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Community-based management of acute malnutrition (CMAM) Conference 2021

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Concern Worldwide and Irish Aid hosted a virtual conference on the community-based management of acute malnutrition (CMAM) in March 2021. The conference aimed to provide a forum for health and nutrition practitioners to exchange evidence and experiences in scaling up treatment services for wasting and nutritional oedema in fragile contexts and translate these into practical actions and advocacy. The conference was a mix of presentations on the ‘main stage’ and in smaller parallel sessions as well as daily panel discussions. Smaller working groups also met on the last day to identify practical considerations and priority actions to further refine and scale up several of the core CMAM adaptations and approaches (Box 1). These working groups have continued to shape short summary papers on each of the themes that will soon be available along with the main conference report.

All presentations and conference materials are available on the Concern website www.concern.net/CMAM2021 These include case studies summarising the experience of seven governments in scaling up wasting services as well as broader learning from South Asia. A report prepared by ENN in advance of the conference entitled ‘Scale-up of severe wasting management within the health system: a stakeholder perspective on current progress’ is also available at the same link.  

Box 1: Main adaptations and approaches to CMAM explored in the conference

Simplified approaches

  1. Family mid-upper-arm circumference (MUAC)
  2. Community health worker (CHW)-led treatment of wasting
  3. Simplified nutrition protocols (usually a combination of expanded admission criteria based on MUAC >125mm and oedema, the use of a single treatment product (ready-to-use therapeutic food (RUTF)) for severe and moderate wasting, using modified RUTF dosages based on MUAC not weight)

Other adaptations to improve delivery of wasting services

    4. Management of small and nutritionally at-risk infants under six months and their mothers (MAMI)
    5. CMAM Surge

Cross-cutting themes

    6. Integration of severe wasting services into health systems
    7. Management of moderate wasting services

Important themes highlighted during the conference were as follows:

Coverage still remains far too low. Twenty years ago, CMAM promised access, scale and coverage. Coverage has increased tenfold since CMAM was first introduced but much more still needs to be done to realise this promise. This must include revitalising the community aspect – putting the ‘C’ back in CMAM.

The cost of producing and delivering RUTF must be reduced. To do this, we need to invest in developing alternative formulas that achieve the same or similar outcomes with non-dairy formulations, support more localised production and unlock global competition.

More funding is needed for wasting treatment. We must explore innovative financing mechanisms, such as the Global Financing Facility, particularly to ensure the long-term financing of RUTF supply.

We must continue to simplify protocols and tools to improve access, increase coverage and reduce cost. We need to ensure quality and continuity of services but we must also ensure that the ‘perfect’ does not become the enemy of the ‘good’.

Wasting is a continuum from severe to moderate. There is an arbitrary, unhelpful divide between severe and moderate wasting. We need to improve the continuum of care for wasted children across this spectrum of severity and across age groups – starting from maternal malnutrition through to the management of small and nutritionally at-risk infants under six months through to children under five years of age.

Family MUAC and CMAM Surge are essentially ready to scale while other adaptations – particularly CHW-led treatment of wasting and simplified nutrition protocols – will require more testing, endorsement from the World Health Organization (WHO) and major increases in funding before governments can bring them to scale. The MAMI Care Pathway Package, an integrated, contextualised approach for managing small and nutritionally at risk infants under six months, is in the early phases of scale up with evidence growing and a formal trial planned in Ethiopia.1

The update of WHO guidelines on the prevention and treatment of wasting, expected at the end of 2021, is critical to enable scale-up by government. The guideline development process, currently underway, is expected to review evidence related to CHW-led treatment of wasting, simplified nutrition protocols and the management of small and nutritionally at-risk infants under six months of age.

Integration of services for severe wasting into health systems in all fragile contexts is essential and governments of these countries must play a central role. The Country Operational Road Maps being developed as part of the United Nations-led Global Action Plan on Child Wasting2 will inform the development of a Road Map for Action and offer an opportunity to plan strategies and funding to support this more fully.

Innovative approaches and funding to prevent and treat the large caseload of moderately wasted are critical.  Of the at least 30 million wasted children currently not covered by treatment services, the majority suffer from moderate wasting. These children will swiftly become more severely wasted and face even higher mortality risk.

A full conference report will be available by the end of May 2021. For more information, please contact Kate Golden at kate.golden@concern.net  Visit www.concern.net/CMAM2021

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Community-based management of acute malnutrition (CMAM) Conference 2021. Field Exchange 65, May 2021. p7. www.ennonline.net/fex/65/cmamconferencereport

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