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The state of global SAM management coverage 2012

A family in Niger who struggle to make ends meet; their youngest daughter is recurrently treated for severe acute malnutritionSummary of report1

Thanks to Saul Guerrero, ACF-UK, for preparing this article.

Location: Global

What we know: Geographical coverage and treatment coverage are needed to evaluate SAM management coverage. These can be directly or indirectly measured.

What this article adds: The 2012 Global SAM Management Update found improved reporting on geographical coverage (49 out of 60 countries) and most (86.6%) were able to report treatment coverage using indirect national estimates. Only 14 countries out of the 60 in 2012 were aiming for country-wide scale up. Indications are that indirect national estimates are overestimating achieved treatment coverage and give no indication of variation in coverage. Direct coverage surveys have advantages in this regard but limitations too. Other factors (barriers) influence SAM service update.

’The State of Global SAM Management Coverage 2012’, an annex to the Global SAM Management Update (see news piece), was produced jointly by UNICEF, ACF-UK and the Coverage Monitoring Network. 

To evaluate SAM management coverage, two distinct types of coverage are considered; geographical coverage2 and treatment coverage3. Geographical coverage aims to measure the availability of services for the treatment of SAM. The availability of services however does not equate with service access and uptake. In order to measure the accessibility and uptake of SAM management services, treatment coverage is used. SAM treatment coverage is defined as the proportion of children with SAM who receive therapeutic care. This information can be estimated either directly or indirectly. Direct coverage assessment methodologies to measure treatment coverage use a combination of qualitative and quantitative methodologies4.

Geographical coverage in 2012

Geographical coverage results by country are presented in Figure 1. The fact that the large majority of countries reported such data is a positive indication of improved reporting and understanding compared to 2011. Nevertheless, although a large majority of countries reported national level geographical coverage data, an improvement in reporting does not guarantee the representativeness and accuracy of such data.

Source: UNICEF Global SAM Update Database

Firstly, national averages provide little information on sub-national variations, which in countries with uneven or localised distribution of SAM prevents a more in depth understanding of whether services are in the right location to meet needs. Secondly, defining geographical coverage based on health care facilities has limitations in terms of providing a deeper understanding of the catchment area of these facilities (i.e. spatial distribution, number of households/individuals per facility/quality of health services and physical proximity).

Treatment coverage in 2012:

Source: UNICEF Global SAM Update Database

The representativeness of these indirect estimates are however problematic; indirect national estimates provide no information about the spatial distribution of coverage (high and low coverage areas) but instead offer an average estimate which may not be representative of any sub-national area.

Comparing indirect and direct treatment coverage

Discrepancies are evident between national level indirect estimates and sub-national direct estimates (provided by assessments compiled by the Coverage Monitoring Network) of treatment coverage. This suggests that indirect national estimates are overestimating the levels of treatment coverage which are being achieved. One of the challenges with the accuracy of indirect estimation lies with the calculation of the denominator (‘SAM burden’). This is due to: (1) often unavailable up-to-date census data to define the national under five population (2) Prevalence data not being based on seasonal changes and (3) the use of an average incidence correction factor. In addition, the global figures of cases admitted into SAM management services (the numerator) are derived from a range of information management systems which vary in quality and hence can be problematic.

In an effort to address some of the challenges from indirect methods, direct methods for estimating SAM coverage at the national and subnational level have been developed in recent years. Direct coverage surveys within the appropriate context provide a different lens to coverage estimation, being better suited to indicate coverage with more precision at a particular point in time than the indirect method. Nevertheless, there are also challenges around using these direct survey methodologies. Direct methods are commonly used at the sub-national level, but their use in estimating national SAM coverage remains limited. The limited use of direct estimations at a national level remains a significant barrier to gaining a reliable understanding of SAM coverage.

Assessing the bottlenecks

Availability of services (geographical coverage) does not equate with service access and uptake (treatment coverage). There are many other factors which positively and negatively influence uptake and success of SAM management. The data from sub-national coverage assessments compiled by the Coverage Monitoring Network provides some insight into barriers which influence attendance at SAM treatment services (Figure 3).

*Number of times mentioned, multiple assessments, 2003-2013


Strengthen routine SAM management data. Enhanced availability and quality of nutrition information is essential for a better understanding of needs (the burden of SAM) and to strengthen programming.

Review and consolidate the definition of geographical coverage. Two main revisions to this definition used in annual reporting should be reviewed and consolidated. Firstly, the way healthcare facilities are classified must be reviewed. Secondly, the current (facility-based) definition should be reviewed and expanded to capture the level of availability and equity of access.

Improving estimates of treatment coverage. A twin track approach is required to continue to strengthen understanding and estimation of coverage. Improved routine data will enable more accurate estimations around programme coverage and quality. At the same time, efforts must be made to refine and strengthen, promote, finance and support the use of adequate methodologies for direct treatment coverage estimation. In the short term, there should be efforts to strengthen the evidence base. In the mid-term, a technical and operational framework for supporting national coverage surveys needs to be developed. In the long term, there should be efforts to integrate SAM coverage estimation into national nutrition/health assessments.


Show footnotes

1Available at

2SAM geographical coverage definition =Health care facilities delivering treatment for SAM / Total number of health care facilities

3SAM treatment coverage definition = Admissions / Burden = Population 6-59m x [Prevalence + (Prevalence x 1.6)]

4For other key definitions, see ‘UNICEF global SAM manage ment update (2012)’ news piece in this issue of Field Exchange (47).

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Summary of report (). The state of global SAM management coverage 2012. Field Exchange 47, April 2014. p55.



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