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CMAM Surge: the way forward

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By Kate Golden and Sophie Whitney

Kate Golden is Senior Nutrition Adviser at Concern Worldwide. Her career started in Ethiopia in 2003 in one of the early pilots of community-based management of acute malnutrition. Since then, she has worked in South Sudan, Sudan and Lebanon and supported Concern nutrition programming and strategy development in roughly 20 countries across Africa and Asia as a global adviser.

Sophie Whitney is a Thematic Expert in Nutrition for the European Commission’s Humanitarian Aid and Civil Protection (DG ECHO). She has experience of over 20 years in the nutrition sector, on the field and at policy level, and with international non-governmental organisations and United Nations agencies prior to her current position. She is currently based in Nairobi and provides technical support to operations in Eastern and Southern Africa regions.

New capacity to support CMAM Surge learning and scale-up

To capitalise on the extensive learning from community-based management of acute malnutrition (CMAM) Surge implementation to date and on emerging opportunities to scale up the approach, sustained funding, technical expertise and strong coordination at local, country, regional and global level will be needed. Concern Worldwide (Concern), with support from Directorate-General for European Civil Protection and Humanitarian Aid Operations (DG ECHO) via the Enhancing Responses to Nutrition Emergencies (ERNE) programme, now has increased capacity to lead and coordinate implementation, adaptation and learning on CMAM Surge globally and to directly support its implementation in selected countries.1

Concern relaunched the Global CMAM Surge Technical Working Group (TWG) in late 2020 to provide strategic direction to this work. Members include representatives from non-governmental organisations (NGOs), United Nations (UN) agencies and the Kenyan Ministry of Health (MoH), and Concern is currently working to include more government health partners and health system strengthening actors. The aim of the TWG is to coordinate learning, promote best practice, identify opportunities for collaboration and support advocacy for the continued scale-up of the approach. The group will link closely with the West African CMAM Surge Task Force and other regional or country-level coordination mechanisms. 

Concern also now has a dedicated CMAM Surge Adviser situated within its global technical assistance team. The CMAM Surge Adviser, with input from the Global TWG, will work to build the capacity of partners implementing CMAM Surge, coordinate the operational research planned in the global learning agenda, including pilots of adaptations such as Health Surge, promote cross-country experience sharing, synthesise best practice and revise and expand the existing CMAM Surge guidance and tools. 

The most important work, however, will happen at country level as governments and other health and nutrition actors engage more with the approach and determine if and how it can help to strengthen quality health service delivery in their contexts. CMAM Surge implementation is expected to continue across the 12 countries currently implementing the approach and will expand to at least two more.2

What needs to be done

Coordinate learning and promotion of best practices via the Global CMAM Surge Technical Working Group (TWG)

The Global TWG will provide strategic oversight of a global learning agenda for CMAM Surge over the course of 2021 and 2022.3 Many adaptations and learning initiatives are already planned or underway across different countries. The aim of the learning agenda, which centres on five priority areas (see Box 1), is to bring coherence to those plans and coordinate tools, methods and sharing across initiatives. Concern’s global CMAM Surge Adviser will finalise and share the specific research questions, methods and timelines for learning agenda priorities in coordination with the TWG in early 2021. The learning agenda will remain a living document and Concern will regularly share updates on progress and changes via Concern’s CMAM Surge webpage and other channels. Work under some of the research questions is already planned and funded. For example, Concern will work in partnership with the Kenyan health authorities in Marsabit County to explore how CMAM Surge data can be used to initiate community level actions to better manage wasting. 

Concern will make updated tools, learning briefs and other CMAM Surge resources available via a dedicated website.4 Concern, in coordination with the TWG, will also fully update the existing global CMAM Surge guide by the end of 2021, likely with the addition of Health Surge tools and guidance, if the approach proves useful. Online workshops and exchanges on key topics will also be held and the Concern team is available to provide technical support to CMAM Surge implementers, with a particular focus on (but not exclusive to) Niger, Ethiopia, Sudan, Kenya, Pakistan, Chad and Democratic Republic of Congo where Concern is or will be implementing the approach.

Box 1: Key areas of the CMAM Surge global learning agenda

  1. Assessing the overall value of CMAM Surge
  2. Improving specific CMAM Surge steps (and guidance)
  3. Shifting from CMAM Surge to a more holistic Health Surge
  4. Integrating CMAM Surge into existing early warning/early action, outbreak response and the health system more generally
  5. Using CMAM Surge to strengthen community level action and coordination

Secure multi-year funding for CMAM Surge

Because the main advantages of CMAM Surge are expected to accrue over time, reliable, multi-year funding, ideally as part of broader support for health system strengthening initiatives, is needed. Usually, a minimum of one year – a full seasonal cycle – is required before the benefits of the approach become apparent. The DG-ECHO has been an early and continued champion of the CMAM Surge approach, promoting its uptake by endorsing CMAM Surge as a core approach to be funded in its annual Humanitarian Implementation Plans. DG-ECHO is now supporting Concern in CMAM Surge activities over three years in four countries via the ERNE programme. As a humanitarian donor, however, DG-ECHO typically focuses almost exclusively on emergency response, for which funding cycles are very short-term.

Greater engagement of development donors and actors, particularly within the health sector, to advocate more multi-year funding for CMAM Surge will be a key priority for the TWG and Concern. Other actors at global and country level should also advocate for this to help ensure that CMAM Surge is in place and functioning before an emergency strikes. Concern and the Global TWG will seek opportunities to pilot and document a partnership with development and humanitarian donors in a single country where development funds are used to support longer-term CMAM Surge set-up and monitoring and a humanitarian actor is poised to provide flexible and rapid funding when pre-agreed CMAM Surge thresholds are crossed to respond to a district- or region-wide emergency. This would be a very practical demonstration of cooperation across the humanitarian-development nexus but will require close coordination and an openness to new funding modalities by different actors.

Take time to build Ministry of Health (MoH) leadership of the approach and engage more with other health actors

To date, partner support for CMAM Surge has predominantly focused on the health facility and health district level with the exception, perhaps, of Kenya.5 This was appropriate during the early stages of trialling and adapting the approach. Now, however, with more experience behind us and as we look at the potential path to scaling up the approach, more structured engagement with higher levels of government within health systems is essential. More direct engagement with the UN agencies, NGOs, donors and other actors who support and fund broader health system strengthening initiatives will also be needed. Now is the time to bring more of the relevant national MoH departments and decision makers and other health actors into CMAM Surge design and planning processes to avoid CMAM Surge remaining a nutrition-centric approach. This is not a new lesson for the nutrition sector but a critical one. Hindsight around the experience of scaling up CMAM itself over the past 20 years underscores the importance of understanding and integrating into health systems from the outset. This will be a priority for Concern and the Global TWG in 2021.

Such meaningful partnerships will take time, however – another reason to pursue longer-term funding cycles. While many supporting partners are well positioned to deepen their MoH partnerships around CMAM Surge, government decision makers and managers will only embrace the approach if and when they are convinced of its added value. In almost all contexts, therefore, more in-depth analysis of existing health systems and a clearer articulation of how the CMAM Surge approach (and eventually the Health Surge approach) fits within health system strengthening efforts should be a critical next step. We will need to borrow heavily from existing health sector tools for this purpose. Concern has initiated a health facility capacity assessment in the nearly 200 health facilities where they are supporting CMAM Surge in four countries under the ERNE programme.6 This is just one example of the broader health system analysis tools that CMAM Surge practitioners will need and which Concern and the Global TWG will continue to collate and integrate into the CMAM Surge guidance and toolkit.

Further refine and pilot a more holistic Health Surge approach

There is significant momentum behind the shift to a more holistic Health Surge approach. This must be a joint endeavour of government and non-governmental health and nutrition actors. 7 As a first step, Concern’s health and nutrition teams, in coordination with the Global TWG, are drafting a set of simple Health Surge programming tools. The aim is to pilot these in a coordinated manner during 2021 in Kenya and Niger with support from Concern and in Mali with support from Save the Children International. The Global TWG and health practitioners will be engaged in the review, finalisation of tools and evaluation of the pilot experience.

Integrate CMAM Surge data into early warning/early action systems

CMAM Surge data can provide existing early warning/early actions systems with more dynamic, contextualised nutrition information than that which is traditionally used.8  More work is needed, however, to determine exactly how to integrate CMAM data into early warning/early action systems at country level, including both the early warning data systems and the mechanisms for triggering early action and rapid support/funding. Under the ERNE programme, Concern will trial ways to link CMAM Surge data to its vulnerability criteria for targeting and triggering timely cash transfers to communities and households. Concern will continue to work in partnership with government health teams in Kenya to refine sub-county and county CMAM Surge dashboards and explore how they can be better integrated into systems used by the National Drought Management Authority. The Global TWG will also actively engage with experts in early warning/early action to identify opportunities and strategies for better integration with CMAM Surge, focusing on up to three countries as case studies. Clearer guidance on how to assess existing early warning/early action systems and identify opportunities to link CMAM Surge data and support into them will be developed as part of the global CMAM Surge guide update by end of 2021. 

Be practical: putting CMAM Surge into context

As outlined above, CMAM Surge aims to support health system functions and complement health system strengthening activities. It is certainly not a panacea for all the weaknesses in the health system but it can be an important complement to ongoing initiatives in certain contexts. CMAM Surge likely adds the greatest value in contexts with regular fluctuations in caseloads by introducing simple steps and mechanisms to better manage nutrition and health services during peaks in demand. However, many secondary advantages have also been observed, including health worker empowerment and strengthened relationships between health facility teams, community agents and health district management teams. The Health Surge approach, still in its early development, also has potential to enhance the delivery of quality child health services throughout the year in similar contexts but more robust evaluation will be needed before expanding beyond the planned pilots.

Conclusion

CMAM Surge has garnered a remarkable level of interest and expansion since its inception in 2012. Its appeal lies in its relative simplicity, ability to harness local data and knowledge for more effective planning of health facility activities and focus on empowering health staff to better manage their own workload. The way forward from 2021 is fairly well charted in the global learning agenda and workplan that will be overseen by the Global TWG and in the scale-up plans at country level.9 Concern, with support from DG-ECHO, will strive to lead this process but, like the CMAM Surge approach itself, further development and scale-up will need to be adaptive and responsive to opportunities and challenges as they arise. Concern is ready and excited to work closely with government health teams and partners to support this process.

 

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Endnotes

1 The ERNE programme supports integrated nutrition and emergency response programming in DRC, Ethiopia, Niger, South Sudan and Sudan. https://www.concern.net/press-releases/concern-launches-major-eu-funded-programme-tackle-childhood-malnutrition

2 See field article in this special section of Field Exchange entitled “The ‘CMAM Surge’ approach: setting the scene”

3 See Global CMAM Surge TWG description and terms of reference at https://www.concern.net/insights/cmam-surge-approach 

4 currently at https://www.concern.net/insights/cmam-surge-approach - dedicated platform coming soon

5 See field article in this special section of Field Exchange entitled “Implementing the IMAM Surge approach – experiences from Kenya ”

6 The health facility assessment tool is based on the WHO’s Service Availability and Readiness Assessment manual https://www.who.int/healthinfo/systems/sara_introduction/en/  and is available from Concern upon request.

7 See field article in this special section of Field Exchange entitled “Expanding CMAM Surge beyond nutrition – towards a broader Health Surge approach”

8 See field article in this special section of Field Exchange entitled, “CMAM Surge: lessons learned on the journey so far”

9 See field article in this special section of Field Exchange entitled, “CMAM Surge: lessons learned on the journey so far”

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Kate Golden and Sophie Whitney (). CMAM Surge: the way forward. Field Exchange 64, January 2021. p47. www.ennonline.net/fex/64/cmamsurgewayforward

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