From the editor
Rabia, seven months, with her mother at an OTP
Aim and structure of this special issue
This Field Exchange special issue on ‘Lessons for the scale up of Community-based Management of Acute Malnutrition (CMAM)’ mainly aims to provide some insights on scaling up CMAM from a government perspective. A large part of this edition is therefore taken up with the proceedings of an international conference on government experiences of CMAM scale up held in Addis Ababa, 14-17 November, 2011. A collaborative initiative between the Government of Ethiopia and the ENN, participation was heavily biased towards senior government representatives from 22 African and Asian countries. There were however, some representatives from United Nations (UN) agencies, non-governmental organisations (NGOs), academia, bilateral donors, foundations and individual experts. Nine government-led country case studies (Ethiopia, Pakistan, Niger, Somalia, Kenya, Ghana, Sierra Leone, Malawi, and Mozambique) were presented at the conference. These take the form of nine field articles at the core of this issue, with a tenth article on experiences from India that includes a postscript of developments post conference. The Addis conference contributions are complemented by two more field articles from Nigeria and Zimbabwe and a selection of research, evaluation and news that all speak to the CMAM scale up theme.
The overall aim of the Addis Ababa conference was to identify examples of CMAM scale up success and common challenges. Two important caveats should be stated here. Firstly, whilst successful practices in scaling up CMAM were noted, it should not be assumed that what has been done in one context or at one time in the past represents the best action for another context or time. Secondly, the aim was not to prescribe set ways to organise CMAM scale-up, particularly in terms of how the programme is structured and managed. Rather, the aim was to point towards some features that need to be addressed and the local and global mechanisms that could be strengthened in order to guide and support scale-up more effectively.
To help distil lessons for CMAM scale up, a synthesis of lessons learned from government CMAM scale up was produced by the ENN1. This extended editorial summaries the synthesis findings and identifies the key learning points and ways forward that emerged from the case studies and conference proceedings. These are presented under ten emerging themes, illustrated with country-specific examples that are detailed in the field articles included in this edition. The Addis Ababa conference was a unique experience for the ENN, and we hope you will get a taster of the rich experience and discourse in this special edition.
Before we embark on the synthesis summary, the ENN editorial team want to give a sense of current thinking around CMAM scale up within the ENN and also ‘flag’ a few issues that continue to be vigorously debated within the ENN. First off, who would have thought that small pilot programmes in Ethiopia and northern Sudan between 2000 and 2001 that used Ready to Use Therapeutic Food (RUTF) to treat SAM in the community would, less than 12 years later, be replicated globally in at least 60 plus countries at scale? The latest CMAM mapping by UNICEF (see research section) indicates that since 2009, there has been an almost 100% increase in the number of children under five years treated as part of CMAM programming. The figure is very close to 2 million. The speed and scope of scaling up CMAM is quite breathtaking and unprecedented in terms of the scaling up of other nutrition interventions. However, and without wishing to be overly cautious or even to sound negative, there are major challenges that need to be tackled in order to take this promising approach to a level whereby the majority of children that develop severe acute malnutrition (SAM) will have access to appropriate care administered through government run health systems in the long term. Actions to help plan integration into national health systems are reflected in two news pieces: a framework on integration of SAM management being piloted by UNICEF EASRO, and a guidance written by Action Contre la Faim on the same topic.
It is sobering to consider that the figure of 2 million SAM cases treated probably represents less than 10% of the global SAM case load. This partly reflects the fact that countries such as India with the most significant caseloads are only at the beginning of scale up. It also undoubtedly reflects the fact that scaling up is difficult on many levels. It is probably true to say that the majority of the 2 million SAM children admitted to CMAM in 2011 were ‘easier to reach’ children. It may therefore get harder and harder to increase coverage as scale up continues.
Interestingly the global mapping does not capture what is happening with moderate acute malnutrition (MAM) for which the case load could be as much as ten times higher than that of SAM. An explicit focus on the SAM only aspect of CMAM seems to increasingly be a feature of scale up efforts; both the UNICEF and ACF initiatives described in this issue of Field Exchange focus on SAM management, a position reflected in the 2007 WHO/UNICEF/UNSCN/WFP Joint Statement that addresses the community based management of SAM only. Yet for others it seems MAM does fall within the scope of CMAM – the original CTC model stipulated the inclusion of SFPs within CMAM programming2 and current CMAM working definitions from FANTA2 and the CMAM Forum specifically include MAM children within their scope. Indeed at ENN we may well be guilty of this increasing ‘blind spot’ when it comes to MAM, opting to focus most of our attentions on SAM management in CMAM in the Addis conference. Part of our rationale for this at the Addis conference was the lack of a clear framework for treatment and prevention of MAM and absence of leadership around the inclusion of MAM treatment in the context of CMAM; we did not want any ensuing debate to overshadow the lesson capture at the heart of the conference. MAM management certainly featured in some of the nine case study countries but not consistently so, and there were many related questions emerging (with few answers). Furthermore, where MAM does feature in programming, the emphasis seems to be on food/ specialised product interventions with little programming around non-food MAM interventions. So one of ENNs (many) lessons from the conference experience is we need to talk about MAM. To this end, we encourage you to submit experiences, research and challenges to Field Exchange on this topic, and especially welcome those that describe non-food MAM interventions.
Financing challenges around long-term CMAM programming featured heavily in the government experiences shared in Addis. Three key financing issues that emerged and need urgent attention are: how to move from humanitarian funding to longer-term funding where CMAM is scaled up on the back of an emergency, whether scaled up CMAM programming is sustainable on a country by country basis and if so, how will financing arrangements for long-term programming be configured, particularly with regard to the proportion of funding to come from national government and international donor agencies.
Quality of programming was also a major concern and this is reflected in some of the content in this issue. The UNICEF mapping report indicates that less than 32% of countries were able to meet SPHERE standards for recovery and only 19.4% met standards for defaulting. SPHERE standards may be an appropriate aim but is it too much to expect these be attained during the process of scale up for government implemented programmes in non-emergency contexts? There is little clarity around what standards are acceptable and realisable in such contexts and over what time-frame they can be reached.
These are just some of the major challenges facing agencies and governments moving forward in their attempts to roll out CMAM. CMAM scale up has started at a sprint. However, the goal we all desire, which is universal programme coverage for acute malnutrition, will involve a marathon which like all marathons, requires an enormous and perhaps unprecedented level of political and financial commitment amongst all key stakeholders. How this plays out in the next few years will be fascinating. For the millions of families living with acute malnutrition it could well be a matter of life and death.
Jeremy Shoham and Marie McGrath, ENN
Paths for scaling up CMAM: Broad lessons and ways forward
Globally, it is estimated that over 19 million children are severely acutely malnourished at any one time. These children have a greater than nine fold increased risk of dying compared to a well-nourished child3. The 2008 Maternal and Child Nutrition Lancet series recognises severe acute malnutrition (SAM) as one of the top three nutrition-related causes of death in children under-five4. It emphasises the importance therefore of addressing acute malnutrition for meeting the Millennium Development Goal 4 (MDG4) of reducing child mortality5. This message has been taken up in international fora, particularly by the 2010 multi stakeholder global effort to “Scale Up Nutrition” (SUN)6.
CMAM is an innovative approach which successfully treats the majority of children with SAM, including those who are HIV positive, at home. The approach engages communities in order to identify severely malnourished children early before their condition deteriorates to a stage where they require inpatient care for medical complications. It allows effective treatment of uncomplicated SAM cases, in terms of essential medicines, simple orientation for caregivers, and specially formulated RUTF, to be given on a weekly basis at low level existing decentralised health structures or distribution sites within a day’s walk of people’s homes. The approach includes inpatient care for complicated cases of SAM (usually <10% of the caseload) and in some situations, depending on context and resources, with supplementary feeding or other programmes aiming to address moderate acute malnutrition (MAM).
The CMAM approach was first implemented in 2001 and based on early successes, was taken up by a number of international non-governmental organisations (NGOs) working in emergency contexts in countries of Africa with various degrees of government involvement. In 2007, the United Nations (UN) endorsed the communitybased approach for management of SAM with a joint statement7. Endorsement of the approach came as a result of operational research conducted over the previous seven years which provided evidence of its impact8, and work from similar community-based programmes9). This global endorsement paved the way for the further expansion of the approach by creating consensus within the global nutrition community and amongst international agencies and donors on what is the optimal programming approach for the treatment of SAM. It also enabled governments to start establishing and scalingup CMAM programming at national level. A shift of focus to seeing community-based management of SAM as a requirement of routine health activities has emerged as a result.
From three countries implementing small scale CMAM programmes between 2000 and 2003, by mid-2010, 55 countries were implementing CMAM to some degree. A recent UNICEF initiative has started to map and review some key indicators of progress in adopting and scaling up the approach10. The review found that 55 countries had made inroads into adopting the approach. In 52 of these countries, CMAM guidelines were in place, indicating institutional endorsement. In 34 countries, CMAM was included in national nutrition policy. The review also described the variable progress that countries were making to integrate CMAM into regular primary health care activities such as in the areas of Integrated Management of Childhood Illness (IMCI), Infant and Young Child Feeding (IYCF), HIV/AIDS and the challenges being faced at country level.
The UNICEF mapping review estimated that over 1 million children were admitted for treatment of SAM using the CMAM approach in 2009 and that the majority of these children were in Africa. The scale-up of CMAM programming in developing countries is continuing at a rapid pace across the world, particularly in Africa and Asia, and has government and multi-donor support. According to the UNICEF review, a further seven countries (Cambodia, Laos, Vietnam, India, Iraq, Mongolia, South Africa) were planning to introduce the approach in 2011.
In summary, we now have a globally recognised CMAM approach which many countries are implementing and at various stages of scaling up. The impetus for scaling up CMAM for the management of SAM12 lies largely within the health sector and with community structures and systems. The aim of national scaling up is therefore to achieve national coverage of a sustained, quality service provided as an integral part of the health system and with a strong community base. The management of SAM in this way will contribute to achieving national impact on mortality and ultimately MDG 4.
A note on terminology
The term ‘CMAM scale-up’ is often conjoined with the term ‘integration’ on the basis that scale up is not possible without some level of integration. However, the term ‘integration’ is not always clearly understood. A working definition that was agreed at the conference11 has four key elements, as follows:
- [Treatment of] SAM and MAM are integral parts of CMAM
- CMAM is one of the basic health services to which a child has access, delivered by the same means by which other services are delivered.
- This is embedded as part of a broader set of nutrition activities (IYCF, stunting, micronutrients etc).
- This, in turn, is integrated within a multisectoral approach to tackle the determinants of undernutrition.
CMAM may take different shapes and forms at national level. Different names and acronyms are used to describe the same or similar approaches.
Getting CMAM onto the national agenda
Young girl and her grandmother at Kaedi hospital, Mauritania
In terms of getting CMAM onto national agendas, a key enabling factor in many countries has been the onset of major or periodic emergencies. Emergencies highlight the issue of SAM and provide the context (availability of partners and resources and willingness to operate outside the norm) in which CMAM can be introduced and demonstrated to work at limited scale. A good example comes from Pakistan where CMAM was scaled up in the wake of the 2010 floods. There is a danger that CMAM introduced in this way can lead to a lack of ownership by local authorities and unsustainable models of implementation which are later difficult to transition. However, there are good examples where this has not been the case. CMAM scale up has been rapid, particularly over the past five years in many diverse country contexts and often after emergencies (See Box 1 for some examples, more details are provided in the field articles). If agencies approach CMAM with a sufficient degree of engagement and consultation, governments are able to take greater ownership of CMAM and bring in other stakeholders to support national capacity development.
Box 1: Country examples of the speed of CMAM scale-up
Malawi: From 2 district pilot (all facilities in those districts implementing outpatient care) 2002/3 to all 28 districts implementing the programme in 2011, in a total of 70% of all health facilities.
Ethiopia: From first pilot in 2001 slow expansion, then from 2008 rapid expansion. Currently 8,000 sites offering CMAM services, outpatient care in 49% of health posts and in 48% of health centres with 82% recovery.
Kenya: Ministry-led programmes implemented in three of the most affected provinces of the arid & semi-arid lands. From 2009 to 2011, the proportion of health facilities offering CMAM services has increased from 50% to 83%. Caseloads in the urban programme have steadily doubled each year from an initial 1,600 in 2008 to 4,700 in 2010, whist maintaining quality within sphere standards for recovery and death rates.
Ghana: From initial MOH pilot in April 2008 (one district in each of two regions, in each district one inpatient and 2-5 outpatient sites) to all 19 health centres within the two districts by March 2009. Sierra Leone: From initial MOH pilot of 20 outpatient and three inpatient sites in 2007, to 245 outpatient (20% of all primary health units) and 19 inpatient sites (at least one per district) in 2011.
Mozambique: Initial slow expansion then quicker once new guideline endorsed in 2010. By 2011, 229 out of 1,280 health facilities are implementing outpatient care, however in some this is only as a phase 2 treatment according to CMAM protocols.
Somalia: From 30 OTPs in 2006 to 935 in 2011.
Niger: Initiation of CMAM in 2005. Inpatient care for SAM with complications in all 50 national, regional and district hospitals. Outpatient care in 772 out of 800 health centres by 2011.
Beyond the emergency, factors that can facilitate CMAM being brought onto the national agenda as a service within the routine health system are: 1) advocacy and support from a key agency at national level (particularly for the provision of supplies), 2) discussions between international or regional CMAM experts, national nutrition experts and government officials in order to help demonstrate the burden of SAM in the country, its implications, and build understanding of the approach through debate on the technical protocols, and 3) implementation of pilots at limited scale to visibly show the striking results that can be realised in terms of recovery and coverage and to inform the adaptation of the approach to the country context. This last factor has been a key driver in many countries (See Box 2). National or local experiences of piloting CMAM implementation carry considerable weight when it comes to adopting the approach nationally and seem to carry more weight than global endorsements.
Box 2: Influence of national pilots in Ethiopia on national ‘buy in’ to scale up CMAM
Ethiopia’s experience was initially led by the onset of an emergency and by advocacy efforts by international experts and NGOs. CMAM was first implemented out of the necessity to try something new during the 2001 emergency in the south of the country. High mortality rates experienced in large therapeutic feeding centres run in previous emergencies meant that local officials were not prepared to allow agencies to run these types of programmes again. After agreements with government officials at district and regional level were obtained by an NGO (Concern) and despite no global endorsement for the approach, outpatient care was piloted that year.
This introduction - of what was then a radical new approach - was facilitated by the decentralised structure of the health system in Ethiopia whereby a certain degree of autonomy for decision making is held at regional level. The positive initial experience was followed by pilot and operational research CMAM programmes beginning in 2003. Though these pilots were NGO supported, they were carried out with close collaboration of regional and district health authorities and implemented by MoH staff at facilities with NGO support.
Once the pilot experiences were shared both within the country at a national workshop and internationally, it was regional health bureaus that took the lead in pushing the CMAM agenda forward, continually bringing it onto the national agenda with the support of the NGOs. UN agencies also took up support at national level in 2004 for the integration of the approach into the health system. In 2008, the MoH drove forward the further scale-up and decentralisation of CMAM. This came in response to dramatic and rapid increases in the number of SAM cases in two emergency affected regions. This led government to call on UNICEF to support the roll out of the approach as part of the health extension package, initially to 1,239 and now to over 6,400 health posts nationally.
In most case study countries, getting CMAM onto policy agendas has been facilitated by having a central technical working group, or an existing government unit with wide buy in from nutrition actors, speaking with one voice to advocate for CMAM. The level of influence of this group can be defined by the existing position of nutrition at the national level and therefore the level at which discussions about CMAM take place.
Though being firmly rooted in the health sector facilitates the uptake of the CMAM approach by all health staff, it can also limit the uptake of critical crosssectoral aspects, particularly for community mobilisation.
Where nutrition institutionally cuts across sectors, the benefits can be twofold. Firstly it can facilitate crosssectoral work, and secondly by having a profile and decision making apparatus above and beyond health, there is the potential to mobilise greater political will for nutrition initiatives and as a result increase resource allocation.
Finally, a new framework for engagement between local authorities and nutrition partners, addressing the necessity for scale up and down in response to periodic emergencies and based on capacities to respond rather than SAM cut-off points, shows promise for guarding against unsustainable approaches to implementing CMAM13.
Integrating CMAM into existing policy frameworks and national development plans
When it comes to the integration of CMAM into existing policies and plans, the need to reflect CMAM in a national overarching health policy is paramount if scaleup of the delivery of treatment through national health structures is to be properly supported and resourced. CMAM is not, and must not be presented as nor implemented as, a vertical programme but as an integral part of health and nutrition packages.
In most countries, there has been no clear plan for CMAM scale-up (with geographical and coverage targets, costing, support needs, training strategy, etc.). In some respects that has been one of the features of the approach, i.e. that its uptake is organic and demand driven rather than prescribed ‘from above’. The lack of long term funding has played a key role in limiting the ability to plan CMAM and there is the risk that without plans, demand can exceed supply, resources can be wasted and quality can be compromised.
The lack of good costing and cost effectiveness data has also impinged on countries’ ability to come up with national scale-up plans, or even to integrate CMAM into existing operational plans. This gap is now being filled with an increasing number of cost effectiveness studies finding similar results and offering the potential for CMAM to be reflected in decision making tools and plans (see Box 3). These studies find CMAM to have a similar cost-effectiveness ratio to other priority child health interventions and to be ‘highly cost-effective”’ as defined by WHO14.
Box 3: Cost effectiveness of CMAM
A recent study15 assessed the cost effectiveness of CMAM to prevent deaths due to SAM in children under five using data from a rural district in Malawi in 2007. The method compared the cost of providing CMAM compared to the alternative existing inpatient only approach. The incremental costs and effects (numbers of deaths) between the two options were combined to estimate an incremental cost-effectiveness ratio (ICER).
The results showed that the implementation of CMAM as an addition to the existing health services in the district produced a cost effectiveness ratio of $42 per Disability adjusted life year (DALY) averted. This figure is very close to the findings of similar analyses carried out for an urban CMAM programme in Lusaka, Zambia ($41 per DALY)16 and a rural CMAM programme in Bangladesh ($26 per DALY)17.
WHO categorises interventions as cost-effective if they cost less per DALY as a country’s gross domestic income per capita. Using this comparison, CMAM compares very favourably, for example the gross domestic income per capita for Zambia is $1,23018. These cost effectiveness figures are also within the general range of cost-effectiveness ratios estimated for other priority child health care interventions in low-income countries. These include measles vaccination ($29-$58), case management of pneumonia ($73)19, integrated management of childhood illness ($38), universal salt iodisation ($34-36), iron fortification ($66-70) and insecticide treated bed nets for malaria prevention ($11 for sub-Saharan Africa)20.
Extrapolation of these results must consider potential differences in context (i.e. SAM prevalence rates, population density and coverage) but authors suggest that the findings are relevant to a large number of settings where SAM is found. The figure of around $41/DALY averted has consequently been used by the World Bank for the inclusion of CMAM in their analysis of what scaling up nutrition will cost.21
Most countries have progressed with the development of national guidelines, a process that has served as a necessary step to building consensus and national ‘buy in’ for the approach, for adapting it to the country context and as a prerequisite for the reflection of CMAM in policy. Job aids, including agreed monitoring and reporting formats, supervision checklists and specific training materials are also identified as critical tools for capacity development. The development of national CMAM guidelines is an important step for building consensus and buy-in and for standardising the approach in the country.
Haile Gebrselassie, Ethiopian former Olympic Champion and world record holder, in address to conference delegates
CMAM’s place within the health system and nutrition programmes
How CMAM is structured within the health system and as a component of wider nutrition programming is important. Though this integration is widely believed to be advantageous in terms of efficient use of resources and increased coverage, country experience shows that how CMAM fits within existing structures and systems must be context specific. Whether CMAM is part of IMCI, whether it is delivered at health clinic or health post level, depends on the capacity of those programmes and structures. A great deal more learning is needed on a country by country basis about how to integrate CMAM into broader essential health and nutrition programmes.
The value of decentralisation of CMAM in bringing the service closer to the population is clear, yet progression to further decentralisation has to be balanced with the capacity of the health system and resources available to support lower level implementation.
Links to IYCF, growth monitoring programmes (GMP) or ‘child health weeks’ should be made, but this depends on the status and strength of those interventions in the country in question. Where complementary nutrition prevention and treatment interventions are in place, attempts can usefully be made to forge links both to widen opportunities for identification of children with SAM, to provide continuity of care and rehabilitation for children and ultimately, to forge links which address the underlying health determinants of acute malnutrition and thereby, prevent its occurrence. CMAM can help to bring these issues onto the agenda. Particularly effective links have been demonstrated between HIV/TB programming and CMAM and to a lesser extent between IYCF and CMAM.
Many countries implementing CMAM scale up also have some level of supplementary feeding programmes (SFPs) for the management of moderate acute malnutrition (MAM) in place. However, there is lack of clarity over whether a direct link between SFPs and CMAM is feasible or advisable in non-emergency contexts, and if so in which contexts. MAM treatment through supplementary feeding may not be a sustainable national strategy for many governments. There is therefore a need to explore alternative means to address MAM through inter-sectoral approaches and nutrition-sensitive programming. More evidence is therefore needed on effective mechanisms (including cost) to manage MAM other than traditional SFPs.
The need for clarity of roles and functions within the health delivery system and amongst support partners is clear from the case studies. A positive complementary collaboration between development partners with clear division of roles is identified as one of the important enabling factors for the scale-up of CMAM.
The case study evidence seems to indicate that a specific government unit/group supporting CMAM is not a prerequisite for scale-up but may add value in terms of quality assurance and standardisation. Such a group requires dedicated resources to function but can help to provide the continuity and predictability of support required for scale-up.
CMAM capacity strengthening
Attempts are being made to strengthen capacities for CMAM integration from health facility to district, sub-national and the national level in all countries. The key obstacle identified for scale-up is the inadequate capacity of health systems at all levels and across all elements (service delivery, workforce, health information systems, access to essential medicines, health financing and leadership and governance). Specific challenges for CMAM include numbers of staff, their competencies, and motivation of and over-reliance on volunteers. Furthermore, the long term commitment required for capacity strengthening for systems and structures is widely identified as a significant challenge with short term funding modalities.
Key NGOs are increasingly being called on to be responsive to government rather than donor agendas and to focus on capacity strengthening. This requires a shift both on the part of NGOs, away from pursuing the more readily available short term emergency funding whenever it comes along, and on the part of donors, to make available more appropriate longer term funding channels for CMAM.
Experience shows that with proper planning, integration can allow more staff to be trained. Integrating trainings, i.e. CMAM with IYCF or understanding and identification of SAM within the full training package for community health workers is a way of managing training resources more efficiently and minimising time spent away from service. An additional common assertion is the need to focus additional training on management of CMAM (planning, logistics and supply chain management, monitoring, supervising and reporting) with district health teams.
Where high health staff turnover is an issue, the training of all staff in facilities and focus on building capacity of the district health team has allowed sufficient capacity to be built up in order for new staff to be mentored on the CMAM protocols from within. This reduces the burden on national trainers and builds ownership at local level. Integration of CMAM into pre-service training is also held up as preferable in all cases, though progress on this has only been made in a few countries so far.
In general, a combination of classroom training by experienced trainers, followed by close practical on the job mentoring and learning visits where health workers support each other, is the most effective way to maintain the quality of training, help trainees to retain skills and minimise time out of the facility (See Box 4). In order to facilitate reliable and predictable CMAM capacity, there is a need to locate CMAM in a variety of pre-service training curricula at national level. All CMAM actors should actively disseminate good practices, tools, materials, training programmes and other relevant resources directly to governments and, where feasible, governments and development partners should facilitate cross-country learning and networking.
Box 4: Country examples of capacity strengthening
In Mauritania*, Burkina Faso*, Niger, Somalia, Mozambique and Pakistan, the difficulties of ensuring quality and experienced trainers as the training of trainers (TOT) cascades down has led to demonstrated dilution in the quality of training and resulted in a shift in approach.
In Niger, large numbers of trainers were trained using the TOT approach leading to good ownership of CMAM by the government. However, the lack of practical and training skills of the trainers, and lack of oversight by the more experienced national technical team, led to questions of quality. Systematic on the job follow-up and supportive supervision was identified as a means to rectify the situation, however, it was recognised that the existing pool of trainers did not have sufficient skills and experience to do this. This is gradually being addressed through additional inputs by the expert technical team working with existing trainers and carrying out follow-up. In Mozambique, the close follow-up of service delivery required after trainings has been identified as a potential role for NGOs.
In Somalia, it was quickly recognised that the TOT led to the wrong people being trained and skills not being passed down. Providing on the job mentoring was, however, a challenge in the Somalia context given the access issues. To address this, a system of international partners mentoring local partners who would then conduct the follow-up on the ground was instituted. This system aims to help local implementing partners not only to better support CMAM on the ground but also to improve their technical capacity in nutrition, as well as their skills in project cycle management, proposal writing and reporting. The system is reported to be working successfully, e.g. Action Contre la Faim (ACF) acting as a training centre for local organisations and Oxfam NOVIB partnering with a local NGO for capacity building.
Other countries (Malawi, Kenya, Ghana, Ethiopia, Sierra Leone) recognised the inadequacy of TOT for CMAM from the outset and used a combination of classroom training by experienced trainers followed by close on the job mentoring. In Malawi, a national training team (39 people) comprises experienced members from District Health Offices where CMAM has been implemented successfully and NGO partners. In Ethiopia, additional UNICEF staff were recruited to support sub-national trainings and particularly to support follow-up to the training. In Kenya, for the urban and 22 ASAL (arid and semiarid) districts, programme TOT was combined with practical training at health facilities. District health teams were supported by experienced trainers to provide training for their own staff. On the job support followed, which was scaled down based on each facility’s ability to implement the protocols. Lessons were that on the job support was essential for the retention of skills and continuity of scale-up. They also found that, as the majority of training was on the job, staff were not taken out of facilities. This experience also illustrated that with proper planning, this method actually allowed more staff to be trained than the traditional TOT approach.
*Source: FANTA, 2010. Review of Community-Based Management of Acute Malnutrition Implementation in West Africa, Summary Report (2011). Burkina Faso, Mali, Mauritania, and Niger. http://www.fantaproject.org/publications
Different countries have responded in different ways to capacity constraints. For example, by placing additional nutrition staff at district and regional levels, experimenting with mobile teams and mobilising existing support staff to be involved in the CMAM service. The most appropriate solutions will be context specific. A common conclusion is that the need for assessment of existing capacities and gaps to identify where additional resources are most urgently required would help address gaps more efficiently.
Strengthening the role of the community
There has been a lack of attention to the community component of CMAM which is attributed to insufficient understanding of the importance of this element of programming, lack of funds, insufficient expertise, concerns about overburdening the system and lack of leadership in that area. Who to involve in CMAM and how cannot be prescribed, although conducting investigation of potential community agents and channels, sensitising them about the programme and eliciting their involvement in elements such as case finding are critical steps in CMAM implementation and sustainability. CMAM without a strong community base is limited in its coverage and impact, and therefore strategic advocacy for incorporation of this element of CMAM in wider policies will be required in order to reflect the comprehensive approach.
The existence of community level health workers can greatly influence the progression of CMAM by providing an instant delivery mechanism for mobilisation, screening and, in some cases, treatment for uncomplicated SAM. However they are not a prerequisite. There is experience of using volunteers and key community figures effectively for mobilisation. These modalities are not without their challenges, particularly in the area of incentives, and a balance must be struck between motivation, the amount of work that is required of volunteers and the geographical areas they are expected to cover.
The implications of not focusing on the community mobilisation component of the CMAM approach (community sensitisation, screening, referral and followup mechanisms) have been experienced in a majority of the case study countries and reflected in poor coverage. However, increasingly and with the help of coverage assessments to identify the problem and the barriers to access, this lesson is being learned. The importance of routinely implementing coverage assessments and of building national capacity to do so is consequently also emphasised. The community-level component of CMAM can be sustained by governments through existing largescale programmes with a community element (e.g. primary health-care services) and a national community mobilisation strategy, cutting across sectors, would support scale-up of CMAM, other nutrition programmes and other basic services.
Supervision, monitoring and coverage
Anganwadi worker with children in Anganwadi centre in India
With the exception of coverage, most country programmes are reaching internationally-agreed programme performance targets. Supervision and monitoring for CMAM is a common challenge for the majority of countries. However, some positive experiences have been joint supervision with support partners, third party monitoring and triangulation of information through community level informants. Simplification of monitoring formats (currently often overcomplicated and rarely analysed or acted upon) and clear systems for analyses, action and feedback are required. These issues and the timeliness of reporting may be partly addressed by methods currently being piloted using rapid SMS technology. Once monitoring has been simplified, it may be possible to include some aspects at least into national health management information systems (HMIS). This process has begun in a minority of countries.
For monitoring the performance of CMAM in any context, Sphere indicators are still the main markers used (at least for recovery, default, death and coverage). There have been questions raised as to their appropriateness in the non-emergency context. However, well run national programmes are achieving results within these standards for recovery, default and death. This is not the case for coverage and as new assessment methods become increasingly applied to assess coverage at national level, we are gaining information about the kind of coverage that is possible over time.
The HMIS is critical in the flow of management information through all levels. CMAM needs to be incorporated but until then, governments and partners may need to run parallel information systems or include a simple set of indicators in the existing system.
Impressive scale-up has been achieved in a number of countries, at its most successful reaching implementation in up to 70-90% of health facilities. Where CMAM is perhaps set apart from other interventions is that, embedded in the approach, is the fact that unless there is quality implementation (including the community component), true coverage22 is not achievable. The challenge for countries therefore has been to reconcile the push for geographical coverage with that of achieving ‘true’ coverage of the population in need. This has proven to be more achievable using a phased approach, with expansion based on demonstrated quality of service and availability of resources (human and material).
Measures to assess and act upon poor coverage have then been added so that, within areas where the service is up and running, coverage of the population in need can be gradually increased. This approach has, in some cases, been undermined by agencies trying to implement too much too soon, rushing to increase geographical coverage, or to programme supplies without checks for quality or building of sufficient local capacities. The results are compromised service quality and poor coverage, undermining the critical effectiveness of the programme and the motivation of communities. This challenge has been partly attributed to short term funding and has been identified frequently in numerous countries.
The drive to achieve geographical/facility coverage is common to the scale-up of all interventions but it must be balanced with the maintenance of programme quality, including coverage of all those in need.
CMAM and the provision of RUTF
Given the finances required to provide sufficient RUTF to cure a child of SAM (approximately $50-60), it is clear that major RUTF benefactors are required to get CMAM off the ground. Emergency resources have provided these funds in many cases and in other contexts, external agencies are covering the costs.
Pipeline breaks are common. A minority of these are attributed to shortage in global supplies and issues of customs clearance. However the majority are a result of insufficient buffer stocks and poor forecasting related to late reporting, late communication of requests, and insufficient planning to take account of increases in caseload. Increments in caseload may happen due to expansion, intensification of mobilisation activities or the use of RUTF for other target groups, e.g. children with MAM.
These issues are reported even in instances where parallel delivery systems supported by UN agencies and NGOs are being implemented. The registering of RUTF as an essential supply/commodity has facilitated easier integration into the national supply chain in some countries. However it is clear that considerable supply chain support is needed if supplies are to be delivered through government mechanisms (see Box 5).
Box 5: Ethiopia RUTF supply chain experience
As the weight and volume of RUTF is much greater than the usual medicinal commodities which go through PHARMID23, the decision was made for UNICEF to work directly with regional and zonal health bureaus to deliver directly to them. NGOs would support delivery down to facility level.
Regional Health Bureaus (RHBs) submit requests based on monthly caseloads that are reported to them by technical CMAM focal points at district level. These same focal points are responsible for RUTF distribution. Unfortunately requests are often limited by storage capacity. Currently, plans are in place to enter RUTF supply into the national Integrated Pharmaceutical and Logistics system (IPLS). However this will be a gradual process as the capacity of that system for RUTF is built.
The Food by Prescription programme (FBP) in Ethiopia has already managed to integrate RUTF into IPLS for a limited number of sites, at health centre and hospital levels. Requests are based on numbers treated over two month periods and a minimum two month and maximum four month buffer stock is held at each facility depending on storage capacity. There is also an emergency refill mechanism in place. Monitoring at facility level is supported by an NGO (Save the Children US) and when RUTF arrives at the facility it enters the pharmacy system and is distributed based on prescrip- tions received by patients. The NGO carried out logistics training for pharmacy staff in all the FBP facilities. It is felt that IPLS is a strong management system and avoids serious misuse of the product.
Forecasting mistakes have been made as a result of using calculations based on population, SAM prevalence and estimated coverage, all of which are fraught with inaccuracies. Forecasting of district/ sub-national/ national requirement based on consumption makes more sense but improvements to the accuracy and timeliness of reporting are required for this to be reliable. Extrapolation is also required where reports are missing, or to take account of expansion plans and any predicted surges in prevalence. The inclusion of stock reporting into CMAM admissions reports, designated minimum stock levels defined on a facility basis, and the use of rapid SMS for RUTF stock reporting and requests have produced positive results.
By producing RUTF closer to home, the transit times for receiving RUTF are dramatically cut, thus alleviating some of the pressure on accurate forecasting. Additional benefits of local production are the potential for cost reductions (mostly due to decrease in transport costs), and most importantly, the support for local industry and farmers.
Another key consideration is the patent held by Nutriset/IRD49 for the production of RUTF (and related products) in many countries. A patent user agreement with Nutriset/IRD50 must be established for production in those countries where the Nutriset/ IRD has registered a common patent agreement24. There are no restrictions in countries where Nutriset/IRD have not registered patents. Though this agreement provides access to technical support to the producer to set up production and quality control mechanisms, it is an additional hurdle in establishing local production, with restrictions in countries where an exclusive patent exists (Niger and Mozambique25). There is also a ‘price’ as in return for this Agreement, the IRD invites the beneficiaries to make a 1% contribution of the turnover earned by the sale of the products covered by the Usage Agreement, in order to support and fund IRD’s research and development actions.
In many countries, local production of RUTF is believed to be the most appropriate complement, if not replacement, to global supplies. In addition to the patent, two main limiting factors restricting the setting up of local production have been the sourcing and cost of ingredients (particularly sourcing of quality peanuts and the costs of milk powder) and the quality control measures required to ensure an absolutely safe product is supplied.
An accreditation process developed by UNICEF in collaboration with Médecins Sans Frontières (MSF) and the Clinton Health Access Initiative (CHAI) to ensure quality of the product has particularly stringent criteria for aflatoxin, commonly found in peanuts. Though this criterion has delayed accreditation of production in some cases and added to lead times, it is clear that a balance must be struck between the desire for local production and the need for a safe quality product.
A child eating RUTF in Malawi
Governments need to develop a clear policy on local production of RUTF, which can lead to new partnerships, tax-dispensations and other cost-reducing measures.
The quest for quality peanuts has led some local producers to form closer public private partnerships with NGOs and farmers in order to improve farming and storage practices and guarantee markets for product. These initiatives, which depend on producers being able to buy peanuts in bulk at certain times of the year, require capital and finding investors is a current challenge for local producers.
The evolution of the CMAM approach has been evidence based, whereby protocols are tested operationally at limited scale, with rigorous monitoring in place to assess effectiveness. This strong background to the approach and a culture of transparently disseminating results both internationally and through national learning forums is reported to be a key enabling factor and has undoubtedly contributed to its success. Continuation of this culture, reaching into the development of new coverage assessment methodologies, testing of new RUTF formulations, operational piloting of innovative methods to strengthen referrals, monitoring and supervision or for testing new modalities for the management of MAM, is important if the integrity of the approach is to be maintained.
Generating sustained political commitment around CMAM
As with all forms of undernutrition, the effective implementation and scaling up of CMAM requires decisive and continuous government commitment. The presence of emergencies creates a strong but short lived impact to boost CMAM, even when countries lack the capacity to intervene themselves. In the long run, however, political commitment is key to ensure programme coordination between government and donor agencies, to guarantee effective implementation and coordination across all government tiers and to devise and sustain transparent and effective funding schemes. The executive can play a critical role in embedding local level CMAM within national poverty reduction and development goals.
Political leadership and government coordination is decisive in ensuring the long-term success of CMAM scale up. The executive can play a strategic role in enhancing the importance of CMAM in the national development agenda, in strengthening the mandate of the MoH and in ensuring the continued and coordinated financing of such programmes from government or donor contributions (see Box 6 for a Malawi example). The case study experiences suggests that the executive has played a key role in placing nutrition high onto the national agenda of case study countries but this did not always include the treatment of SAM.
Box 6: Positioning of Nutrition in Malawi
In Malawi, policy direction and resource mobilisation for nutrition falls under the Office of the President and Cabinet (OPC). A nutrition committee chaired by the OPC hosts technical working groups for different nutrition areas. The implementation of nutrition policies sits under the MoH, i.e. the MoH is responsible for the operational plans for implementing CMAM within the essential health package including placing a line item in budgets of district implementation plans for CMAM. This allows MoH to focus on implementation while the policy environment is strengthened by being at a higher level. Similarly the recognition of nutrition as cross cutting, including plans in Malawi to have a nutritionist in every ministry, can help to bring nutrition issues firmly onto the agenda in multiple ministries and facilitate cross-sectoral collaboration.
Longer term development programming requires CMAM to be approached as part of a wider government nutrition strategy involving broader coordination across different government sectors (health, nutrition, education, social development, agriculture), with donors, local level actors and service providers to tackle the basic and underlying causes of all forms of undernutrition, including SAM. The Executive has a pivotal role in facilitating inter-sectoral coordination within government and with external stakeholders and improving the sustainability and quality of CMAM programming.
Where CMAM programming is isolated and separate from national level priorities or governments lack the capacity to be more directly involved with the efforts of external agencies implementing CMAM, there is a strong likelihood that programming will remain dependent on the (uncertain) availability of emergency funding. This in turn will undermine long term planning and prospects of CMAM scale up. In situations where government priorities are not set out, international actors need to facilitate the articulation of government priorities/strategies and then align with these. Donors also need to increase efforts that bring about alignment of international actors (UN) with government strategies.
Effective decentralisation of CMAM
The effective decentralisation and implementation of CMAM at the local level is another key factor for successful scale up. Whilst it is important that the Executive remains involved in national level programming, it is also critical that the government strengthens the potential for programme ownership at the district level The extent to which CMAM can be effectively implemented at the district level depends, among other things, on the government’s existing degree of decentralisation, availability of expertise and human capacity at lower tiers of government and the availability of good quality data to identify target populations, risk areas and progress indicators. Leadership and authority for CMAM scale-up must be decentralised to the district level along with the necessary resources in support of decentralised plans.
CMAM implementation is especially enhanced when the MoH has an effective presence throughout all government levels or is already delivering other types of programmes through a decentralised structure. The review of country case studies highlighted that there are multiple drivers that can facilitate (and in some cases make up for the lack of) decentralisation structures, e.g. effective training and supervision, remuneration and career promotion schemes and reliable reporting. Total decentralisation, without a national framework and stewardship also carries risks (see Box 7).
Box 7: Decentralisation: pros and cons in Pakistan
With the devolution of the MoH in Pakistan (18th amendment), the sole responsibility of health and nutrition policy and planning now rests with the provinces. This development has brought a number of possibilities and concerns. On the plus side, it may empower lower levels of government by giving them more autonomy and enhance responsiveness and efficiency allowing quicker action where problems are identified. The devolution may also ensure greater equity within provinces. Concerns at the outset are around capacity (insufficient technical, human and financial resources to manage services well), emergency situations (such as how provinces will manage to coordinate a large response when national response has been challenging), inter-provincial problems, especially due to lack of routine health information collection, and lack of a provincial funding mechanisms. National level stewardship is needed to complement a decentralised approach.
As has been illustrated by studies on chronic malnutrition, a greater involvement of concerned and committed government officials and local elites can produce a more inclusive selection of beneficiaries, a more transparent use of resources, and greater community involvement. Local elites are in a privileged position to shape decision making at the local level and influence policy making at the national level. Effective CMAM implementation and scale up is likely to emerge where there is increased local ownership.
The provision of a continuous and predictable funding stream is a key requisite for ensuring sustained CMAM scale-up. Ensuring a continuous and transparent flow of funds for CMAM scale-up poses two challenges for implementing countries. The first is to shift away from short term emergency funding and the second is to move away from donor dependency in a way that governments are directly in charge of the allocation and management of CMAM funds.
Overcoming the first financial challenge requires long term development funded programmes rather than short term emergency funding windows. Donor support is currently important both for the provision of SAM treatment supplies, as well as the funding of related activities such as distribution of supplies and capacity strengthening. Whilst some donors are beginning to make available longer term funding arrangements for CMAM as part of a wider nutrition package, these mechanisms are currently only offered to UN agencies and international NGOs.
In order to promote consensus around a long term donor funding strategy, governments and donors would need to develop accurate funding estimates of CMAM interventions and expected outcomes. To date, there are few country specific cost benefit analyses of CMAM, and donors and partner agencies keep separate estimates for the funding of SAM treatments, nutrition therapeutic supplies, as well as additional support activities, supplies, distribution and capacity strengthening. Governments and donors will also need to agree scale up targets, the financial implications of such targets, the percentage of resources that can be provided by governments in the short term, and a progressive and realistic funding strategy by government that would see them taking increasing financial and accounting responsibility for funding the programme.
Volunteer Health Workers at the Sai training, Gokwe South in Zimbabwe
At present, governments and their partners develop short term proposals to get specific funding from donors for CMAM scale up. There is a need to convince donors that support for RUTF provision, for example, should become part of disaster risk reduction (DRR) and that efforts should be made to improve sustainability of RUTF provision, as well as enable better planning and integration of CMAM into health and other sectors. There is also a need for external partners to better align themselves with government priorities. International NGOs should not always capitalise on emergency funding windows when longer-term funding windows may serve the same end. Donors, for their part, need to re-evaluate the appropriateness of their current funding mechanisms for long-term scale up of CMAM. A conceptual shift in how treatment of SAM is to be approached and funded is needed so that the emphasis of external agencies, whether responding to emergencies or longer-term development needs, is to strengthen government capacity (including funding capacity) to at least be able to treat endemic levels of SAM in non-emergency years (see Box 8).
Box 8: Concern’s experience of applying thresholds to CMAM support in Uganda
Concern is supporting the MoH in the Karamoja region of Uganda to implement CMAM. Support is focused on capacity development of the district health teams to manage the programme and on the process of integrating CMAM within existing supervision, monitoring, reporting and supply systems. Concern has employed a flexible system designed to provide minimal, adequate additional staff and resource support from Concern on an as-needed basis to MoH health facilities during times when SAM levels spike beyond existing MoH capacity to manage.
Concern and the district health teams have worked together to define the maximum numbers of SAM cases that each facility is able to deal with on a weekly basis. Gaps in clinical capacity and resources at each participating facility should these thresholds be exceeded have also been identified. This has allowed support needs to be outlined and agreement to be reached as to the stage at which this additional support can be withdrawn. Concern, the district health teams and the participating health facilities have signed agreements outlining roles and responsibilities of each party in the event that Concern is called upon to implement this emergency response system. For example when agreed thresholds are exceeded, Concern provides additional clinical staff and supplies to participating facilities as agreed. Where access to existing facilities proves problematic for patients, Concern is prepared to open additional outreach clinics on a temporary, asneeded basis. Concern is also prepared to provide temporary, as-needed staff to support mobilisation efforts, management of facilities, HMIS and logistics systems. (Source: Concern Uganda Project Report)
Governments need to present clear costing of CMAM, demonstrate progressive financial commitment (for example, through earmarked government funds), and identify the elements of CMAM support that need further resources. In the event of emergencies, governments should be prepared with clear, costed plans for surge scale-up to meet increased demand. This can help to limit the loss of government ownership frequently seen in emergencies. Furthermore, donors and other cooperating partners (e.g. UN agencies and INGOs) need to better align their funding and implementation policies and strategies for CMAM with longer-term government nutrition and CMAM policies.
Filling RUTF jars in the RUTF factory In Mozambique
Overcoming the second challenge for scale-up requires moving away from donor dependency and incorporating funds into government budgets. The most expensive funding line is the provision of RUTF, a key component of CMAM treatment. Much of the challenge to enhance government ownership is to find alternative means for the production and funding of RUTF. In only one case study has the MoH started procurement of RUTF from its own budget to supplement external procurement (Malawi). In other cases, greater government ownership has been sought through health budgets, however, health budgets remain a small share of the governments’ overall budget, and most of these funds are destined to cover human resources (salaries).
The case studies illustrate the dramatic lack of consistent and comparable costing data across the board. At the macro level, it is difficult to gauge the magnitude of the required investment to significantly reduce SAM and MAM in a given period of time. Similarly, there are no comparable figures about CMAM coverage or rate of CMAM expansion per country. This lack of data is especially proble
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Reference this page
Jeremy Shoham and Marie McGrath (2012). From the editor. Field Exchange 43: Government experiences of CMAM scale up, July 2012. p1. www.ennonline.net/fex/43/fromtheeditor