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The role of coordination in CMAM Surge scale-up in West and Central Francophone Africa

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By Diane Moyer, Amanda Yourchuck and Patricia Hoorelbeke

Diane Moyer is the current Regional Humanitarian Nutrition Advisor for Western and Central Africa for Save the Children International. She has over 10 years of field experience managing nutrition programmes in Asia and Western and Central Africa in both humanitarian and development contexts.

Amanda Yourchuck is an Emergency Nutrition Advisor for the United States Agency for International Development (USAID) Advancing Nutrition. She has over 10 years of experience supporting wasting treatment and prevention activities and was previously a Nutrition and Health Advisor with Concern Worldwide where she served as the technical focal point for global community-based management of acute malnutrition (CMAM) Surge activities.

Patricia Hoorelbeke is Head of the Directorate-General for the European Civil Protection and Humanitarian Aid Operation (DG-ECHO) office in Mali. Patricia is from a bio-engineering background and has worked in West and Central Africa since 1998 with experience working for Action Against Hunger as a country and regional director and UNICEF.

The authors acknowledge the support of the Directorate General for European Civil Protection and Humanitarian Aid Operations (DG ECHO) for the work described in this article.

The need for a responsive health system in West and Central Africa

In July 2020, it was anticipated that more than 15 million children in West and Central Africa (WCA) would become wasted over the course of the year.¹ All countries in the region have national community-based management of acute malnutrition (CMAM) protocols with countries continuing to scale up geographic coverage of CMAM services. Yet, in 2018, only an estimated 30% of children in need of treatment received it (Woodhead et al, 2019).

Nearly two decades of insecurity, marked by political instability and the emergence and spread of armed groups, alongside increasing climate vulnerability have only exacerbated the nutrition situation. The region has experienced several successive food crises with vulnerable households unable to sufficiently recover between shocks. Several WCA countries have been recently identified as ‘hotspots’ at risk of significant deterioration of the food security situation caused by the above drivers as well as the secondary effects of the COVID-19 pandemic (FAO & WFP, 2020). The persistently high levels of child wasting and unpredictable operating environment require that the region’s health systems be prepared to respond rapidly to changing needs.

Scale-up of CMAM Surge

The CMAM Surge approach was designed with many of the challenges facing WCA in mind – to build the capacity of health systems to trigger rapid responses to deteriorating nutrition situations. Niger was the first country to implement CMAM Surge in the region where Concern Worldwide (Concern) had been supporting CMAM service delivery in the Tahoua Region since 2005 beginning with direct service provision in response to a food security crisis. The focus later shifted to supporting the health system to integrate wasting treatment into the package of basic health services for children under five years of age. Following subsequent food crises in 2009 and 2011, the CMAM Surge approach was introduced in 2014 to better respond to recurring shocks. In 2016, several francophone regional trainings and consultations orientated a wider pool of stakeholders to the concept of CMAM Surge.

During this same period, the Directorate-General for European Civil Protection and Humanitarian Aid Operations (DG ECHO) prioritised finding better ways to respond to an increasingly volatile context and growing humanitarian needs in the West Africa region. The 2017 DG ECHO Humanitarian Implementation Plan (HIP) for West Africa included a specific focus on the development of national capacities to ensure an adequate level of preparedness. This included a focus on improved capacity for quality data collection and dissemination for early warning and early action and support for comprehensive and participatory risk assessments. For the nutrition sector, DG ECHO urged its partners to strengthen nationally and locally appropriate systems and strategies, responsive to seasonal trends and risks. DG ECHO specifically referred to the CMAM Surge approach in its Disaster Risk Reduction strategy as a means to strengthen local capacity to understand risks and design shock-responsive mechanisms that would allow continuity of quality essential treatment services in the face of surges in demand. As a result, several different partners included CMAM Surge in proposals to DG ECHO as part of their nutrition programmes in intervention areas in Niger, Mali, Burkina Faso and Mauritania.

Coordination mechanisms

Given the large number of DG ECHO partners implementing CMAM Surge in the region, the value of strong coordination mechanisms, both within countries and at regional level, was quickly recognised. This was particularly important given the newness of the CMAM Surge approach to most implementing partners. At regional level, a WCA CMAM Surge Taskforce was established in 2017. This group was led by Save the Children International (SCI) from the regional hub of Dakar in close collaboration with the Concern Worldwide Niger and headquarters teams. Members included non-governmental organisation (NGO) implementing partners, United Nations (UN) agencies and donors. The objective of this group was to convene CMAM Surge implementing partners on a monthly, and later quarterly, basis to support the sharing and harmonisation of good practices and tools and ensure a consistent understanding of the approach amongst all actors while driving the continued contextualisation and growth of the approach to meet the specific regional needs and challenges. Terms of reference for members and a workplan were developed that aimed to develop guidance and tools in response to the needs identified by its members. The Regional Taskforce also provided support to a regional CMAM Surge review workshop held in Niamey, Niger in September 2018 which many Taskforce member organisations and government staff representing country programmes from across the region and other francophone CMAM Surge implementing countries attended. This workshop allowed for in-person, cross-country exchanges about the experiences and challenges encountered when introducing CMAM Surge into a new operating context and for taking stock of regional experience to date.

Coordination was also required at country level where several DG ECHO partners were simultaneously working to scale up the approach in different regions and districts. This was particularly important in Niger and Mali, both of which had high numbers of implementing partners operating in each country. In Niger, coordination was initially fairly informal and organic. As the number of CMAM Surge implementing partners grew, the DG ECHO Nutrition Alliance, a forum that brings together DG ECHO’s nutrition partners in-country, was used to keep implementing partners informed of CMAM Surge activities. Coordination for the approach has since evolved into a more formal mechanism, embedded in the national nutrition technical working group. In Mali, a more purposive approach to coordination was taken from the beginning of scale-up. The following section shares the key enabling factors and challenges to coordination in Mali as the approach was rapidly scaled up by partners between 2017 and 2019.

Scale-up of CMAM Surge in Mali: A case study

The situation in Mali has become one of the most complex crises in the world with a population that faces growing humanitarian needs. Many regions experience a volatile security situation, leading to population displacement and additional strain on an already fragile health system that struggles with weak governance, lack of funding and trained human resources and frequent shortages of drugs and nutrition inputs. Regular seasonal outbreaks of malaria, acute respiratory infection (including pneumonia) and diarrhoea combined with chronic poverty, food insecurity and poor caring practices lead to surges of child wasting that increase burdens on already stretched health facilities. Mali continues to have one of the worst health situations in the world with child mortality exceeding 101 deaths per 1000 live births. Global acute malnutrition (GAM) rates commonly reach the serious and emergency thresholds, particularly in the northern part of the country (Figure 1).

Figure 1: GAM prevalence by region (SMART, 2019)

CMAM has been implemented in Mali since 2006 with the first national guidelines finalised in 2007. Early funding for CMAM in Mali was provided primarily by emergency donors which led many implementing partners to adopt an emergency-style implementation model that was often in parallel with other health services (Deconinck et al, 2010). Humanitarian and development actors have since advocated for and supported the better integration of wasting treatment within the basic package of services offered by the health system. The CMAM Surge approach was a natural next step to continue to support this integration process through a concerted health system strengthening approach and by specifically helping health facilities to better prepare for and respond to frequent shocks and stresses.

From pilot to scale-up

SCI implemented a CMAM Surge pilot project as part of its broader nutrition programme in the Mopti Region in 2017 with financial support from DG ECHO. Given this experience with the Mopti pilot, in 2018 SCI was given additional financial support by DG ECHO to coordinate and provide technical support to DG ECHO’s other implementing partners who were just initiating the CMAM Surge approach in their programme areas. This was done to strengthen their technical capacities for a smooth, harmonised scale-up of the approach.

Figure 2: Map showing implementation partners by region in Mali

Box 1: Mali CMAM Surge scale-up by numbers

Time period: 2017-2019

NGO implementing partners: 8

Districts: 17 across 6 regions (Kayes, Koulikoro, Ségou, Mopti, Tombouctou and Gao)

Government health staff trained: 591

Health facilities with Surge response plans: 238

Key implementation components

SCI put in place four key components that helped to facilitate the scale-up process as follows:

Set up of coordination mechanisms at multiple levels of the health system

Coordination mechanisms were put in place at multiple levels, each with clearly defined roles and responsibilities. A technical working group was first formed by SCI and other DG ECHO implementing partners to agree on ways of working, objectives and the sharing of lessons learned. As government capacity increased, this group evolved into a National Taskforce chaired by the Ministry of Health (MoH) CMAM Surge focal point and expanded to include participation from other relevant stakeholders such as the UNICEF. Through regular technical working group and subsequent National Taskforce meetings, good practices, challenges and recommendations were shared amongst actors.

Part of the process of setting up the implementing partner technical coordination mechanism was the signing of memoranda of understanding between DG ECHO’s NGO implementing partners. While this process took time and delayed the start of activities in the field, it was critical for ensuring clarity around roles and responsibilities, establishing consistent ways of working and enabling the cascading of coordination down to sub-regional and local levels when implementation began.  

Sub-regional and local level coordination mechanisms were set up by the implementing partners in their regions of operation and included participation from sub-regional MoH focal points. This was particularly important to ensure the smooth coordination and harmonisation of approaches in areas where more than one implementing partner was operating (Figure 2). The objective was also to share common costs across partners, particularly those of the trainings and stakeholder sensitisation activities that took place early on.

Focused joint capacity building

The capacity building component was essential to the success of scale-up and aimed to ensure that all stakeholders, both new implementing partners and local actors, had the same understanding of the approach and how to implement it. Special attention was given to the transfer of competencies to the MoH to support the future sustainability of the approach. A standard training of trainers (TOT) model was used with the first TOT involving national and regional level MoH actors with technical support from SCI and the Concern Worldwide Niger team.

The step phase of CMAM Surge training took place in two parts. Firstly, traditional classroom training was provided to identified health facility focal points. This was followed by on-site support from the trained CMAM Surge focal points at health facilities to implement the CMAM Surge set up steps. Halfway through the two-year scale-up period, a review was undertaken to improve the content and make it more appropriate for target trainees. More emphasis was placed on on-site training and coaching and learning by doing which was found to be more effective than the classroom-style multi-day trainings.

However, during the capacity building process, some implementing partners found they had not allocated adequate resources to build local capacity on CMAM Surge. Most implementing partners planned for one initial five-day training that only covered the setting of thresholds and Surge action plan development. Additional costs such as communication with stakeholders, validation of responses plans and follow-up support were not included in initial budgets. This meant that these activities had to take place at a smaller scale with SCI providing some support for key activities such as Surge action plan validation, pulling from resources allocated to their coordination resources.

Harmonised monitoring and evaluation

Monitoring and evaluation mechanisms were intentionally harmonised at several levels. All NGO partners, and therefore all implementation sites, used a common CMAM Surge supervision tool that was jointly developed by the implementing partners and validated by the MoH Nutrition Directorate. Supervision visits were also undertaken jointly between implementing partners and government actors and involved all partners working in the same operating area whenever possible. Quarterly workshops attended by both implementing partners and government focal points provided an opportunity to review processes, identify bottlenecks and share best practices. Shared monitoring and evaluation standards also helped to ensure that the scale-up was done to the same standard across regions according to the CMAM Surge Operational Guide. This common CMAM Surge monitoring framework was eventually adopted by the government as part of the national CMAM protocol.

A focus on accountability and government leadership

MoH focal points identified at each health system level (national, regional, local) were intended to ensure government leadership and ownership at all steps of the scale-up process. To ensure accountability across system levels, stakeholder meetings were held to disseminate information on progress and results, such as the number of health facilities implementing CMAM Surge or sharing experiences on the efficiency of a triggered Surge response. Dissemination activities took place via CMAM Surge-specific coordination mechanisms and other existing national platforms such as the Cadre Commun de Sante – a group of DG ECHO-funded implementing partners delivering emergency health interventions across the northern regions of Mali. Implementation updates were also shared through a ‘WhatsApp’ group which created friendly competition between local stakeholders seeking to highlight their achievements and an incentive for active participation, thus reinforcing local level accountability. The sharing of progress and positive results via these platforms helped to facilitate the adoption of the CMAM Surge approach by the government at the end of the initial scale-up period.

Due to implementation delays in some districts, less time was available to gain full government buy-in to the approach and coordination mechanisms before the start of implementation. Communication and sensitisation among regional and local stakeholders were done shortly before the start of facility-level implementation. This led to the perception that CMAM Surge was an NGO-led approach and created an expectation that the implementing partners would provide all the relevant inputs when Surge actions were triggered, rather than health facilities and districts first looking to their own internal capacities. While government leadership was still present in terms of buy-in and interest in the approach, government ownership in terms of financial or in-kind contributions to Surge responses was compromised.

Despite these challenges in some geographic areas, the interest of the local authorities that began during the initial 2017 pilot continued to grow during scale-up. The ongoing engagement of government at all levels throughout the pilot and scale-up process helped to facilitate ownership of the approach at the policy level. The government has since integrated the CMAM Surge approach within the national CMAM protocol and has formally adopted the joint supervision and monitoring tools developed as part of the coordinated scale-up process. As a next step, the leadership of the National Taskforce and regional bodies should be fully transitioned over to the MoH with implementing partners stepping back into a technical assistance role. This will require an increase in government ownership and a gradual shift towards national actors stepping into resource Surge actions.  

Momentum around the Surge approach continues to grow with UNICEF investing in a pilot of the Health Surge approach² which applies CMAM Surge principles and steps to a broader range of morbidities. This pilot will also be implemented with support from SCI beginning in 2021.

Regional lessons for scale-up

Three enablers of successful scale-up have been identified from the country and regional coordination experiences. Further opportunities to leverage or build from this experience are highlighted below.  

Donor leadership and engagement

DG ECHO’s interest in the CMAM Surge approach was the catalyst for scale-up in the region. As well as including CMAM Surge in its HIP, DG ECHO called for and directly invested in purposeful coordination to ensure that all partners worked together to develop adequate tools which was key to delivering coordinated quality action.  In addition, DG ECHO’s nutrition technical team actively engaged in the regional scale-up process, participating in the Regional Taskforce, undertaking field visits and engaging in CMAM Surge technical discussions with implementing partners.

However, despite DG ECHO’s active leadership and engagement in the scale-up process at the proposal stage, not all implementing partners had the necessary information and technical reference materials to fully understand the requirements of the approach in terms of the time commitment and resources required. At the time, there were very few publicly available technical resources – the CMAM Surge Operational Guide was available online and had been circulated to partners but it included limited information on planning for approach start-up and scale-up. It was difficult for some implementing partners to estimate the required human, financial and logistical resources for all the steps of the approach. In some instances, this led to inadequate planning of both time and resources, resulting in implementation delays and some steps not being adequately addressed. To avoid these issues in the future, donors could support their partners with more information about suggested approaches prior to the proposal development process and support them during the proposal review to ensure plans are achievable and budgets are sufficient. This could include generic budget and activity guidance and suggested performance indicators. More experienced partners could also be leveraged to support during the activity inception and start-up stages, as was done in Mali where Concern provided initial training to SCI staff at the start of their pilot project.

Including time to build a common understanding of the approach

Without a common understanding of the approach, scale-up may be inconsistent, leading to confusion among stakeholders and limiting success. When introducing a new approach such as CMAM Surge it is important to allow adequate time for sensitisation and the creation of a common vision for the approach at national and sub-national levels. This vision needs to be shared by government actors and across implementing partners. This process can take several months and must be allowed for in the implementation timeline. While this can be challenging when working under the short-term timeframes of emergency funding mechanisms, it is critical to establish expected ways of working, shared responsibilities and accountability mechanisms as part of the CMAM Surge start-up and scale-up processes.

The importance of a common understanding of the CMAM Surge approach at the regional and global level was identified early in the scale-up process and is what drove the creation of the regional CMAM Surge Taskforce. This was done to minimise the possibility of a fracturing of the CMAM Surge approach as less experienced actors sought to adapt the approach for their different operating contexts. While contextualisation is critical, it is important that all actors understand the core components of the approach before adjustments are made. Omission of key steps or their incorrect application could lead to inappropriate interventions that may affect sustainability or be damaging to the health system. The CMAM Surge Taskforce has played a key role in ensuring that the quality and integrity of the approach has been maintained across actors and contexts.

Importance of a clear, agreed accountability process

Common understanding builds a foundation for accountability. Stakeholders can then be held accountable to a set of common expectations and a shared understanding of roles and responsibilities. In the case of Mali, a formalised coordination framework and the signing of MOUs facilitated a faster, smoother and more harmonised scale-up. The formality of the process, including the engagement and interest of the donor in these partner discussions, also helped to ensure that commitments were taken seriously and adhered to. Through regular meetings, partners were able to share best practices, alert each other to bottlenecks and seek advice from their peers and thus generate an in-country community of practice. This regular engagement also brought to light challenges much earlier than may have happened if communication was limited to standard reporting timelines and processes, giving more flexibility to implementing partners as a group to think creatively in response to unexpected issues.

Next steps in the region

In 2017, only Niger and Mali were implementing CMAM Surge in the region with the support of Concern Worldwide and SCI. Today CMAM Surge is being implemented in an estimated 900 health facilities across 70 districts in six countries (Niger, Mali, Burkina Faso, Mauritania, Chad and Senegal) with ongoing scale-up in each.

There is a continuing need for coordination and collaboration among Surge actors in the region. DG ECHO has included Health Surge as a proposed activity in the region’s 2021 HIP. The growing stakeholder interest in the emerging Health Surge approach has led to a reinvigoration of the CMAM Surge Regional Taskforce which is guiding regional discussions in coordination with the CMAM Surge Global Technical Working Group around Health Surge to ensure stakeholders have a common understanding of how to pilot and expand this new version of CMAM Surge. Lessons learned from the rapid regional scale-up of CMAM Surge will need to be integrated into new Health Surge operational guidance that will also need to include details on if and when facilities that are currently implementing CMAM Surge should transition to the broader Health Surge approach.

Finally, for both CMAM Surge and the emerging Health Surge approach, there is a need to better communicate the long-term commitment to health systems strengthening that is integral to implementing Surge approaches. While the approach appeals to emergency donors and actors, given its aim is to improve response to shocks, the approach requires the time investment more commonly seen in development-focused activities. Both donors and implementing partners need to understand that CMAM Surge is a long-term investment in capacity and systems strengthening. This means that emergency donors should look at longer funding timelines for Surge efforts but also that development donors should integrate Surge into their long-term systems strengthening efforts. Surge approaches present an opportunity to bring emergency and development actors together to strengthen coordination within the humanitarian-development nexus and develop creative solutions to meet the unique and dynamic needs of shock-prone areas of protracted crises. Some shifts in funding timelines have been seen in the region with CMAM and Health Surge activities in Niger and Mali receiving multi-year funding to integrate the approaches into the health system.

Coordinated efforts between donors and their implementing partners will also better facilitate the eventual transition of Surge activities fully over to government. It is important to bear in mind that CMAM and Health  Surge operate within the spectrum of health systems strengthening; in some contexts implementing partners will need to play a substitution or support role while building system and government capacity to eventually take on more direct investment in the resourcing of Surge actions. Complementary support to sustainable financing, planning and appropriate revenue-generating mechanisms is required to enable the eventual transition of Surge and other health systems strengthening efforts fully over to governments.

The regional and global coordination mechanisms aim to continue documenting and disseminating learning as scale-up continues within WCA and globally. Moving forward, a more concerted effort will also be made to ensure coordination and sharing across regions via these mechanisms so that eastern and western African counterparts can learn from each other, as well as from colleagues implementing Surge in other parts of the world.

For more information, please contact Diane Moyer. 

Concern resources on CMAM Surge in French are available at https://www.concern.net/insights/cmam-surge-approach

 

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Deconinck, H., Paluku, B. and De Bernardo, D. Review of Community-Based Management of Acute Malnutrition Implementation in Mali, November 18–December 3, 2009. Washington, D.C.: Food and Nutrition Technical Assistance II Project (FANTA2), AED, 2010.

FAO and WFP. 2020. FAO-WFP early warning analysis of acute food insecurity hotspots: July 2020. Rome. https://doi.org/10.4060/cb0258en

Woodhead, S., Rio, D. and Zagre, N. (2019). Regional perspectives on simplified approaches for the management of children with acute malnutrition: West and Central Africa. Field Exchange issue 60, July 2019. p33. www.ennonline.net/fex/60/simplifiedapproachesinafrica

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Diane Moyer, Amanda Yourchuck and Patricia Hoorelbeke (). The role of coordination in CMAM Surge scale-up in West and Central Francophone Africa. Field Exchange 64, January 2021. p27. www.ennonline.net/fex/64/cmamsurgewestcentralafrica

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