financial contribution from government.

The integration of NACS into the human resource function was partial with a mean score of 3.7. This implies that nutrition activities are provided by the Ministry of Health but are limited in terms of dedicated staff for nutrition, clear job descriptions, performance appraisals, staff competence, motivation and minimal supervision to lower level health facilities. Motivated and skilled staff, capacity building activities, availability of support staff, and patient empowerment were highlighted as key drivers for integration. Several studies on integration have documented human resource challenges and recommended that adequate and skilled health work force are needed for effective implementation of policies and programs designed by the national governments [17,19,43,44]. Current literature also recommends the recruitment of nutritionists at the various levels with clear job descriptions, the provision of capacity building activities to address service delivery gaps and the motivation of staff through performance appraisals, staff development and local incentives.

The integration of NACS within the health information system function was partial with a mean score of 3.2. This means that services are provided by the Ministry of Health but limited in terms of availability of updated data capture and reporting tools, staff competence in use of the Health Management Information System (HMIS) and District Health Information System 2(DHIS2) as well as poor documentation. In addition, previous studies have highlighted similar challenges of staff capacity gaps, user access to the information systems, poor documentation [45–47]. These weaknesses revealed in the current health management information system imply limitations in tracking progress towards the desired set nutrition targets, underestimation of the burden of malnutrition in the district thus failure to respond appropriately.

The health technologies and supplies function scored lowest with a mean integration score of 1.5. This means that the procurement and distribution of nutrition commodities and supplies is heavily dependent on donor support. Although an initial step has been taken to include the nutrition commodities on the essential medicine list, the majority of the supply chain management functions are not implemented by the Ministry of Health. For instance, the product selection, forecasting, quality assurance, procurement, inventory management and distribution are still solely done by partners. Further reviews of the supply chain system, generated recommendations which were limited to strengthening the supply chain system in the private sector and not the public sector [48]. This implies that sustainable and universal access to nutrition commodities (consumables and non-consumables) will require strategic shift from donor driven support to government led stewardship and coordination of this function.

Strengths and limitations

In this study, a mixed method design was used to assess the extent of integration, with key health managers serving as the information source which was a strength. However it is important to note that the assessment was limited to a single district which limits generalizability of the findings, representing a weakness.

Conclusion

NACS integration within and beyond the health system was generally weak and lacked adequate support. Among the building blocks, service delivery showed relatively fairer integration whereas financing and health supplies were notably weaker. Governance, financing and community follow-up under service delivery require more government investment for enhanced integration. The key drivers for integration were; good leadership, funding, competent staff, quality improvement approaches, nutrition talks, community dialogues, health and nutrition education talks as well as nutrition logistics and supplies.

These findings highlight opportunities for improvement in achieving a fully integrated nutrition delivery and the scaling up of the NACS.

Recommendations

In view of these findings, we suggest the following recommendations to enhance practices and policies related to integration of nutrition interventions and potential areas for future research. In order to strengthen the information system, the Ministry of Health will need to address gaps across the system by providing updated registers that capture nutrition data elements and indicators to the districts, building the capacity of health staff in data management. Addressing gaps in service delivery will require; building the capacity of a critical mass of services providers in nutrition packages, quality improvement approaches, strengthening the follow up and referral mechanism, utilising the Village Health Teams and linkage facilitators for basic nutrition services.

Future nutrition strategic plans for both national and district level should be developed premised on the six health system building blocks with a solid framework for integration. To enhance ownership, co-ordination, accountability and sustainability of nutrition interventions, the Ministry of Health should empower the districts in governance and leadership skills. Strengthening the health supply chain system will require strengthening the governance and leadership structures of the Ministry of Health to co-ordinate all the key stakeholders in the supply system, building capacity of service providers in the Supply Chain Management functions, allocating central government funds for nutrition commodities, promoting local production, and close monitoring and supervision of the processes. Additionally, we recommend increased government budget allocation to nutrition at district level, and support districts in leveraging and pooling partner support to a centralized district account for transparency, improved co-ordination and efficient and effective use of resources.

Finally future research could concentrate on assessing the extent of integration of nutrition interventions across all levels of service delivery, including multiple districts and at the national level.

Supporting information

Acknowledgments

We appreciate the Tororo district political and administrative team for their permission and support during the data collection period. We thank the supervisors, data collectors, health staff, mothers and their infants for their participation in the study. Finally, Special appreciation go to Drs. Richard Kajura, Godfrey Bwire and Arthur Bagonza for their encouragement and peer support.