Special focus on government experiences of CMAM scale up

ISSN 1743-5080 (print) July 2012 Issue 43

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From the Editor

Éditorial

Contents

Field Articles

15 CMAM rollout in Ethiopia: the ‘way in’ to scale up

nutrition

21 Effectiveness of public health systems to support national roll-out strategies in Ghana

27 Integrated Management of Acute Malnutrition (IMAM) scale up: Lessons from Somalia operations

39 Capacity development of the national health system for CMAM scale up in Sierra Leone

45 Community management of acute malnutrition in Mozambique

51 Management of acute malnutrition in Niger: a countrywide programme/Prise en charge de la malnutrition aiguë au Niger: Un programme national

67 Scaling up CMAM in the wake of 2010 floods in Pakistan

74 Creating an enabling policy environment for effective CMAM implementation in Malawi

78 Integrated management of acute malnutrition in Kenya including urban settings

85 Managing severe acute malnutrition in India: prospects and challenges

88 Postscript CMAM in India: What happened next?

90 From Pilot to Scale-Up: The CMAM Experience in Nigeria

95 Frontline experiences of Community Infant and Young Child Feeding in Zimbabwe

97 Postscript cIYCF in Zimbabwe

Research

36 Linear programming to design low cost, local RUTF

9 UNICEF Global reporting update: SAM treatment in UNICEF supported countries

News

58 Framework for integration of management of SAM into national health systems

62 Integration of the management of severe acute malnutrition in health systems: ACF Guidance

63 En-net update, March-May 2012

63 MAMI-2 research prioritization – call for collaborators

64 Conference on Government experiences of CMAM scale-up: meeting report

64 Nutrition Exchange 2012 (formerly Field Exchange Digest) now available

65 CMAM Forum Update

65 FANTA-2 reviews of national experiences of CMAM

65 A standard for standards in humanitarian response

65 What do you think of Field Exchange?

66 Update on Minimum Reporting Package (MRP) trainings in London and Nairobi

Evaluation

83 Management of acute malnutrition programme review and evaluation

Professional Profile

98 Dr Nadera Hayat Burhani

Aim and structure of this special issueThis Field Exchange special issue on ‘Lessons for the scale up of Community-based Managementof Acute Malnutrition (CMAM)’ mainly aims to provide some insights on scaling up CMAM from agovernment perspective. A large part of this edition is therefore taken up with the proceedings ofan 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 theENN, participation was heavily biased towards senior government representatives from 22 Africanand Asian countries. There were however, some representatives from United Nations (UN) agen-cies, non-governmental organisations (NGOs), academia, bilateral donors, foundations andindividual experts. Nine government-led country case studies (Ethiopia, Pakistan, Niger, Somalia,Kenya, Ghana, Sierra Leone, Malawi, and Mozambique) were presented at the conference. Thesetake the form of nine field articles at the core of this issue, with a tenth article on experiences fromIndia that includes a postscript of developments post conference. The Addis conference contribu-tions are complemented by two more field articles from Nigeria and Zimbabwe and a selection ofresearch, evaluation and news that all speak to the CMAM scale up theme.

Objectif et structure de cette édition spécialeCette édition spéciale de Field Exchange consacrée aux « Leçons pour le déploiement de laprise en charge communautaire de la malnutrition aiguë (PCMA) » vise principalement àfournir des éclairages sur le déploiement de la PCMA d’un point de vue gouvernemental. Unegrande partie de ce numéro porte en conséquence sur le déroulement de la conférenceinternationale sur les expériences gouvernementales en matière de déploiement de la PCMAqui s’est tenue à Addis-Abeba du 14 au 17 novembre 2011. La conférence était issue d’unecollaboration entre le Gouvernement de l’Ethiopie et l’ENN et la majorité des acteursprésents étaient des représentants gouvernementaux de haut rang venus de 22 paysafricains et asiatiques. Étaient également présents des représentants des Nations Unies(ONU) et d’agences non-gouvernementales (ONG), des personnalités des milieux universi-taires, des bailleurs de fonds bilatéraux, des fondations et des experts individuels. Neufétudes de cas sur des pays et menées par des gouvernements (l’Éthiopie, le Pakistan, le Niger,la Somalie, le Kenya, le Ghana, la Sierra Leone, le Malawi et le Mozambique) ont été présen-tées lors de la conférence. Ces études de cas par pays sont présentées sous la forme de neufarticles de terrain qui sont au cœur de ce numéro, un dixième article relatant les expériencesobtenues en Inde, y compris une note sur les développements survenus après la conférence.Dans ce numéro, les contributions issues de la conférence d’Addis sont accompagnées dedeux articles provenant du Nigéria et du Zimbabwe, ainsi que d’un choix de recherches,d’évaluations et de nouvelles qui traitent toutes du déploiement de la PCMA.

L’objectif global de la conférence d’Addis Abeba était d’identifier des exemples dedéploiement fructueux d’initiatives de PCMA ainsi que des défis communs dans le domaine.Deux mises en garde importantes doivent être mentionnées ici. Tout d’abord, le fait que despratiques de déploiement PCMA réussies aient été relevées ne signifie pas nécessairementque ce qui a été fait dans un contexte ou à un moment donné dans le passé représente lemeilleur procédé à appliquer dans un autre contexte ou à un autre moment. Deuxièmement,le but n’était pas de prescrire des moyens tout faits pour organiser le déploiement de laPCMA, notamment en termes de structure et de gestion du programme. Le but était plutôtd’attirer l’attention sur quelques caractéristiques qui doivent être abordées et les mécan-ismes locaux et mondiaux qui pourraient être renforcés afin de guider et de soutenir ledéploiement de manière plus efficace.

Rabia, seven months, withher mother at an OTP

Lucia Zo

ro, N

orthern Nigeria, 2011

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the number of children under five years treated as part ofCMAM programming. The figure is very close to 2 million.The speed and scope of scaling up CMAM is quite breath-taking and unprecedented in terms of the scaling up ofother nutrition interventions. However, and withoutwishing to be overly cautious or even to sound negative,there are major challenges that need to be tackled inorder to take this promising approach to a level wherebythe majority of children that develop severe acute malnu-trition (SAM) will have access to appropriate careadministered through government run health systems inthe long term. Actions to help plan integration intonational health systems are reflected in two news pieces:a framework on integration of SAM management beingpiloted by UNICEF EASRO, and a guidance written byAction Contre la Faim on the same topic.

It is sobering to consider that the figure of 2 millionSAM cases treated probably represents less than 10% ofthe global SAM case load. This partly reflects the fact thatcountries such as India with the most significant case-loads are only at the beginning of scale up. It alsoundoubtedly reflects the fact that scaling up is difficulton many levels. It is probably true to say that the majorityof the 2 million SAM children admitted to CMAM in 2011were ‘easier to reach’ children. It may therefore get harderand harder to increase coverage as scale up continues.

Interestingly the global mapping does not capturewhat is happening with moderate acute malnutrition(MAM) for which the case load could be as much as tentimes higher than that of SAM. An explicit focus on theSAM only aspect of CMAM seems to increasingly be afeature of scale up efforts; both the UNICEF and ACFinitiatives described in this issue of Field Exchange focuson SAM management, a position reflected in the 2007WHO/UNICEF/UNSCN/WFP Joint Statement thataddresses the community based management of SAMonly. Yet for others it seems MAM does fall within thescope of CMAM – the original CTC model stipulated the

The overall aim of the Addis Ababa conference was toidentify examples of CMAM scale up success andcommon challenges. Two important caveats should bestated here. Firstly, whilst successful practices in scalingup CMAM were noted, it should not be assumed thatwhat has been done in one context or at one time in thepast represents the best action for another context ortime. Secondly, the aim was not to prescribe set ways toorganise CMAM scale-up, particularly in terms of how theprogramme is structured and managed. Rather, the aimwas to point towards some features that need to beaddressed and the local and global mechanisms thatcould be strengthened in order to guide and supportscale-up more effectively.

To help distil lessons for CMAM scale up, a synthesisof lessons learned from government CMAM scale up wasproduced by the ENN1. This extended editorialsummaries the synthesis findings and identifies the keylearning points and ways forward that emerged from thecase studies and conference proceedings. These arepresented under ten emerging themes, illustrated withcountry-specific examples that are detailed in the fieldarticles included in this edition. The Addis Ababa confer-ence was a unique experience for the ENN, and we hopeyou will get a taster of the rich experience and discoursein this special edition.

Before we embark on the synthesis summary, theENN editorial team want to give a sense of current think-ing around CMAM scale up within the ENN and also ‘flag’a few issues that continue to be vigorously debatedwithin the ENN. First off, who would have thought thatsmall pilot programmes in Ethiopia and northern Sudanbetween 2000 and 2001 that used Ready to UseTherapeutic Food (RUTF) to treat SAM in the communitywould, less than 12 years later, be replicated globally in atleast 60 plus countries at scale? The latest CMAMmapping by UNICEF (see research section) indicates thatsince 2009, there has been an almost 100% increase in

1 Government experiences of scale-up of Community-based Management of Acute Malnutrition (CMAM). A synthesis of lessons. ENN, January 2012. Download from www.ennonline.net

2 Khara, T., Collins, S. (2004). Community-therapeutic care (CTC). Emergency Nutrition Network 2004; (special supplement 2): 1-55.

article-cadre sur l’intégration de la prise en charge de laMAS piloté par UNICEF EASRO et des lignes directricesrédigées par Action Contre la Faim sur le même sujet.

Il est triste de réaliser que le chiffre de 2 millions decas de MAS traités représente probablement moins de 10% de la charge mondiale des cas. Cela démontre en partieque des pays comme l’Inde accusant les nombres de casles plus élevés n’en sont qu’aux débuts du déploiement.Cela prouve également sans aucun doute que ledéploiement est difficile à divers niveaux. Il n’est proba-blement pas faux d’avancer que la majorité des 2 millionsd’enfants admis pour MAS au sein de la PCMA en 2011étaient les enfants les « plus faciles à atteindre ». Il peutdonc devenir plus difficile d’augmenter la couverture aufur et à mesure que le déploiement se poursuit.

Il est intéressant de constater que la cartographiemondiale ne tient pas compte de la malnutrition aiguëmodérée (MAM), pour laquelle pourtant la charge detravail pourrait être jusqu’à dix fois supérieure à celle dela MAS. De plus en plus, l’effort de déploiement semblemettre l’accent de façon explicite sur l’aspect MAS de laPCMA uniquement ; les initiatives de l’UNICEF aussi bienque de l’ACF décrites dans ce numéro de Field Exchangese concentrent sur la prise en charge de la MAS, uneposition reflétée dans la déclaration conjointeOMS/UNICEF/UNSCN/PAM de 2007 qui traite de la priseen charge communautaire de la MAS uniquement. Or,certains semblent considérer que la MAM entre dans lechamp d’application de la PCMA - le modèle STC originalprévoyait l’inclusion des PNS2 au sein des programmes dePCMA et les définitions de travail actuelles de la PCMAélaborées par FANTA2 et le Forum PCMA incluent spéci-fiquement les enfants souffrant de MAM au sein de leurchamp d’application. À l’ENN, nous nous sentons un peucoupables d’avoir relégué la MAM dans notre « anglemort », vu que nous avons concentré notre attention surla prise en charge de la MAS dans le cadre de la PCMA lorsde la conférence d’Addis. L’absence d’un cadre clair pourle traitement et la prévention de MAM et l’absence deleadership quant à l’inclusion du traitement du MAMdans le cadre de la PCMA sont les raisons pour lesquellesnous n’avons pas inclus le thème de la MAM à la

Pour aider à tirer des enseignements du déploiementde la PCMA, l’ENN a produit une synthèse des apprentis-sages tirés du déploiement de la PCMA par legouvernement1. Cet éditorial élargi synthétise les résul-tats et identifie les points clés de l’apprentissage et lespistes à suivre qui ont émergé des études de cas et dudéroulement de la conférence. Ceux-ci sont présentésdans le cadre de dix nouveaux thèmes illustrés par desexemples spécifiques à chaque pays, détaillés dans lesarticles de terrain figurant dans cette édition. Laconférence d’Addis-Abeba a été une expérience uniquepour l’ENN, et nous espérons que cette édition spécialevous donnera un avant-goût des discours et de l’expéri-ence enrichissante qui l’ont caractérisée.

Avant de se lancer dans une synthèse résumée,l’équipe rédactionnelle de l’ENN souhaiterait esquisserune ébauche de réflexions actuelles entourant ledéploiement de la PCMA et signaler quelques questionstoujours vivement débattues au sein de l’ENN. Toutd’abord, qui aurait pensé que les programmes pilotesmis en œuvre à petite échelle en Ethiopie et au nord duSoudan entre 2000 et 2001 utilisant d’aliments thérapeu-tiques prêts à l’emploi (ATPE) pour traiter la MAS au seinde la communauté seraient, moins de 12 ans plus tard,repris au niveau mondial à grande échelle dans pasmoins de 60 pays ? La dernière cartographie de la PCMAréalisée par l’UNICEF (voir la section consacrée à larecherche) indique une augmentation de presque 100 %du nombre d’enfants de moins de cinq ans traités dans lecadre de programmes PCMA depuis 2009. On approchedes 2 millions. La vitesse et la portée du déploiement dela PCMA sont vraiment à couper le souffle et sans précé-dent comparées au déploiement d’autres interventionsnutritionnelles. Toutefois, sans faire d’excès de prudenceet surtout sans sombrer dans le défaitisme, n’oublionspas que des défis majeurs doivent être affrontés si l’onsouhaite que cette approche prometteuse soit amenée àun niveau suffisant pour que la majorité des enfants quidéveloppent la malnutrition aiguë sévère (MAS) aientaccès à des soins appropriés à long terme administréspar les systèmes de santé gouvernementaux. Lesmesures visant à aider l’intégration au sein des systèmesde santé nationaux sont reflétées dans deux articles : un

1 Government experiences of scale-up of Community-based Management of Acute Malnutrition (CMAM). A synthesis of lessons (Des expériences gouvernementales du déploiementde la prise en charge communautaire de la malnutrition aiguë (PCMA). Une synthèse des enseignements). ENN, janvier 2012. Téléchargeable sur www.ennonline.net.

inclusion of SFPs within CMAM programming2 andcurrent CMAM working definitions from FANTA2 and theCMAM Forum specifically include MAM children withintheir scope. Indeed at ENN we may well be guilty of thisincreasing ‘blind spot’ when it comes to MAM, opting tofocus most of our attentions on SAM management inCMAM in the Addis conference. Part of our rationale forthis at the Addis conference was the lack of a clear frame-work for treatment and prevention of MAM and absenceof leadership around the inclusion of MAM treatment inthe context of CMAM; we did not want any ensuingdebate to overshadow the lesson capture at the heart ofthe conference. MAM management certainly featured insome of the nine case study countries but not consistentlyso, and there were many related questions emerging (withfew answers). Furthermore, where MAM does feature inprogramming, the emphasis seems to be on food/specialised product interventions with little programmingaround non-food MAM interventions. So one of ENNs(many) lessons from the conference experience is we needto talk about MAM. To this end, we encourage you tosubmit experiences, research and challenges to FieldExchange on this topic, and especially welcome those thatdescribe non-food MAM interventions.

Financing challenges around long-term CMAMprogramming featured heavily in the government expe-riences shared in Addis. Three key financing issues thatemerged and need urgent attention are: how to movefrom humanitarian funding to longer-term fundingwhere CMAM is scaled up on the back of an emergency,whether scaled up CMAM programming is sustainable on

conférence ; en effet, nous voulions éviter que le débatqui s’ensuivrait éclipse les enseignements au cœur de laconférence. La prise en charge de la MAM apparaît claire-ment dans certains des neuf pays de l’étude de cas maispas systématiquement, et de nombreuses questionsconnexes ont émergé (avec peu de réponses). En outre,dans les programmes comprenant la MAM, l’accentsemble porter sur les interventions en matière de nourri-ture/produits spécialisés, peu d’aspects des programmesportant sur les interventions non-alimentaires en matièrede MAM. Ainsi, l’une des leçons retenues par l’ENN(même plusieurs) issues de l’expérience de la conférenceest la suivante : nous devons aborder la MAM. À cette fin,nous vous encourageons à soumettre des contributions àField Exchange faisant part de vos expériences, d’élé-ments de recherche et de défis sur ce sujet, et nousaccueillons tout particulièrement les contributionsdécrivant les interventions non-alimentaires en matièrede MAM.

Les problèmes de financement à long termeentourant les programmes de PCMA ont occupé uneplace importante dans les expériences gouvernemen-tales partagées à Addis. Trois questions de financementclés ont émergé et nécessitent une attention urgente, àsavoir : comment passer d’un financement humanitaire àun financement à long terme lorsque la PCMA est initiale-ment déployée à l’occasion d’une urgence ; si ledéploiement des programmes de PCMA est durable surune base pays par pays et, le cas échéant, de quellemanière les modalités de financement des programmes àlong terme seront établies, en particulier en ce qui a traità la proportion de financement à apporter par legouvernement national et les organismes bailleurs defonds internationaux.

La qualité des programmes s’est également avéréeune préoccupation majeure, ce qui est reflété dans une

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a country by country basis and if so, how will financingarrangements for long-term programming be config-ured, particularly with regard to the proportion offunding to come from national government and interna-tional donor agencies.

Quality of programming was also a major concernand 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 forrecovery and only 19.4% met standards for defaulting.SPHERE standards may be an appropriate aim but is it toomuch to expect these be attained during the process ofscale up for government implemented programmes innon-emergency contexts? There is little clarity aroundwhat standards are acceptable and realisable in suchcontexts and over what time-frame they can be reached.

These are just some of the major challenges facingagencies and governments moving forward in theirattempts to roll out CMAM. CMAM scale up has started ata sprint. However, the goal we all desire, which is univer-sal programme coverage for acute malnutrition, willinvolve a marathon which like all marathons, requires anenormous and perhaps unprecedented level of politicaland financial commitment amongst all key stakeholders.How this plays out in the next few years will be fascinat-ing. For the millions of families living with acutemalnutrition it could well be a matter of life and death.

Jeremy Shoham and Marie McGrath, ENN

Paths for scaling up CMAM: Broadlessons and ways forwardThe contextGlobally, it is estimated that over 19 million children areseverely acutely malnourished at any one time. Thesechildren have a greater than nine fold increased risk ofdying compared to a well-nourished child3. The 2008Maternal and Child Nutrition Lancet series recognisessevere acute malnutrition (SAM) as one of the top threenutrition-related causes of death in children under-five4.It emphasises the importance therefore of addressingacute malnutrition for meeting the MillenniumDevelopment 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 successfullytreats the majority of children with SAM, including thosewho are HIV positive, at home. The approach engagescommunities in order to identify severely malnourishedchildren early before their condition deteriorates to astage where they require inpatient care for medicalcomplications. It allows effective treatment of uncompli-cated SAM cases, in terms of essential medicines, simpleorientation for caregivers, and specially formulated RUTF,to be given on a weekly basis at low level existing decen-tralised health structures or distribution sites within aday’s walk of people’s homes. The approach includesinpatient care for complicated cases of SAM (usually<10% of the caseload) and in some situations, dependingon context and resources, with supplementary feeding orother programmes aiming to address moderate acutemalnutrition (MAM).

The CMAM approach was first implemented in 2001and based on early successes, was taken up by a numberof international non-governmental organisations (NGOs)working in emergency contexts in countries of Africa

with various degrees of government involvement. In2007, the United Nations (UN) endorsed the community-based approach for management of SAM with a jointstatement7. Endorsement of the approach came as aresult of operational research conducted over the previ-ous seven years which provided evidence of its impact8,and work from similar community-based programmes9).This global endorsement paved the way for the furtherexpansion of the approach by creating consensus withinthe global nutrition community and amongst interna-tional agencies and donors on what is the optimalprogramming approach for the treatment of SAM. It alsoenabled governments to start establishing and scaling-up CMAM programming at national level. A shift of focusto seeing community-based management of SAM as arequirement of routine health activities has emerged as aresult.

From three countries implementing small scaleCMAM programmes between 2000 and 2003, by mid-

3 The odds of dying is estimated to be 9.4 times higher in severely wasted children.

4 Black, M.D et al (2008). The Lancet. Vol. 371, Issue 9608, pp.243-260.

5 Bhutta, Z.A et al (2008). Interventions for maternal and child undernutrition and survival. Lancet Maternal and Child Undernutrition Series. The Lancet, volume 371, Issue 9610, pp.417-440.

6 http://www.scalingupnutrition.org/key-documents/7 WHO, UNICEF, UNSCN, WFP, 2007 Joint Statement8 Collins, S., Dent, N., Binss, P., Bahwere, P., Sadler, K and

Hallam, A., 2006a. Management of severe acute malnutri-tion in children. The Lancet, 368(9551), pp.1992–2000. Initial research programmes used the term Community-based management of Therapeutic Care (CTC). When the approach was endorsed the name was changed to the more generic term Community-based Management of Acute Malnutrition (CMAM).

9 Collins, S., Sadler, K., Dent, N., Khara, T., Guerrero, S,. Myatt, M., Saboya, M. and Walsh, A., 2006b. Key Issues forthe Success of Community-based Management of severe malnutrition. Food and Nutrition Bulletin, volume 27 (supple-ment-SCN Nutrition Policy Paper No. 21), S49-82.

Axes pour le déploiement de la PCMA :enseignements généraux et voies à suivreLe contexteGlobalement, on estime que plus de 19 millions d’enfantssont gravement atteints de malnutrition aiguë à unmoment de leur vie. Pour ces enfants, le risque de décèsest plus de neuf fois plus élevé par rapport à un enfantbien nourri3. La série 2008 de The Lancet sur la Nutritionmaternelle et infantile place la malnutrition aiguë sévère(MAS) parmi les trois principales causes de décès liées à lanutrition chez les enfants de moins de cinq ans4. Elle metdonc l’accent sur l’importance de lutter contre la malnu-trition aiguë pour atteindre l’Objectif du Millénaire pourle développement 4 (OMD 4), à savoir réduire la mortalitéinfanto-juvénile5. Ce message a été repris dans les forumsinternationaux, en particulier par l’initiative à l’échellemondiale de 2010 impliquant toute une série d’acteursmultiples pour le déploiement de la nutrition, « Scale UpNutrition » (SUN)6.

La PCMA est une approche novatrice permettant detraiter avec succès la majorité des enfants atteints deMAS, y compris ceux qui sont séropositifs, à leur domicile.L’approche se base sur l’engagement des communautésafin d’identifier les enfants sévèrement malnutris avantque leur état se détériore jusqu’à atteindre un stade où ilsont besoin de soins en milieu hospitalier pour traiter lescomplications médicales. Elle permet un traitement effi-cace des cas simples de MAS, en termes de médicamentsessentiels, de conseils simples pour les dispenseurs desoins et d'ATPE formules spécialement et destinés à êtredistribués sur une base hebdomadaire au sein de struc-tures de santé décentralisées existantes à basse échelleou au sein de sites de distribution situés maximalement àune journée de marche du domicile. L’approchecomprend des soins hospitaliers pour les cas compliquésde MAS (habituellement <10 % de la charge de travail) etdans certaines situations, en fonction du contexte et desressources, des programmes de nutrition supplémentaireou d’autres programmes visant à traiter la malnutritionaiguë modérée (MAM).

L’approche PCMA a été mise en œuvre pour lapremière fois en 2001 et suite à son succès rapide, a été

reprise par plusieurs organisations non gouvernemen-tales (ONG) internationales travaillant dans des contextesd’urgence dans des pays d’Afrique avec différents degrésde participation de la part du gouvernement. En 2007,l’Organisation des Nations Unies (ONU) a approuvé l’ap-proche à base communautaire pour la gestion de la MASpar l’intermédiaire d’une déclaration commune7. Lareconnaissance de l’approche a été le fruit de recherchesopérationnelles menées au cours des sept années précé-dentes, lesquelles ont fourni des preuves de son impact8,ainsi que les travaux de programmes similaires à basecommunautaire9. Cette reconnaissance à l’échelle mondi-ale a ouvert la voie à l’expansion de l’approche via laformation d’un consensus au sein de la communautémondiale œuvrant dans le domaine de la nutrition etparmi les organismes internationaux et les bailleurs defonds sur ce qu’est l’approche de programmation opti-male pour le traitement de la MAS. Elle a également

partie du contenu de ce numéro. Le rapport de cartogra-phie de l’UNICEF indique que moins de 32% des paysavaient réussi à se conformer aux normes SPHERE en cequi concerne le rétablissement et seulement 19,4 % en cequi concerne le taux d’abandon. Certes, les normesSPHERE semblent être un objectif approprié mais n’est-ilpas irréaliste d’exiger qu’elles soient respectées au coursdu processus de déploiement des programmesgouvernementaux mis en œuvre dans des contextes horsurgence ? Il est difficile de déterminer les normes accept-ables et réalisables dans de tels contextes et les délaisque l’on peut exiger.

Il ne s’agit là que de quelques-uns des défis majeursauxquels sont confrontés les organismes et les gouverne-ments dans leurs démarches de déploiement de la PCMA.Le déploiement de la PCMA a démarré sur les chapeauxde roues. Cependant, l’objectif que nous souhaitons tous,à savoir une couverture universelle des programmes trai-tant la malnutrition aiguë, impliquera un marathon qui,comme tous les marathons, exige des performances depointe et possiblement un niveau sans précédent entermes d’engagement politique et financier de la part detous les intervenants clés. Le déroulement dans lesprochaines années sera fascinant. Pour les millions defamilles vivant avec la malnutrition aiguë, il pourrait biens’agir d’une question de vie ou de mort.

Jeremy Shoham et Marie McGrath, ENN

2 Khara, T., Collins, S. (2004). Community-therapeutic care (CTC). Emergency Nutrition Network 2004; (special supplement 2): 1-55.

3 On estime que les risques de décès sont 9,4 fois plus élevés chez les enfants émaciés.

4 Black, M.D et al (2008). The Lancet. Vol. 371, édition 9608, pp.243-260.

5 Bhutta, Z.A et al (2008). Interventions for maternal and child undernutrition and survival (Interventions pour la survie des mères et des enfants souffrant de sous-nutrition).Lancet Maternal and Child Undernutrition Series. The Lancet, volume 371, édition 9610, pp.417-440.

6 http://www.scalingupnutrition.org/key-documents/7 Déclaration commune OMS, UNICEF, UNSCN, PAM, 2007 8 Collins, S., Dent, N., Binss, P., Bahwere, P., Sadler, K et

Hallam, A., 2006a. Management of severe acute malnutri-tion in children (Prise en charge de la malnutrition aiguë sévère chez les enfants). The Lancet, 368(9551), pp.1992–2000. Les programmes de recherche initiaux utili-saient le terme de gestion des soins thérapeutiques commu-nautaires (STC). Lorsque la démarche a été approuvée le nom a été changé pour un terme plus générique, à savoir la pris en charge communautaire de la malnutrition aiguë (PCMA).

9 Collins, S., Sadler, K., Dent, N., Khara, T., Guerrero, S,. Myatt,M., Saboya, M. et Walsh, A., 2006b. Key Issues for theSuccess of Community-based Management of severe mal- nutrition (Questions clés pour la réussite de la prise en charge communautaire de la malnutrition sévère). Food andNutrition Bulletin, volume 27 (supplément-document politiquedu Comité permanent de la nutrition No. 21), S49-82.

Editorial Éditorial

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2010, 55 countries were implementing CMAM to somedegree. A recent UNICEF initiative has started to mapand review some key indicators of progress in adoptingand scaling up the approach10. The review found that 55countries had made inroads into adopting theapproach. In 52 of these countries, CMAM guidelineswere in place, indicating institutional endorsement. In34 countries, CMAM was included in national nutritionpolicy. The review also described the variable progressthat countries were making to integrate CMAM intoregular primary health care activities such as in the areasof Integrated Management of Childhood Illness (IMCI),Infant and Young Child Feeding (IYCF), HIV/AIDS and thechallenges being faced at country level.

A note on terminologyThe term ‘CMAM scale-up’ is often conjoined withthe term ‘integration’ on the basis that scale up isnot possible without some level of integration.However, the term ‘integration’ is not always clearlyunderstood. A working definition that was agreedat the conference11 has four key elements, asfollows: • [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, micronutrientsetc).

• This, in turn, is integrated within a multisectoral approach to tackle the determinants of undernutrition.

CMAM may take different shapes and forms atnational level. Different names and acronyms areused to describe the same or similar approaches.

Remarque sur la terminologie

L’expression « déploiement de la PCMA » est souventjumelée à l’expression « intégration » étant donné quele déploiement n’est pas possible sans un certainniveau d’intégration. Toutefois, le terme « intégration» n’est pas toujours bien compris. Une définition detravail convenue lors de la conférence12 comprendquatre éléments clés, à savoir :• [les traitements de] la MAS et la MAM font partie intégrante de la PCMA

• La PCMA est l’un des services de santé de base à laquelle un enfant a accès ; ce service est fourni par les mêmes moyens que les autres services.

• Elle est intégrée au sein d’un ensemble plus large d’activités en rapport avec la nutrition (ANJE, retard de croissance, micronutriments, etc.).

• Ceci est à son tour intégré dans une approche multisectorielle pour s’attaquer aux causes de la sous-nutrition.

La PCMA peut prendre des formes différentes au niveaunational. Des noms et acronymes divers sont utiliséspour décrire des approches identiques ou similaires

permis aux gouvernements de commencer à établir età déployer les programmes de PCMA au niveaunational. Cela a débouché sur un changement devision, à savoir que la prise en charge de la MAS baséesur la communauté a commencé à être considéréecomme une activité de santé de routine incontourn-able.

De trois pays ayant mis en œuvre des programmesPCMA à petite échelle entre 2000 et 2003, on est passéà 55 pays ayant mis en œuvre des mesures PCMA àplus ou moins grande envergure à la mi-2010. Unerécente initiative UNICEF a entrepris de cartographieret d’examiner certains indicateurs clés de progrèsdans l’adoption et le déploiement de la démarche10.L’examen a révélé que 55 pays avaient entreprisd’adopter l’approche. 52 de ces pays appliquaient leslignes directrices PCMA, indiquant une approbationinstitutionnelle. Dans 34 de ces pays, la PCMA avait étéincluse au sein de la politique nationale en matière denutrition. L’examen a également décrit les progrèsvariables effectués par les pays pour intégrer la PCMAaux activités de santé régulières, par exemple dans ledomaine de la prise en charge intégrée des maladiesde l’enfant (PCIME), de l’alimentation du nourrisson etdu jeune enfant (ANJE) et du VIH/sida, ainsi que lesdéfis qui se posent au niveau des pays.

L’examen cartographique réalisé par l’UNICEFestime que plus d’un million d’enfants ont été admispour le traitement de MAS en utilisant l’approchePCMA en 2009 et que la majorité de ces enfants setrouvaient en Afrique. Le déploiement de la program-mation PCMA dans les pays en développement sepoursuit à un rythme rapide à travers le monde, enparticulier en Afrique et en Asie, en bénéficiant dusoutien gouvernemental et multi-bailleurs de fonds.Selon le compte-rendu de l’UNICEF, sept autres pays(Cambodge, Laos, Vietnam, Inde, Iraq, Mongolie,Afrique du Sud) avaient l’intention d’introduire ladémarche en 2011.

En résumé, il existe maintenant une approchePCMA mondialement reconnue que de nombreuxpays mettent en œuvre et qui en est à divers stades de

10 UNICEF et Valid International, 2010. Global Mapping Review of community-based management of acute malnutrition witha focus on severe acute malnutrition (Examen cartographiquemondial de la prise en charge communautaire de la malnu-trition aiguë avec un accent sur la malnutrition aiguë sévère).Une mise à jour de la cartographie réalisée par l’UNICEF en 2010 est incluse dans ce numéro de Field Exchange.

11 Lorsque la PCMA comprend également des interventions destinées à faire face à la malnutrition aiguë modérée (MAM),un rôle plus important peut être joué par d’autres secteurs, tels que l’éducation, l’agriculture et la sécurité alimentaire. Cependant, vu les lacunes actuelles en termes de recherche et d’accords sur les interventions liées à la MAM hors situa-tions d’urgence, la PCMA est couramment mise en œuvre sans composante MAM dans ces contextes.

12 En raison des différences d’interprétation de l’expression « intégration », un groupe d’experts techniques s’est porté volontaire pour développer une « définition de travail » pouvant ensuite être utilisée au cours des discussions ultérieures dans le cadre de la conférence (et pourra peut-être servir de point de départ pour une élaboration de défi-nition post-conférence).

10 UNICEF and Valid International, 2010. Global Mapping Review of community-based management of acute malnutrition with a focus on severe acute malnutrition. An update by UNICEF to the mapping conducted in 2010 is included in this issue of Field Exchange.

11 Because of the different interpretation of ‘integration’, a group of technical experts volunteered to develop a ‘working’definition that could then be used for subsequent discussionsin the conference (and perhaps a starting point for further work on a definition post conference).

12 Where CMAM also includes interventions to address moderate acute malnutrition (MAM), a greater role may be played by other sectors, such as education, agriculture and food security. However with the current lack of research andagreement on interventions to address MAM in the non-emergency context, CMAM is commonly implemented with-out a MAM component in these contexts.

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The UNICEF mapping review estimated that over 1million children were admitted for treatment of SAMusing the CMAM approach in 2009 and that the majorityof these children were in Africa. The scale-up of CMAMprogramming in developing countries is continuing at arapid pace across the world, particularly in Africa andAsia, and has government and multi-donor support.According to the UNICEF review, a further seven coun-tries (Cambodia, Laos, Vietnam, India, Iraq, Mongolia,South Africa) were planning to introduce the approach in2011.

In summary, we now have a globally recognisedCMAM approach which many countries are implement-ing and at various stages of scaling up. The impetus forscaling up CMAM for the management of SAM12 lieslargely within the health sector and with communitystructures and systems. The aim of national scaling up istherefore to achieve national coverage of a sustained,quality service provided as an integral part of the healthsystem and with a strong community base. The manage-ment of SAM in this way will contribute to achievingnational impact on mortality and ultimately MDG 4.

Getting CMAM onto the national agendaIn terms of getting CMAM onto national agendas, a keyenabling factor in many countries has been the onset ofmajor or periodic emergencies. Emergencies highlightthe issue of SAM and provide the context (availability ofpartners and resources and willingness to operateoutside the norm) in which CMAM can be introduced anddemonstrated to work at limited scale. A good examplecomes from Pakistan where CMAM was scaled up in thewake of the 2010 floods. There is a danger that CMAMintroduced in this way can lead to a lack of ownership bylocal authorities and unsustainable models of implemen-tation which are later difficult to transition. However,there are good examples where this has not been thecase. CMAM scale up has been rapid, particularly over the

déploiement. L’impulsion du déploiement de la PCMApour la prise en charge de la MAS11 dépend en grandepartie du secteur de la santé et des structures et systèmescommunautaires. L’objectif du déploiement à l’échellenationale est donc de mettre en place une couverturenationale offrant un service continu et de qualité formantpartie intégrante du système de santé et avec une solidebase communautaire. En gérant la MAS de cette façon, oncontribuera à exercer une incidence à l’échelle nationalesur la mortalité et, à terme, à réaliser l’OMD 4.

Inscrire la PCMA au programme nationalLorsqu’il est question de hisser la PCMA sur la scènenationale, l’apparition de situations d’urgence majeuresou périodiques s’est avéré être un facteur clé dans denombreux pays. Les urgences mettent en évidence leproblème de la MAS et fournissent le contexte approprié(la disponibilité des partenaires et des ressources et lavolonté d’opérer en dehors de la norme) pour l’introduc-tion de la PCMA et permettent également de montrer lefonctionnement de celle-ci à échelle limitée. Un bonexemple est celui du Pakistan, où la PCMA a été déployéeà la suite des inondations de 2010. Le danger existant estque ce moyen d’introduire la PCMA peut conduire à unmanque d’implication de la part des autorités locales et àdes modèles non durables de mise en œuvre ce qui peutrendre la transition plus difficile par la suite. Néanmoins, ilexiste de bons exemples où cela n’a pas été le cas.

Le déploiement de la PCMA a été rapide, en particulierau cours des cinq dernières années dans de nombreuxcontextes nationaux différents, et souvent suite à des situ-ations d’urgence (voir encadré 1 pour quelques exemples,plus de détails sont fournis dans les articles de terrain). Siles agences parviennent à envisager la PCMA avec suff-isamment d’engagement et de consultation, lesgouvernements seront plus en mesure d’adopter la PCMAet d’entrainer d’autres parties pour soutenir le développe-ment des capacités nationales.

Au-delà de l’urgence, les facteurs grâce auxquels laPCMA est susceptible d’être intégrée au programmenational en tant que service au sein du système de santéde routine sont les suivants : 1) la sensibilisation et lesoutien d’une agence clé au niveau national (en particulier

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past five years in many diverse country contexts andoften after emergencies (See Box 1 for some examples,more details are provided in the field articles). If agenciesapproach CMAM with a sufficient degree of engagementand consultation, governments are able to take greaterownership of CMAM and bring in other stakeholders tosupport national capacity development.

Beyond the emergency, factors that can facilitateCMAM being brought onto the national agenda as aservice within the routine health system are: 1) advo-cacy and support from a key agency at national level(particularly for the provision of supplies), 2) discussionsbetween international or regional CMAM experts,national nutrition experts and government officials inorder to help demonstrate the burden of SAM in thecountry, its implications, and build understanding of theapproach through debate on the technical protocols,and 3) implementation of pilots at limited scale to visi-bly show the striking results that can be realised interms of recovery and coverage and to inform the adap-tation of the approach to the country context. This lastfactor has been a key driver in many countries (See Box2). National or local experiences of piloting CMAMimplementation carry considerable weight when itcomes to adopting the approach nationally and seem tocarry more weight than global endorsements.

In most case study countries, getting CMAM ontopolicy agendas has been facilitated by having a centraltechnical working group, or an existing governmentunit with wide buy in from nutrition actors, speakingwith one voice to advocate for CMAM. The level of influ-ence of this group can be defined by the existingposition of nutrition at the national level and thereforethe level at which discussions about CMAM take place.

Though being firmly rooted in the health sectorfacilitates the uptake of the CMAM approach by allhealth staff, it can also limit the uptake of critical cross-

sectoral aspects, particularly for community mobilisa-tion.

Where nutrition institutionally cuts across sectors,the benefits can be twofold. Firstly it can facilitate cross-sectoral work, and secondly by having a profile anddecision making apparatus above and beyond health,there is the potential to mobilise greater political will fornutrition initiatives and as a result increase resourceallocation.

Finally, a new framework for engagement betweenlocal authorities and nutrition partners, addressing thenecessity for scale up and down in response to periodicemergencies and based on capacities to respond ratherthan SAM cut-off points, shows promise for guardingagainst unsustainable approaches to implementingCMAM13.

Integrating CMAM into existing policy frameworks andnational development plansWhen it comes to the integration of CMAM into existingpolicies and plans, the need to reflect CMAM in anational overarching health policy is paramount if scale-up of the delivery of treatment through national healthstructures is to be properly supported and resourced.CMAM is not, and must not be presented as nor imple-mented as, a vertical programme but as an integral partof health and nutrition packages.

In most countries, there has been no clear plan forCMAM scale-up (with geographical and coveragetargets, costing, support needs, training strategy, etc.).In some respects that has been one of the features ofthe approach, i.e. that its uptake is organic and demanddriven rather than prescribed ‘from above’. The lack oflong term funding has played a key role in limiting the

Malawi: From 2 district pilot (all facilities in thosedistricts implementing outpatient care) 2002/3 to all28 districts implementing the programme in 2011, in atotal of 70% of all health facilities.

Ethiopia: From first pilot in 2001 slow expansion, thenfrom 2008 rapid expansion. Currently 8,000 sites offer-ing CMAM services, outpatient care in 49% of healthposts and in 48% of health centres with 82% recovery.

Kenya: Ministry-led programmes implemented inthree of the most affected provinces of the arid &semi-arid lands. From 2009 to 2011, the proportion ofhealth facilities offering CMAM services has increasedfrom 50% to 83%. Caseloads in the urban programmehave steadily doubled each year from an initial 1,600in 2008 to 4,700 in 2010, whist maintaining qualitywithin sphere standards for recovery and death rates.

Ghana: From initial MOH pilot in April 2008 (onedistrict in each of two regions, in each district oneinpatient and 2-5 outpatient sites) to all 19 healthcentres within the two districts by March 2009. Sierra Leone: From initial MOH pilot of 20 outpatientand 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 quickeronce new guideline endorsed in 2010. By 2011, 229out of 1,280 health facilities are implementing outpa-tient care, however in some this is only as a phase 2treatment according to CMAM protocols.

Somalia: From 30 OTPs in 2006 to 935 in 2011. Niger: Initiation of CMAM in 2005. Inpatient care forSAM with complications in all 50 national, regionaland district hospitals. Outpatient care in 772 out of800 health centres by 2011.

Box 1: Country examples of the speed of CMAMscale-up

pour la fourniture de matériel), 2) les discussionsentre des experts internationaux ou régionaux enmatière de PCMA, des experts nationaux sur lanutrition et des représentants du gouvernementafin d’aider à démontrer le fléau que représente laMAS pour le pays et les conséquences de cettedernière, et d’aider à saisir l’approche par un débatsur les protocoles techniques, et 3) la mise enœuvre de projets pilotes à échelle limitéemontrant de manière visible les résultats frappantsqui peuvent être obtenus en termes de récupéra-tion et de couverture et la mise sur pied d’unefaçon d’adapter l’approche au contexte du pays.Ce dernier facteur a été déterminant dans denombreux pays (voir encadré 2). Les expériencesnationales ou locales de mise en œuvre de pilotesde programmes PCMA ont un poids considérablequand il s’agit d’adapter l’approche à l’échellenationale et semblent avoir plus d’impact que lesapprobations à l’échelle mondiale.

Dans la plupart des pays étudiés, l’intégrationde la PCMA aux programmes politiques a été facil-itée par la présence d’un groupe de travailtechnique central, ou d’une unité de gouverne-ment existante largement approuvée par lesacteurs de la nutrition, parlant d’une seule etmême voix pour plaider en faveur de la PCMA. Leniveau d’influence de ce groupe peut être définipar la position actuelle de la nutrition au niveaunational et, par conséquent, le niveau auquel lesdiscussions sur la PCMA ont lieu.

Bien que le fait que l’approche PCMA soitfermement enracinée dans le secteur de la santéfacilite l’adoption de celle-ci par l’ensemble dupersonnel de santé, cela peut également limiterl’adoption d’aspects intersectoriels critiques, enparticulier pour la mobilisation communautaire.

Lorsque la nutrition figure dans tous lessecteurs au niveau institutionnel, les avantagespeuvent être doublés. Premièrement, cela peutfaciliter le travail intersectoriel, et d’autre part enayant un profil et des outils de prise de décision

au-dessus et au-delà du domaine de la santé, il estpossible de mobiliser davantage la volonté poli-tique au profit des initiatives en matière denutrition et d’améliorer ensuite la distribution desressources.

Enfin, grâce à un nouveau cadre d’engagemententre les autorités locales et les partenaires denutrition sur la nécessité d’un déploiement enamont et en aval d’une réaction aux situationsd’urgence périodiques et se fondant sur les capac-ités de réaction plutôt que sur les seuils de MAS, onpeut se prémunir contre les approches nondurables de mise en œuvre de la PCMA13.

Intégrer la PCMA aux cadres politiques existants etaux plans de développement nationauxQuand il s’agit d’intégrer la PCMA aux politiques etaux plans existants, la nécessité de refléter la PCMAdans une politique de santé nationale globale estprimordiale si l’ont veut que le déploiement del’administration du traitement à travers les struc-tures de santé nationales soit correctementsoutenu et financé. La PCMA n’est pas, et ne doitpas être présentée ni mise en œuvre, comme unprogramme vertical mais comme une partie inté-grante des mesures de santé et de nutrition.

Dans la plupart des pays, il n’y a pas eu de planclair pour le déploiement de la PCMA (avec desobjectifs géographiques et de couverture, calculdes coûts, des besoins de soutien, une stratégie deformation, etc.). À certains égards, ceci a été l’unedes caractéristiques de l’approche, à savoir que sonadoption est organique et axée sur la demandeplutôt que sur une quantité prescrite « par en haut». Le manque de financement à long terme a joué

Malawi : de 2 districts pilotes (tous les établissements dans lesdistricts où des soins ambulatoires ont été mis en œuvre) en2002/3 à l’ensemble des 28 districts de mise en œuvre duprogramme en 2011, pour un total de 70 % de tous les établisse-ments de santé.

Éthiopie : une expansion lente depuis le premier pilote en 2001,puis une expansion rapide à partir de 2008. Actuellement, 8 000sites offrant des services PCMA, des soins ambulatoires dans 49% des postes de santé et dans 48 % des centres de santé avec untaux de rétablissement de 82 %.

Kenya : programmes dirigés par les ministères mis en œuvredans trois des provinces les plus touchées des terres arides etsemi-arides. De 2009 à 2011, la proportion des établissementsde santé offrant des services PCMA a augmenté de 50 % à 83 %.La charge de travail du programme urbain double régulièrementchaque année, étant partie d’un total initial de 1 600 en 2008 à 4700 en 2010, tout en maintenant la qualité selon les normes deSphère pour les taux de récupération et de décès.

Ghana : du projet pilote initial du MS en avril 2008 (un districtdans chacune des régions, dans chaque district un site de soinsd’hospitalisation et 2-5 établissements de soins ambulatoires) àl’ensemble des 19 centres de santé dans les deux districts enmars 2009.

Sierra Leone : Du projet pilote initial du MS de 20 sites de soinsambulatoire et 3 sites de soins d’hospitalisation en 2007, à 245sites de soins ambulatoires (20 % de toutes les unités de santéprimaires) et 19 sites de soins hospitaliers (au moins un pardistrict) en 2011.

Mozambique : lente expansion initiale puis plus rapide aprèsapprobation de la ligne directrice en 2010. En 2011, 229 sur 1280 établissements de santé mettent en œuvre les soins ambula-toires, mais dans certains cas, cela correspond seulement à unephase 2 de traitement conformément aux protocoles PCMA.

Somalie : de 30 programmes de soins ambulatoires en 2006 à935 en 2011.

Niger : introduction de la PCMA en 2005. Soins offerts auxpatients hospitalisés pour MAS avec complications dans les 50hôpitaux nationaux, régionaux et de district. Soins ambulatoiresdans 772 sur les 800 centres de santé en 2011.

Encadré 1 : Exemples de la vitesse du déploiement de laPCMA dans différents pays

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13 WHO categorises interventions as cost effective if they cost less per DALY than a country’s gross domestic income per capita.

13 Voir Peter Hailey et Daniel Tewoldeberha (2010). Suggested New Design Framework for CMAM Programming (Nouveau cadre suggéré pour la conception des programmes en matière de PCMA).Field Exchange, édition n° 39, septembre 2010. p42. http://fex.ennonline.net/39/suggested.aspx et présentation de la Conférence PCMA 2011 sur l’intégration et le déploiement à l’adresse : http:// cmamconference2011.org/country-presentations/

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ability to plan CMAM and there is the risk that with-out plans, demand can exceed supply, resourcescan be wasted and quality can be compromised.

The lack of good costing and cost effectivenessdata has also impinged on countries’ ability tocome up with national scale-up plans, or even tointegrate CMAM into existing operational plans.This gap is now being filled with an increasingnumber of cost effectiveness studies finding similarresults and offering the potential for CMAM to bereflected in decision making tools and plans (seeBox 3). These studies find CMAM to have a similarcost-effectiveness ratio to other priority childhealth interventions and to be ‘highly cost-effec-tive”’ as defined by WHO14.

Most countries have progressed with the devel-opment of national guidelines, a process that hasserved as a necessary step to building consensusand national ‘buy in’ for the approach, for adapting

Ethiopia’s experience was initially led by the onset of anemergency and by advocacy efforts by international expertsand NGOs. CMAM was first implemented out of the necessityto try something new during the 2001 emergency in thesouth of the country. High mortality rates experienced inlarge therapeutic feeding centres run in previous emergenciesmeant that local officials were not prepared to allow agenciesto run these types of programmes again. After agreementswith government officials at district and regional level wereobtained by an NGO (Concern) and despite no globalendorsement for the approach, outpatient care was pilotedthat year.

This introduction - of what was then a radical new approach -was facilitated by the decentralised structure of the healthsystem in Ethiopia whereby a certain degree of autonomy fordecision making is held at regional level. The positive initialexperience was followed by pilot and operational researchCMAM programmes beginning in 2003. Though these pilotswere NGO supported, they were carried out with close collab-oration of regional and district health authorities andimplemented by MoH staff at facilities with NGO support.

Once the pilot experiences were shared both within the coun-try at a national workshop and internationally, it was regionalhealth bureaus that took the lead in pushing the CMAMagenda forward, continually bringing it onto the nationalagenda with the support of the NGOs. UN agencies also tookup support at national level in 2004 for the integration of theapproach into the health system. In 2008, the MoH droveforward the further scale-up and decentralisation of CMAM.This came in response to dramatic and rapid increases in thenumber of SAM cases in two emergency affected regions. Thisled government to call on UNICEF to support the roll out ofthe approach as part of the health extension package, initiallyto 1,239 and now to over 6,400 health posts nationally.

Box 2: Influence of national pilots in Ethiopia on national‘buy in’ to scale up CMAM

L’expérience de l’Éthiopie est initialement née de l’apparition d’unesituation d’urgence et des efforts de plaidoyer de la part des expertsinternationaux et des ONG. La PCMA a d’abord été mise en œuvresuite à la nécessité d’essayer quelque chose de nouveau pendant lacrise qui a frappé le sud du pays en 2001. Les taux de mortalité élevésenregistrés dans les grands centres de nutrition thérapeutique mis enplace durant les urgences antérieures ont fait que les responsableslocaux n’étaient pas prêts à permettre aux agences d’exécuter cestypes de programmes à nouveau. Après des accords conclus par uneONG (Concern) avec les autorités gouvernementales au niveau dudistrict et au niveau régional et malgré l’absence d’une reconnais-sance mondiale de l’approche, les soins ambulatoires ont été mis àl’essai cette année.

Cette introduction – c’était alors une approche radicalementnouvelle - a été facilitée par la structure décentralisée du système desanté en Éthiopie où l’on observe un certain degré d’autonomie pource qui est de la prise de décision au niveau régional. L’expérience posi-tive initiale a été suivie par des programmes de recherche pilotes etopérationnels en matière de PCMA à partir de 2003. Ces pilotesétaient soutenus par des ONG, cependant, ils ont été menés en étroitecollaboration avec les autorités de santé régionales et de district et misen œuvre par le personnel du ministère de la Santé dans les installa-tions bénéficiant de l’appui des ONG.

Une fois que les expériences pilotes ont été partagées tant à l’in-térieur du pays lors d’un atelier national qu’au niveau international, cesont les bureaux régionaux de la santé qui ont mené la marche enpropulsant la PCMA sans cesse vers l’avant au sein des projets auniveau national avec le soutien des ONG. Les agences de l’ONU ontégalement fourni un soutien au niveau national en 2004 pour l’inté-gration de l’approche dans le système de santé. En 2008, le ministèrede la Santé s’est concentré sur la poursuite du déploiement et de ladécentralisation de la PCMA en réaction à une augmentation spectac-ulaire et rapide du nombre de cas de MAS dans deux régions frappéespar une urgence. Cela a incité le gouvernement à faire appel àl’UNICEF pour soutenir le déploiement de l’approche dans le cadre du« health extension package » (programme d’extension de la santé),d’abord pour 1 239 postes et maintenant pour plus de 6 400 postesde santé à l’échelle nationale.

Encadré 2 : Influence des pilotes nationaux en Ethiopie depuisl’assentiment des autorités nationales jusqu’audéploiement de la PCMA

un rôle clé dans la limitation de la capacité deplanifier la PCMA et en l’absence de plans, lademande risque de dépasser l’offre, lesressources peuvent être gaspillées et la qualitépeut être compromise.

L’absence de données fiables sur les coûts etla rentabilité a également empiété sur la capac-ité des pays à développer des plans dedéploiement à l’échelle nationale, ou mêmed’intégrer la PCMA dans les plans opérationnelsexistants. Cet écart est à présent comblé au furet à mesure grâce à un nombre croissantd’études de rentabilité parvenant à des résultatssimilaires et offrant la possibilité de refléter laPCMA dans les outils et les plans de processusdécisionnels (voir encadré 3). Ces études conclu-ent que la PCMA présente un rapportcoût-efficacité similaire à celui d’autres interven-tions prioritaires en matière de santé desenfants et une « très bonne rentabilité » tel quedéfini par l’OMS14.

La plupart des pays ont progressé dans ledéveloppement de lignes directrices nationales,un processus nécessaire à la construction d’unconsensus national et à l’approbation de l’ap-proche pour adapter celle-ci au contexte dupays ; ce processus est également une conditionpréalable au reflet de la PCMA dans les poli-tiques. Les outils de travail, y compris desméthodes convenues pour la surveillance etl’élaboration de rapports, des listes de contrôlepour la supervision et du matériel de formationspécifique, sont également considérés commedes outils essentiels pour le développement descapacités. L’élaboration de directives nationalesen matière de PCMA est une étape importantedans la construction d’un consensus et d’uneapprobation et dans la standardisation de l’ap-proche dans le pays.

La place de la PCMA au sein du système desanté et des programmes de nutritionIl est important de savoir comment la PCMA est

14 L’OMS considère que les interventions sont rentbles si elles coûtent moins cher par AVCI que le revenu intérieur brut d’un pays par habitant

14 See Peter Hailey and Daniel Tewoldeberha (2010). Suggested New Design Framework for CMAM Programming. Field Exchange, Issue No 39, September 2010. p42. http://fex.ennonline.net/39/ suggested.aspx and CMAM Conference 2011 presen-tation on integration and scale up: http://cmamconference2011.org/country-presentations/

Haile Gebrselassie,Ethiopian formerOlympic Championand world recordholder, in addressto conference delegates

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it to the country context and as a prerequisite forthe reflection of CMAM in policy. Job aids, includingagreed monitoring and reporting formats, supervi-sion checklists and specific training materials arealso identified as critical tools for capacity develop-ment. The development of national CMAMguidelines is an important step for building consen-sus and buy-in and for standardising the approachin the country.

CMAM’s place within the health system and nutri-tion programmesHow CMAM is structured within the health systemand as a component of wider nutrition program-ming is important. Though this integration is widelybelieved to be advantageous in terms of efficientuse of resources and increased coverage, countryexperience shows that how CMAM fits within exist-ing structures and systems must be contextspecific. Whether CMAM is part of IMCI, whether itis delivered at health clinic or health post level,depends on the capacity of those programmes andstructures. A great deal more learning is needed ona country by country basis about how to integrateCMAM into broader essential health and nutritionprogrammes.

The value of decentralisation of CMAM in bring-ing the service closer to the population is clear, yetprogression to further decentralisation has to bebalanced with the capacity of the health system andresources available to support lower level imple-mentation.

structurée au sein du système de santé etcomment elle s’intègre au sein d’une program-mation plus vaste en matière de nutrition. Bienque cette intégration soit généralement consid-érée comme avantageuse en termesd’utilisation efficace des ressources et d’ac-croissement de la couverture, l’expérience despays montre que la façon dont la PCMA s’inscritau sein des structures et des systèmes existantsdoit être adaptée au contexte spécifique. Que laPCMA fasse partie de la PCIME, qu’elle soitofferte au niveau des cliniques de santé ou despostes de santé, cela dépend de la capacité desprogrammes et des structures en question. Unapprentissage beaucoup plus intense pays parpays est nécessaire quant à la façon d’intégrer laPCMA dans les services de santé essentiels et lesprogrammes de nutrition plus vastes.

Il est clair que la décentralisation de la PCMAa beaucoup de valeur car elle rapproche lesservices de la population, mais la progressionvers une décentralisation plus poussée doit êtreéquilibrée par les capacités du système de santéet les ressources disponibles pour appuyer lamise en œuvre aux échelons inférieurs.

Des liens devraient être tissés avec l’ANJE, lesprogrammes de surveillance de la croissance(growth monitoring program - GMP) ou les «semaines de santé des enfants », mais celadépend de l’état et de la robustesse de ces inter-ventions dans le pays en question. Dans lescontextes où des interventions nutrition deprévention et de traitement complémentairessont en place, des tentatives pour tisser des lienspourront être réalisées à la fois pour élargir lespossibilités de dépistages de la MAS chez lesenfants, pour assurer la continuité des soins desanté et de réadaptation pour les enfants et,

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Links to IYCF, growth monitoring programmes(GMP) or ‘child health weeks’ should be made, butthis depends on the status and strength of thoseinterventions in the country in question. Wherecomplementary nutrition prevention and treatmentinterventions are in place, attempts can usefully bemade to forge links both to widen opportunities foridentification of children with SAM, to provide conti-nuity of care and rehabilitation for children andultimately, to forge links which address the underly-ing health determinants of acute malnutrition andthereby, prevent its occurrence. CMAM can help tobring these issues onto the agenda. Particularlyeffective links have been demonstrated betweenHIV/TB programming and CMAM and to a lesserextent between IYCF and CMAM.

Many countries implementing CMAM scale upalso have some level of supplementary feedingprogrammes (SFPs) for the management of moder-ate acute malnutrition (MAM) in place. However,there is lack of clarity over whether a direct linkbetween SFPs and CMAM is feasible or advisable innon-emergency contexts, and if so in whichcontexts. MAM treatment through supplementaryfeeding may not be a sustainable national strategyfor many governments. There is therefore a need toexplore alternative means to address MAM throughinter-sectoral approaches and nutrition-sensitiveprogramming. More evidence is therefore neededon effective mechanisms (including cost) to manageMAM other than traditional SFPs.

The need for clarity of roles and functions withinthe health delivery system and amongst supportpartners is clear from the case studies. A positivecomplementary collaboration between develop-ment partners with clear division of roles is identifiedas one of the important enabling factors for thescale-up of CMAM.

The case study evidence seems to indicate that aspecific government unit/group supporting CMAMis not a prerequisite for scale-up but may add valuein terms of quality assurance and standardisation.Such a group requires dedicated resources to func-tion but can help to provide the continuity andpredictability of support required for scale-up.

CMAM capacity strengtheningAttempts are being made to strengthen capacitiesfor 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 inade-quate capacity of health systems at all levels andacross all elements (service delivery, workforce,health information systems, access to essentialmedicines, health financing and leadership and

A recent study15 assessed the cost effectiveness of CMAM toprevent deaths due to SAM in children under five using datafrom a rural district inMalawi in 2007. The method comparedthe cost of providing CMAM compared to the alternativeexisting inpatient only approach. The incremental costs andeffects (numbers of deaths) between the two options werecombined to estimate an incremental cost-effectiveness ratio(ICER).

The results showed that the implementation of CMAM as anaddition to the existing health services in the districtproduced a cost effectiveness ratio of $42 per Disabilityadjusted life year (DALY) averted. This figure is very close tothe findings of similar analyses carried out for an urbanCMAM programme in Lusaka, Zambia ($41 per DALY)16 and arural CMAM programme in Bangladesh ($26 per DALY)17.

WHO categorises interventions as cost-effective if they costless per DALY as a country’s gross domestic income per capita.Using this comparison, CMAM compares very favourably, forexample the gross domestic income per capita for Zambia is$1,23018. These cost effectiveness figures are also within thegeneral range of cost-effectiveness ratios estimated for otherpriority child health care interventions in low-income coun-tries. These include measles vaccination ($29-$58), casemanagement of pneumonia ($73)19, integrated managementof childhood illness ($38), universal salt iodisation ($34-36),iron fortification ($66-70) and insecticide treated bed nets formalaria prevention ($11 for sub-Saharan Africa)20.

Extrapolation of these results must consider potential differ-ences in context (i.e. SAM prevalence rates, populationdensity and coverage) but authors suggest that the findingsare relevant to a large number of settings where SAM isfound. The figure of around $41/DALY averted has conse-quently been used by the World Bank for the inclusion ofCMAM in their analysis of what scaling up nutrition will cost.21

Box 3: Cost effectiveness of CMAM

15 Wilford, R., Golden, K. And Walker, D.G., 2011. Cost effectiveness of community-based management of acute malnutrition in Malawi. Health Policy and Planning, 2011, pp.1-11.

16 Bachmann, M. O., 2009. Cost effectiveness of commu-nity-based therapeutic care for children with severe acute malnutrition in Zambia: decision tree model. Cost effectiveness and resource allocation, 7:2.

17 Sadler, K., Puett, C., Mothabbir, G. and Myatt, M., 2011, Community Case Management of Severe Acute Malnutrition in Southern Bangladesh. Feinstein International Centre and Save the Children report. Medford: Feinstein International Centre.

18 Bachmann, M. O., 2010. Cost effectiveness of community-based treatment of severe acute malnutrition in children. Expert review. Pharmaeconomics and Outcome Research, 10(5), pp.605-612.

19 Edejer, T,T., Aikins, M., Black, R., Wolfson, L., Hutubessy, R and Evans, D.B., 2005. Achieving the Millenium development goals for health. Cost effective-ness analysis of strategies for child health in developing countries. BMJ, 331: 1177.

20 Wilford, 2011. See footnote 14.21 Horton, S., Shekar, M., McDonald, C., Mahal, A. and

Brooks, K., 2010. Scaling up nutrition. What will it cost? Washington DC: The World Bank.

quant aux mécanismes efficaces (y compris les coûts)pour gérer la MAM en dehors des PAS traditionnels.

La nécessité de clarifier les rôles et les fonctionsau sein du système de santé et parmi les partenairesde soutien apparaît comme une évidence lorsqu’onse penche sur les études de cas. Une collaborationpositive et complémentaire entre les partenaires audéveloppement avec une division claire des rôles estconsidérée comme l’un des facteurs importantspermettant le déploiement de la PCMA.

Les études de cas semblent indiquer qu’uneunité/groupe de soutien PCMA spécifique au sein dugouvernement n’est pas une condition préalable audéploiement, mais peut ajouter de la valeur entermes d’assurance qualité et de standardisation. Untel groupe nécessite des ressources dédiées afin defonctionner, mais peut contribuer à assurer la conti-nuité et la prévisibilité de l’appui nécessaire audéploiement.

Le renforcement des capacités de la PCMADes tentatives sont faites pour renforcer les capac-ités d’intégration de la PCMA dans lesétablissements de santé au niveau du district, sous-national et national dans tous les pays. Le principal

finalement, pour former des liens en rapport avec lesfacteurs déterminants sous-jacents de la malnutritionaiguë et ainsi prévenir l’apparition de celle-ci. LaPCMA peut contribuer à intégrer ces questions àl’agenda politique. Des liens particulièrement effi-caces ont été mis en évidence entre les programmesconsacrés au VIH/ tuberculose d’une part et la PCMAd’autre part et dans une moindre mesure entre l’ANJEet la PCMA.

De nombreux pays mettant en place ledéploiement de la PCMA disposent également deprogrammes de nutrition supplémentaire (PNS) d’uncertain niveau destinés à la prise en charge de lamalnutrition aiguë modérée (MAM). Cependant, onconstate un manque de clarté quant à savoir si unlien direct entre les PNS et la PCMA est possible ousouhaitable dans des contextes non urgents, et si oui,dans quels contextes exactement. Le traitement de laMAM par alimentation supplémentaire n’apparaîtpeut-être pas comme une stratégie nationale durablepour de nombreux gouvernements. Il est donc néces-saire d’explorer des moyens alternatifs pour résoudrela MAM par le biais des approches intersectorielles etdes programmes prenant en charge la nutrition. Despreuves supplémentaires sont donc nécessaires

Une étude récente15 a évalué la rentabilité de la PCMA pourprévenir les décès dus à la MAS chez les enfants de moins decinq ans en utilisant des données provenant d’un districtrural au Malawi en 2007. La méthode a comparé le coût de laprestation de la PCMA par rapport à l’approche alternativeexistante basée sur l’hospitalisation des patients. Les coûts etles effets (le nombre de décès) supplémentaires entre lesdeux options ont été combinés pour estimer un rapportcoût-efficacité différentiel (RCED).

Les résultats ont montré que la mise en œuvre de la PCMA encomplément aux services de santé existants dans le district aproduit un rapport coût-efficacité de 42 $ par année de viecorrigée du facteur invalidité (AVCI ou DALY en anglais). Cechiffre est très proche des résultats des analyses similaireseffectuées pour un programme urbain de PCMA à Lusaka, enZambie (41 $ par AVCI)16 et un programme PCMA rural auBangladesh (26 $ par AVCI)17.

L’OMS considère que les interventions sont rentables si ellescoûtent moins cher par AVCI que le revenu intérieur brutd’un pays par habitant. Lorsqu’on utilise cette comparaison,la PCMA se positionne très favorablement, par exemple, lerevenu intérieur brut par habitant pour la Zambie est 1,230$18. Ces chiffres de rentabilité se situent également dans leslimites de la gamme générale des ratios coût-efficacitéestimés pour d’autres interventions prioritaires en matièrede santé des enfants dans les pays à faible revenu. Cesdernières comprennent la vaccination contre la rougeole (29$-58 $), la prise en charge des cas de pneumonie (73 $)19, laprise en charge intégrée des maladies de l’enfance (38 $), l’io-dation universelle du sel (34-36 $), l’enrichissement en fer(66-70 $) et des moustiquaires traités à l’insecticide contre lepaludisme (11 $ pour l’Afrique subsaharienne)20.

L’extrapolation de ces résultats doit tenir compte desdifférences potentielles dans le contexte (c.-à-d. taux deprévalence de MAS, densité de population et couverture),mais les auteurs suggèrent que les résultats sont pertinentspour un grand nombre de sites où l’on rencontre la MAS. Lemontant d’environ 41 $/AVCI évitée a par conséquent été util-isé par la Banque mondiale pour l’inclusion de la PCMA àl’analyse du coût du déploiement de la nutrition21.

Encadré 3 : Rentabilité de la PCMA

15 Wilford, R., Golden, K. et Walker, D.G., 2011. Cost effectiveness of community-based management of acute malnutrition in Malawi. Health Policy and Planning (Rentabilité de la prise en charge commu-nautaire de la malnutrition aiguë au Malawi. Politique et planification de la santé), 2011, pp.1-11.

16 Bachmann, M. O., 2009. Cost effectiveness of community-based therapeutic care for children with severe acute malnutrition in Zambia : decision tree model. Cost effectiveness and resource allocation, (Rentabilité des soins communautaires thérapeutiques pour les enfantssouffrant de malnutrition aiguë sévère en Zambie : modèle de schéma de décision. Rapport coût-efficacitéet distribution des ressources) 7 :2.

17 Sadler, K., Puett, C., Mothabbir, G. et Myatt, M., 2011,Community Case Management of Severe Acute Malnutrition in Southern Bangladesh. Feinstein International Centre and Save the Children report (Prise en charge communautaire de la malnutrition aiguë sévère dans le sud du Bangladesh. Rapport du Feinstein International Centre et de Save the Children).Medford : Feinstein International Centre.

18 Bachmann, M. O., 2010. Cost effectiveness of commu-nity-based treatment of severe acute malnutrition in children. Expert review. Pharmaeconomics and Outcome Research (Rentabilité du traitement commu-nautaire de la malnutrition aiguë sévère chez les enfants. Évaluation par un groupe d’experts. Recherchesur la pharmaéconomie et les résultats), 10(5), pp.605-612.

19 Edejer, T,T., Aikins, M., Black, R., Wolfson, L., Hutubessy,R et Evans, D.B., 2005. Achieving the Millenium devel-opment goals for health. Cost effectiveness analysis ofstrategies for child health in developing countries. (Atteindre les objectifs de développement du Millénaireen matière de santé. Analyse coût-efficacité des stratégies de santé de l’enfant dans les pays en développement). BMJ, 331 : 1177.

20 Wilford, 2011. Voir note en bas de page 14.21 Horton, S., Shekar, M., McDonald, C., Mahal, A. et

Brooks, K., 2010. Scaling up nutrition. What will it cost? (Déploiement de la nutrition. Quels seront les coûts ?) Washington DC : La Banque mondiale.

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8

In Mauritania*, Burkina Faso*, Niger, Somalia,Mozambique and Pakistan, the difficulties ofensuring quality and experienced trainers as thetraining of trainers (TOT) cascades down has ledto demonstrated dilution in the quality of train-ing and resulted in a shift in approach.

In Niger, large numbers of trainers were trainedusing the TOT approach leading to good owner-ship of CMAM by the government. However, thelack of practical and training skills of the trainers,and lack of oversight by the more experiencednational technical team, led to questions of qual-ity. Systematic on the job follow-up andsupportive supervision was identified as a meansto rectify the situation, however, it was recognisedthat the existing pool of trainers did not havesufficient skills and experience to do this. This isgradually being addressed through additionalinputs by the expert technical team working withexisting trainers and carrying out follow-up. InMozambique, the close follow-up of servicedelivery required after trainings has been identi-fied as a potential role for NGOs.

In Somalia, it was quickly recognised that the TOTled to the wrong people being trained and skillsnot being passed down. Providing on the jobmentoring was, however, a challenge in theSomalia context given the access issues. Toaddress this, a system of international partnersmentoring local partners who would thenconduct the follow-up on the ground was insti-tuted. This system aims to help localimplementing partners not only to better supportCMAM on the ground but also to improve theirtechnical capacity in nutrition, as well as their

Box 4: Country examples of capacity strengthening

skills in project cycle management, proposal writingand reporting. The system is reported to be workingsuccessfully, e.g. Action Contre la Faim (ACF) actingas a training centre for local organisations andOxfam NOVIB partnering with a local NGO for capac-ity building.

Other countries (Malawi, Kenya, Ghana, Ethiopia,Sierra Leone) recognised the inadequacy of TOT forCMAM from the outset and used a combination ofclassroom training by experienced trainers followedby close on the job mentoring. InMalawi, a nationaltraining team (39 people) comprises experiencedmembers from District Health Offices where CMAMhas been implemented successfully and NGO part-ners. In Ethiopia, additional UNICEF staff wererecruited to support sub-national trainings andparticularly to support follow-up to the training. InKenya, for the urban and 22 ASAL (arid and semi-arid) districts, programme TOT was combined withpractical training at health facilities. District healthteams were supported by experienced trainers toprovide training for their own staff. On the jobsupport followed, which was scaled down based oneach facility’s ability to implement the protocols.Lessons were that on the job support was essentialfor the retention of skills and continuity of scale-up.They also found that, as the majority of training wason the job, staff were not taken out of facilities. Thisexperience also illustrated that with proper plan-ning, this method actually allowed more staff to betrained than the traditional TOT approach.

*Source: FANTA, 2010. Review of Community-BasedManagement of Acute Malnutrition Implementation inWest Africa, Summary Report (2011). Burkina Faso, Mali,Mauritania, and Niger. http://www.fantaproject.org/publications

À cause de la baisse des activités en matière deFormations de formateurs (FF) en Mauritanie*, auBurkina Faso*, au Niger, en Somalie, auMozambiqueet au Pakistan, il est devenu difficile d’assurer desformateurs expérimentés et de qualité, et cela a mené àune dilution évidente de la qualité de la formation et aabouti à un changement de l’approche.

Au Niger, un grand nombre de formateurs ont étéformés en utilisant l’approche FF ce qui a conduit à unebonne appropriation de la PCMA par le gouvernement.Cependant, le manque de compétences des formateursen matière de pratique et de formation et le manque desupervision par l’équipe nationale technique plusexpérimentée ont conduit à des problèmes de qualité.Le contrôle systématique sur le lieu de travail et un suivide soutien ont été désignés comme étant un moyen deremédier à la situation, cependant, on reconnait que labase actuelle de formateurs ne dispose pas de compé-tences suffisantes et de l’expérience nécessaires. Ontente progressivement de remédier à ce problème parle biais d’une participation accrue de l’équipe d’expertstechniques travaillant avec des formateurs existants eteffectuant le suivi. Au Mozambique, le suivi étroit de laprestation des services requis après des formations aété désigné comme rôle potentiel pour les ONG.

En Somalie, il a été rapidement reconnu que la FF avaitconduit à la formation des mauvaises personnes et queles compétences n’avaient pas été transmises. Fournirdu mentorat sur le lieu de travail a cependantreprésenté un défi dans le contexte de la Somalie,compte tenu des problèmes d’accès. Pour résoudre ceproblème, on a mis en place un système de partenairesinternationaux assurant le mentorat des partenaireslocaux dont le rôle était par la suite de mener le suivi surle terrain. Ce système vise à aider les partenaires de miseen œuvre locaux non seulement à mieux soutenir laPCMA sur le terrain mais aussi à améliorer leur capacitétechnique en matière de nutrition, ainsi que leurscompétences en gestion du cycle de projet et en rédac-tion de propositions et de rapports. Selon les échos, lesystème fonctionne très bien, par exemple, Action

Encadré 4 : Renforcement des capacités - Exemples de pays

Contre la Faim (ACF) fonctionne comme centre de forma-tion pour les organisations locales et Oxfam Novibtravaille en partenariat avec une ONG locale pour lerenforcement des capacités.

D’autres pays (le Malawi, le Kenya, le Ghana,l’Ethiopie, la Sierra Leone) ont reconnu l’insuffisancedes formations de formateurs pour la PCMA dès ledépart et ont misé sur des formations en classe par desformateurs expérimentés suivies de près par dumentorat sur le lieu de travail. Au Malawi, une équipede formation nationale (39 personnes) comprend desmembres expérimentés des bureaux de santé de districtoù la PCMA a été mise en œuvre avec succès ainsi quedes membres des ONG partenaires. En Éthiopie, davan-tage de membres du personnel de l’UNICEF ont étérecrutés pour appuyer des formations au niveau local eten particulier pour soutenir le suivi de la formation. AuKenya, dans le cas des districts urbains et de 22 districtsarides et semi-arides (ASAL), le programme de FF a étécombiné avec une formation pratique dans les étab-lissements de santé. Les équipes de santé de district ontété prises en charge par des formateurs expérimentéspour que ces dernières fournissent une formation à leurpropre personnel. Un soutien sur le lieu de travail asuivi, qui a été délégué en fonction de la capacité dechaque établissement à mettre en œuvre les protocoles.Les leçons ont démontré que le soutien à l’emploi étaitessentiel pour le maintien des compétences et la conti-nuité du déploiement. Les équipes ont égalementconstaté que, comme la majorité de la formation sedéroulait au travail, le personnel ne quittait pas l’étab-lissement. Cette expérience a également montréqu’avec une bonne planification, cette méthode perme-ttait de former plus de personnel que dans le cas del’approche FF traditionnelle.

*Source : FANTA, 2010. Review of Community-BasedManagement of Acute Malnutrition Implementation in WestAfrica, Summary Report (2011). Burkina Faso, Mali, Mauritania,and Niger.(Examen de la Prise ne charge communautaire de lamalnutrition aiguë en Afrique occidentale, Résumé de rapport(2011). Burkina Faso, Mali, Mauritanie et Niger) http://www.fantaproject.org/publications

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governance). Specific challenges for CMAM include numbers ofstaff, their competencies, and motivation of and over-reliance onvolunteers. Furthermore, the long term commitment required forcapacity strengthening for systems and structures is widely iden-tified as a significant challenge with short term fundingmodalities.

Key NGOs are increasingly being called on to be responsive togovernment rather than donor agendas and to focus on capacitystrengthening. This requires a shift both on the part of NGOs,away from pursuing the more readily available short term emer-gency funding whenever it comes along, and on the part ofdonors, to make available more appropriate longer term fundingchannels for CMAM.

Experience shows that with proper planning, integration canallow more staff to be trained. Integrating trainings, i.e. CMAMwith IYCF or understanding and identification of SAM within thefull training package for community health workers is a way ofmanaging training resources more efficiently and minimisingtime spent away from service. An additional common assertion isthe 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 allstaff in facilities and focus on building capacity of the districthealth team has allowed sufficient capacity to be built up inorder for new staff to be mentored on the CMAM protocols fromwithin. This reduces the burden on national trainers and buildsownership at local level. Integration of CMAM into pre-servicetraining is also held up as preferable in all cases, though progresson this has only been made in a few countries so far.

In general, a combination of classroom training by experiencedtrainers, followed by close practical on the job mentoring andlearning visits where health workers support each other, is themost effective way to maintain the quality of training, help traineesto retain skills and minimise time out of the facility (See Box 4). Inorder to facilitate reliable and predictable CMAM capacity, there is

obstacle auquel le déploiement fait face réside dans lacapacité insuffisante des systèmes de santé à tous lesniveaux et dans tous les aspects (la prestation de serv-ices, la main-d’œuvre, les systèmes d’information desanté, l’accès aux médicaments essentiels, le finance-ment de la santé et le leadership et la gouvernance). Lesdéfis spécifiques que la PCMA est forcée de releverconcernent la dotation en personnel, les compétencesde celui-ci, ainsi que la motivation des bénévoles et ladépendance à l’égard de ceux-ci. En outre, l’engage-ment à long terme nécessaire pour le renforcement descapacités des systèmes et des structures est générale-ment identifié comme un défi de taille avec desmodalités de financement à court terme.

Les ONG clés sont de plus en plus appelées à réagiraux programmes des gouvernements plutôt qu’à ceuxdes bailleurs de fonds et de se concentrer sur lerenforcement des capacités. Cela exige un changementà la fois de la part des ONG d’une part, qui doiventcesser de faire la chasse aux fonds d’urgencedisponibles à court terme quelle que soit leur prove-nance, et de la part des bailleurs de fonds d’autre part,qui doivent mettre à disposition davantage de moyensappropriés pour le financement à plus long terme de laPCMA.

L’expérience montre qu’avec une bonne planifica-tion, l’intégration peut permettre de former davantagede personnel. L’intégration des formations (à savoirl’ANJE au sein de la PCMA ou la compréhension etl’identification de la MAS) dans le programme de forma-tion complet pour les travailleurs de santécommunautaires constitue une façon de gérer lesressources de formation plus efficacement et enminimisant le temps que le personnel passe en dehorsdu service. Une autre affirmation courante concerne lanécessité d’axer davantage de formations sur la gestionde la PCMA (planification, logistique et gestion de lachaîne d’approvisionnement, suivi, supervision etrapports) à l’attention des équipes de santé de district.

Dans les lieux ayant un taux élevé de rotation dupersonnel de santé, la formation de l’ensemble dupersonnel dans les structures et l’accent sur le renforce-

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Strengthening the role of the communityThere has been a lack of attention to the communitycomponent of CMAM which is attributed to insufficientunderstanding of the importance of this element ofprogramming, lack of funds, insufficient expertise,concerns about overburdening the system and lack ofleadership in that area. Who to involve in CMAM and howcannot be prescribed, although conducting investigationof potential community agents and channels, sensitisingthem about the programme and eliciting their involve-ment in elements such as case finding are critical steps inCMAM implementation and sustainability. CMAM with-out a strong community base is limited in its coverageand impact, and therefore strategic advocacy for incor-poration of this element of CMAM in wider policies willbe required in order to reflect the comprehensiveapproach.

The existence of community level health workers cangreatly influence the progression of CMAM by providingan instant delivery mechanism for mobilisation, screen-ing and, in some cases, treatment for uncomplicatedSAM. However they are not a prerequisite. There is expe-rience of using volunteers and key community figureseffectively for mobilisation. These modalities are notwithout their challenges, particularly in the area of incen-tives, and a balance must be struck between motivation,the amount of work that is required of volunteers and thegeographical areas they are expected to cover.

The implications of not focusing on the communitymobilisation component of the CMAM approach(community sensitisation, screening, referral and follow-up mechanisms) have been experienced in a majority ofthe case study countries and reflected in poor coverage.However, increasingly and with the help of coverageassessments to identify the problem and the barriers toaccess, this lesson is being learned. The importance ofroutinely implementing coverage assessments and ofbuilding national capacity to do so is consequently also

emphasised. The community-level component of CMAMcan be sustained by governments through existing large-scale programmes with a community element (e.g.primary health-care services) and a national communitymobilisation strategy, cutting across sectors, wouldsupport scale-up of CMAM, other nutrition programmesand other basic services.

Supervision, monitoring and coverageWith the exception of coverage, most countryprogrammes are reaching internationally-agreedprogramme performance targets. Supervision and moni-toring for CMAM is a common challenge for the majorityof countries. However, some positive experiences havebeen joint supervision with support partners, third partymonitoring and triangulation of information throughcommunity level informants. Simplification of monitor-ing formats (currently often overcomplicated and rarelyanalysed or acted upon) and clear systems for analyses,action and feedback are required. These issues and thetimeliness of reporting may be partly addressed by meth-ods currently being piloted using rapid SMS technology.Once monitoring has been simplified, it may be possibleto include some aspects at least into national healthmanagement information systems (HMIS). This processhas begun in a minority of countries.

For monitoring the performance of CMAM in anycontext, Sphere indicators are still the main markers used(at least for recovery, default, death and coverage). Therehave been questions raised as to their appropriateness inthe non-emergency context. However, well run nationalprogrammes are achieving results within these standardsfor recovery, default and death. This is not the case forcoverage and as new assessment methods becomeincreasingly applied to assess coverage at national level,we are gaining information about the kind of coveragethat is possible over time.

The HMIS is critical in the flow of management infor-mation through all levels. CMAM needs to be

a need to locate CMAM in a variety of pre-service trainingcurricula at national level. All CMAM actors should activelydisseminate good practices, tools, materials, trainingprogrammes and other relevant resources directly togovernments and, where feasible, governments and devel-opment partners should facilitate cross-country learningand networking.

Different countries have responded in different waysto capacity constraints. For example, by placing addi-tional nutrition staff at district and regional levels,experimenting with mobile teams and mobilising exist-ing support staff to be involved in the CMAM service. Themost appropriate solutions will be context specific. Acommon conclusion is that the need for assessment ofexisting capacities and gaps to identify where additionalresources are most urgently required would help addressgaps more efficiently.

l’objet d’une attention suffisante ; ceci est attribué à unecompréhension insuffisante de l’importance de cetélément des programmes, au manque de fonds, auxcompétences insuffisantes, aux préoccupations liées à lasurcharge du système et au manque de leadership dansce domaine. On ne peut pas prescrire qui impliquer dansla PCMA ni comment le faire, cependant, mener desenquêtes sur les potentiels agents et canaux communau-taires tout en sensibilisant ces derniers à propos duprogramme et en suscitant leur implication dans desaspects tels que le dépistage des cas, sont des étapescruciales dans la mise en œuvre et la durabilité de laPCMA. Sans une solide base communautaire, la portée etl’impact de la PCMA sont limités, par conséquent unplaidoyer stratégique pour l’incorporation de cetélément de la PCMA dans des politiques plus vastes seranécessaire afin de refléter l’approche globale.

La présence des travailleurs de la santé au niveaucommunautaire peut grandement influencer la progres-sion de la PCMA en fournissant un mécanisme instantanépour la mobilisation, le dépistage et, dans certains cas, letraitement de la MAS sans complications. Cependant, cen’est pas une condition préalable. L’implication de bénév-oles et des personnalités clés de la communauté a fait sespreuves en matière de mobilisation. Ces modalitésprésentent des défis, en particulier dans le domaine desincitations, et un équilibre doit être institué entre la moti-vation, la quantité de travail qui est exigé de bénévoles etles zones géographiques qu’ils sont censés couvrir.

Une focalisation insuffisante sur la composante «mobilisation communautaire » de l’approche PCMA(sensibilisation de la communauté, mécanismes dedépistage, d’orientation en vue d’un traitement et desuivi) a été expérimentée dans la majorité des pays del’étude de cas et se traduit par une faible couverture.Cependant, avec l’aide des évaluations de couverturepour identifier le problème et les obstacles à l’accès, cetteleçon est de mieux en mieux intégrée. L’importance de lamise en œuvre systématique des évaluations de couver-ture et du renforcement des capacités nationales pour cefaire a par conséquent également été soulignée. Le voletcommunautaire de la PCMA peut être soutenu par lesgouvernements par l’entremise des programmes de

grande envergure existants contenant un élémentcommunautaire (par exemple des services de soins desanté primaires) et une stratégie nationale de mobilisa-tion communautaire à travers les secteurs supporterait ledéploiement de la PCMA, d’autres programmes de nutri-tion et d’autres services de base.

Supervision, suivi et couvertureHormis la couverture, la plupart des programmesnationaux atteignent les objectifs de performanceconvenus au niveau international. La supervision et lesuivi de la PCMA constituent un défi commun pour lamajorité des pays. Cependant, des expériences positivessont nées de la cotutelle avec des partenaires de soutien,de la surveillance par des tiers et de la triangulation desinformations par le biais d’informateurs au niveaucommunautaire. Une simplification des méthodes desuivi (actuellement souvent trop compliquées etrarement analysées ou prises en compte) et l’élaborationde systèmes clairs pour les analyses, l’action et la rétroac-tion sont nécessaires. Ces problèmes de même que larapidité de l’information peuvent être partiellement réso-lus par les méthodes actuellement à l’essai à l’aide de latechnologie SMS rapide. Une fois que la surveillance auraété simplifiée, il deviendra possible d’inclure au moinscertains aspects dans les systèmes de gestion des infor-mations de la santé (SGIS) nationaux. Ce processus a étéinauguré dans une minorité de pays.

Pour surveiller la performance de la PCMA dans n’im-porte quel contexte, les indicateurs Sphère restent lesprincipaux repères utilisés (au moins pour le rétablisse-ment, les abandons, les décès et la couverture). Desquestions ont été soulevées quant à leur pertinence dansles contextes hors urgence. Cependant, les programmesnationaux bien gérés obtiennent des résultats conformesà ces normes en termes de rétablissement, d’abandons etde décès. Ce n’est pas le cas pour la couverture et étantdonné que de nouvelles méthodes d’évaluation sont deplus en plus appliquées pour évaluer la couverture auniveau national, nous obtenons des informations sur letype de couverture possible au fil du temps.

Le SGIS est essentiel à la circulation de l’informationde gestion à tous les niveaux. La PCMA doit y être incor-

ment des capacités de l’équipe de santé de district ontpermis le développement d’une capacité suffisante pourque les nouveaux employés soient formés de l’intérieur surles protocoles relatifs à la PCMA. Cela réduit la charge desformateurs nationaux et permet la reconnaissance auniveau local. L’intégration de la PCMA dans la formationpré-emploi est également considérée comme préférabledans tous les cas, bien que les progrès sur ce terrain n’aientété accomplis que dans quelques pays jusqu’à présent.

En général, la combinaison d’une formation donnéeen classe par des formateurs expérimentés avec une miseen pratique effectuée juste après via un mentorat sur lelieu de travail et via des visites d’apprentissage où lesagents de santé se soutiennent mutuellement, est lemoyen le plus efficace de maintenir la qualité de laformation, d’aider les participants à s’approprier lescompétences et de minimiser le temps que les partici-pants passent en dehors de l’établissement (voir encadré4). Afin d’assurer des capacités fiables et prévisibles enmatière de PCMA, il est nécessaire d’inclure la PCMA dansune variété de programmes de formation pré-emploi auniveau national. Tous les acteurs de la PCMA devraientdiffuser activement les bonnes pratiques, les outils, lesmatériaux, les programmes de formation et d’autresressources pertinentes directement aux gouvernementset, si possible, les gouvernements et les partenaires audéveloppement devraient faciliter l’apprentissage et leréseautage entre les pays.

Les différents pays ont réagi de différentes manièresaux contraintes de capacité - par exemple, en plaçantdavantage de personnel de nutrition au niveau dudistrict et des régions, en expérimentant avec deséquipes mobiles et en mobilisant le personnel de soutienexistant pour que celui-ci s’implique dans le service de laPCMA. Les solutions les plus appropriées sont spécifiquesau contexte. La conclusion commune est que l’évaluationdes capacités et des lacunes existantes afin d’identifierles endroits où il faut des ressources supplémentaires detoute urgence aiderait à combler les lacunes de manièreplus efficace.

Renforcer le rôle de la communautéLa composante communautaire de la PCMA n’a pas fait

Anganwadi worker with childrenin Anganwadi centre in India

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As the weight and volume of RUTF is much greater thanthe usual medicinal commodities which go throughPHARMID23, the decision was made for UNICEF to workdirectly with regional and zonal health bureaus to deliverdirectly to them. NGOs would support delivery down tofacility level.

Regional Health Bureaus (RHBs) submit requests based onmonthly caseloads that are reported to them by technicalCMAM focal points at district level. These same focalpoints are responsible for RUTF distribution.Unfortunately requests are often limited by storagecapacity. Currently, plans are in place to enter RUTFsupply into the national Integrated Pharmaceutical andLogistics system (IPLS). However this will be a gradualprocess as the capacity of that system for RUTF is built.

The Food by Prescription programme (FBP) in Ethiopia hasalready managed to integrate RUTF into IPLS for a limitednumber of sites, at health centre and hospital levels.Requests are based on numbers treated over two monthperiods and a minimum two month and maximum fourmonth buffer stock is held at each facility depending onstorage capacity. There is also an emergency refill mecha-nism in place. Monitoring at facility level is supported byan NGO (Save the Children US) and when RUTF arrives atthe facility it enters the pharmacy system and is distrib-uted based on prescrip- tions received by patients. TheNGO carried out logistics training for pharmacy staff in allthe FBP facilities. It is felt that IPLS is a strong manage-ment system and avoids serious misuse of the product.

Box 5: Ethiopia RUTF supply chain experience

22 The percentage of children suffering from SAM who are actually being reached by treatment (only measurable by survey/assessment).

23 PHARMID is a parastatal import and distribution company in Ethiopia, with all shares currently held by the Government. PHARMID has been contracted by the MOH to provide drug management services for specific programmes.

incorporated but until then, governments and partnersmay need to run parallel information systems or includea simple set of indicators in the existing system.

Impressive scale-up has been achieved in a number ofcountries, at its most successful reaching implementationin up to 70-90% of health facilities. Where CMAM isperhaps set apart from other interventions is that,embedded in the approach, is the fact that unless there isquality implementation (including the communitycomponent), true coverage22 is not achievable. The chal-lenge for countries therefore has been to reconcile thepush for geographical coverage with that of achieving‘true’ coverage of the population in need. This has provento be more achievable using a phased approach, withexpansion based on demonstrated quality of service andavailability of resources (human and material).

Measures to assess and act upon poor coverage havethen been added so that, within areas where the serviceis up and running, coverage of the population in need canbe gradually increased. This approach has, in some cases,been undermined by agencies trying to implement toomuch too soon, rushing to increase geographical cover-age, or to programme supplies without checks for qualityor building of sufficient local capacities. The results arecompromised service quality and poor coverage, under-mining the critical effectiveness of the programme andthe motivation of communities. This challenge has beenpartly attributed to short term funding and has beenidentified frequently in numerous countries.

The drive to achieve geographical/facility coverage iscommon to the scale-up of all interventions but it mustbe balanced with the maintenance of programme qual-ity, including coverage of all those in need.

CMAM and the provision of RUTFGiven the finances required to provide sufficient RUTF tocure a child of SAM (approximately $50-60), it is clear thatmajor RUTF benefactors are required to get CMAM off

porée, mais jusque-là, les gouvernements et les parte-naires doivent utiliser des systèmes d’informationparallèles ou inclure un ensemble d’indicateurs simplesdans le système existant.

Un déploiement impressionnant a été réalisé dansun certain nombre de pays avec une réussite de mise enœuvre au niveau portée atteignant jusqu’à 70-90 % desétablissements de santé. La PCMA se situe peut-être àpart des autres interventions dans le sens où, au cœurde l’approche est le fait qu’en l’absence d’une mise enœuvre de la qualité (y compris le volet communautaire),une couverture efficace22 n’est pas réalisable. Le défipour les pays a donc été de concilier la pression quant àla couverture géographique avec la pression liée à lanécessité d’une « vraie » couverture pour la populationdans le besoin. Cette démarche s’est avérée être plusréalisable par le biais d’une approche progressive, avecune expansion basée sur la qualité démontrée du serv-ice et la disponibilité des ressources (humaines etmatérielles).

Par la suite, on a ajouté des mesures visant à évaluerla couverture et à réagir au manque de celle-ci afin que,dans les zones où le service est en place et fonctionnel,la couverture de la population dans le besoin puisse êtreaugmentée progressivement. Dans certains cas, cetteapproche a été minée par des organismes qui tentent demettre en œuvre trop de mesures trop rapidement, seprécipitant pour augmenter la couverturegéographique ou encore pour planifier l’arrivée de four-nitures sans effectuer un contrôle de qualité préalableou sans renforcer suffisamment les capacités locales.Cela débouche sur une qualité de service insuffisante etune mauvaise couverture, sapant l’efficacité cruciale duprogramme et la motivation des communautés. Ce défia été attribué en partie au financement à court terme eta souvent été pointé du doigt dans de nombreux pays.

La volonté de parvenir à une couverture au niveaugéographique et/ou au niveau des établissements desanté est commune au déploiement de toutes les inter-ventions, mais doit s’équilibrer avec le maintien de laqualité du programme, y compris la couverture de tousceux dans le besoin.

22 Le pourcentage d’enfants souffrant de MAS qui sont effectivement à portée du traitement et en bénéficient (seulement mesurable par enquête/évaluation).

23 PHARMID est société de distribution et d’importation paraétatique située en Éthiopie, dont toutes les actions sont actuellement détenues par le gouvernement. Le ministère de la Santé a conclu une entente avecPHARMID pour qu’elle fournisse des services de gestion des médicaments dans le cadre de programmes spécifiques.

Comme le poids et le volume des ATPE sont beaucoupplus importants que ceux des médicaments habituelsqui passent par PHARMID23, il a été décidé que l’UNICEFtravaillerait directement avec les bureaux de la santéadministrant les régions et les zones concernées pourleur fournir les ATPE. Les ONG appuieraient la presta-tion jusqu’au niveau des établissements.

Les bureaux régionaux de la santé présentent desdemandes basées sur le nombre de cas mensuels quileur sont signalés par des points focaux techniques dela PCMA au niveau du district. Ces mêmes pointsfocaux sont responsables de la distribution des ATPE.Malheureusement, les demandes sont souvent limitéespar la capacité de stockage. Actuellement, des planssont en place pour intégrer l’approvisionnement enATPE au système pharmaceutique et logistique intégré(SPLI) national. Toutefois, il s’agira d’un processusgraduel vu que la capacité de ce système à inclure lesATPE est en cours de construction.

Le programme d’aliments par ordonnance (APO) enÉthiopie a déjà réussi à intégrer les ATPE au sein duSPLI pour un nombre limité de sites, dans les centresde santé et dans les hôpitaux. Les demandes sontbasées sur les chiffres traités sur des périodes de deuxmois et un stock régulateur d’un minimum de deuxmois et d’un maximum de quatre mois est tenu danschaque établissement en fonction de la capacité destockage. Un mécanisme de recharge d’urgence estégalement en place. Le suivi au niveau de l’établisse-ment est pris en charge par une ONG (Save theChildren US) et quand les ATPE parviennent à l’étab-lissement, ils sont entrés dans le systèmepharmaceutique et distribués sur la base de prescrip-tions reçues par les patients. L’ONG a assuré laformation logistique du personnel des pharmaciesdans toutes les installations des APO. Il est estimé quele SPLI est un système de gestion solide qui évite lesabus importants d’ATPE.

Encadré 5 : Expérience d’une chaîne d’approvisionnement d’ATPE - Éthiopie

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the ground. Emergency resources have providedthese funds in many cases and in other contexts,external agencies are covering the costs.

Pipeline breaks are common. A minority of theseare attributed to shortage in global supplies andissues of customs clearance. However the majorityare a result of insufficient buffer stocks and poorforecasting related to late reporting, late communi-cation of requests, and insufficient planning to takeaccount of increases in caseload. Increments in case-load may happen due to expansion, intensificationof mobilisation activities or the use of RUTF for othertarget groups, e.g. children with MAM.

These issues are reported even in instanceswhere parallel delivery systems supported by UNagencies and NGOs are being implemented. Theregistering of RUTF as an essential supply/commod-ity has facilitated easier integration into the nationalsupply chain in some countries. However it is clearthat considerable supply chain support is needed ifsupplies are to be delivered through governmentmechanisms (see Box 5).

Forecasting mistakes have been made as a resultof using calculations based on population, SAMprevalence and estimated coverage, all of which arefraught with inaccuracies. Forecasting of district/sub-national/ national requirement based onconsumption makes more sense but improvementsto the accuracy and timeliness of reporting arerequired for this to be reliable. Extrapolation is alsorequired where reports are missing, or to takeaccount of expansion plans and any predictedsurges in prevalence. The inclusion of stock report-ing into CMAM admissions reports, designatedminimum stock levels defined on a facility basis, andthe use of rapid SMS for RUTF stock reporting andrequests have produced positive results.

La PCMA et la fourniture d’ATPECompte tenu des fonds nécessaires pour fournir suff-isamment d'ATPE afin de soigner un enfant atteint deMAS (environ 50-60 $), il est clair que l’on a besoin debienfaiteurs fournissant des ATPE si l’on souhaite quela PCMA prenne son envol. Des ressources de secoursont fourni ces fonds dans de nombreux cas et dansd’autres contextes, des organismes externes couvrentles frais.

Les ruptures d’approvisionnement sont monnaiecourante. Une minorité est attribuée à la pénurie dansles approvisionnements mondiaux et à des problèmesde dédouanement. Toutefois, la majorité résulte del’insuffisance de stocks régulateurs et d’une mauvaiseprévision liée à des rapports tardifs, à une communica-tion tardive des demandes et à une planificationinsuffisante lorsqu’il s’agit de tenir compte desaugmentations du nombre de cas. Des augmentationsdu nombre de cas peuvent se produire en raison del’expansion, de l’intensification des activités de mobil-isation ou de l’utilisation d’ATPE pour d’autres groupescibles, par exemple les enfants souffrant de MAM.

Ces problèmes sont signalés même dans les cas oùdes systèmes de prestation parallèles soutenus par lesagences de l’ONU et des ONG sont mis en œuvre. Laclassification des ATPE comme marchandise/produitessentiel a facilité leur intégration au sein de la chaîned’approvisionnement nationale dans certains pays.Toutefois, il est clair qu’un soutien important de lachaîne d’approvisionnement est nécessaire si l’onsouhaite que les approvisionnements soient livrés parle biais de mécanismes gouvernementaux (voirencadré 5).

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By producing RUTF closer to home, the transit timesfor receiving RUTF are dramatically cut, thus alleviatingsome of the pressure on accurate forecasting. Additionalbenefits of local production are the potential for costreductions (mostly due to decrease in transport costs),and most importantly, the support for local industry andfarmers.

Another key consideration is the patent held byNutriset/IRD49 for the production of RUTF (and relatedproducts) in many countries. A patent user agreementwith Nutriset/IRD50 must be established for production inthose countries where the Nutriset/ IRD has registered acommon patent agreement24. There are no restrictions incountries where Nutriset/IRD have not registered patents.Though this agreement provides access to technicalsupport to the producer to set up production and qualitycontrol mechanisms, it is an additional hurdle in establish-ing 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, theIRD invites the beneficiaries to make a 1% contribution ofthe turnover earned by the sale of the products coveredby the Usage Agreement, in order to support and fundIRD’s research and development actions.

In many countries, local production of RUTF is believedto be the most appropriate complement, if not replace-ment, to global supplies. In addition to the patent, twomain limiting factors restricting the setting up of localproduction have been the sourcing and cost of ingredi-ents (particularly sourcing of quality peanuts and the costsof milk powder) and the quality control measures requiredto ensure an absolutely safe product is supplied.

An accreditation process developed by UNICEF incollaboration with Médecins Sans Frontières (MSF) andthe Clinton Health Access Initiative (CHAI) to ensure qual-ity of the product has particularly stringent criteria foraflatoxin, commonly found in peanuts. Though this crite-rion has delayed accreditation of production in somecases and added to lead times, it is clear that a balancemust be struck between the desire for local productionand the need for a safe quality product.

Governments need to develop a clear policy on localproduction of RUTF, which can lead to new partnerships,tax-dispensations and other cost-reducing measures.

The quest for quality peanuts has led some localproducers to form closer public private partnerships withNGOs and farmers in order to improve farming and stor-age practices and guarantee markets for product. Theseinitiatives, which depend on producers being able to buypeanuts in bulk at certain times of the year, require capi-tal and finding investors is a current challenge for localproducers.

The evolution of the CMAM approach has beenevidence based, whereby protocols are tested operationally

at limited scale, with rigorous monitoring in place to assesseffectiveness. This strong background to the approach anda culture of transparently disseminating results both inter-nationally and through national learning forums is reportedto be a key enabling factor and has undoubtedlycontributed to its success. Continuation of this culture,reaching into the development of new coverage assess-ment methodologies, testing of new RUTF formulations,operational piloting of innovative methods to strengthenreferrals, monitoring and supervision or for testing newmodalities for the management of MAM, is important if theintegrity of the approach is to be maintained.

Generating sustained political commitment aroundCMAMAs with all forms of undernutrition, the effective imple-mentation and scaling up of CMAM requires decisive andcontinuous government commitment. The presence ofemergencies creates a strong but short lived impact toboost CMAM, even when countries lack the capacity tointervene themselves. In the long run, however, politicalcommitment is key to ensure programme coordinationbetween government and donor agencies, to guaranteeeffective implementation and coordination across allgovernment tiers and to devise and sustain transparentand effective funding schemes. The executive can play acritical role in embedding local level CMAM withinnational poverty reduction and development goals.

Political leadership and government coordination isdecisive in ensuring the long-term success of CMAMscale up. The executive can play a strategic role inenhancing the importance of CMAM in the nationaldevelopment agenda, in strengthening the mandate of

Des erreurs de prévision ont été commises à la suitede l’utilisation de calculs basés sur la population, laprévalence de la MAS et la couverture estimée, quiaccusent tous de nombreuses inexactitudes. Les prévi-sions des besoins au niveau du district/sous-national/national basées sur la consommation sont plus logiques,mais des améliorations quant à l’exactitude et à la ponc-tualité des rapports sont indispensables pour quecelles-ci soient fiables. Une extrapolation est égalementrequise lorsque des rapports sont manquants ou pourtenir compte des plans d’expansion et de toute augmen-tation prévue en termes de prévalence. L’inclusion desrapports de stock dans les rapports d’admission au seinde la PCMA, la détermination des niveaux de stocks mini-maux en se basant sur l’établissement concerné etl’utilisation des SMS rapides pour les rapports et lesdemandes de stocks d’ATPE ont abouti à des résultatsconcluants.

En produisant des ATPE plus près du domicile, lestemps de transit pour recevoir les ATPE sont considérable-ment réduits, ce qui atténue quelque peu la pressionquant à la précision des prévisions. La production localeoffre en plus des avantages supplémentaires sous la formed’une réduction potentielle des coûts (principalement dueà la diminution des coûts de transport) et, surtout, d’unsoutien de l’industrie et l’agriculture locales.

Le brevet détenu par Nutriset/IRD49 pour la produc-tion d’ATPE (et produits connexes) dans de nombreuxpays est un autre facteur déterminant. Un accord d’utili-sation de brevet doit être conclu avec Nutriset/IRD50pour la production dans les pays où Nutriset/IRD a enreg-istré un accord de brevet commun24. Il n’existe aucunerestriction dans les pays où Nutriset/IRD n’a pas déposéde brevet. Bien que cet accord donne accès à un soutientechnique au producteur afin qu’il puisse mettre en placela production et des mécanismes de contrôle de la qual-ité, il constitue en même temps un obstaclesupplément-0 aire à l’établissement de la productionlocale, avec des restrictions dans les pays où un brevetexclusif a été déposé (le Niger et le Mozambique25). Un «prix » découle également de cet accord, en effet, l’IRDinvite les bénéficiaires à faire une contribution de 1 % du

chiffre d’affaires réalisé par la vente des produits couvertspar l’accord d’utilisation, afin de soutenir et de financer larecherche et les activités de développement de l’IRD.

Dans de nombreux pays, la production locale d’ATPEest considérée comme le complément le plus appropriéde l’approvisionnement mondial, voire comme leremplacement de ce dernier. En plus du brevet, deuxprincipaux facteurs qui restreignent la mise en place de laproduction locale sont l’approvisionnement et le coûtdes ingrédients (en particulier l’approvisionnementd’arachides de qualité et les coûts de la poudre de lait) etles mesures de contrôle de la qualité nécessaires pourassurer un produit entièrement sûr.

Un processus d’accréditation élaboré par l’UNICEF encollaboration avec Médecins Sans Frontières (MSF) etl’Initiative Clinton pour l'accès à la santé (CHAI) destiné àassurer la qualité du produit comporte des critères parti-culièrement stricts concernant l’aflatoxine, commun-ément trouvée dans les arachides. Bien que ce critère aitretardé l’accréditation de la production dans certains caset prolongé davantage les délais, il est clair qu’un équili-bre doit être trouvé entre le désir de voir la productionlocale se développer et la nécessité d’obtenir un produitde qualité et ne présentant aucun danger.

Les gouvernements doivent élaborer une politiqueclaire sur la production locale d’ATPE, ce qui peutconduire à de nouveaux partenariats, des exonérationsfiscales et d’autres mesures de réduction des coûts.

La quête d’arachides de qualité a conduit certainsproducteurs locaux à former plus de partenariats publics-privés avec les ONG et les agriculteurs afin d’améliorer lespratiques agricoles et de stockage et de garantir desmarchés pour le produit. Ces initiatives, qui dépendentde la capacité des producteurs à acheter des arachides envrac à certaines périodes de l’année, ont besoin de capi-taux, et les producteurs locaux font à présent face au défide trouver des investisseurs.

L’évolution de l’approche PCMA est fondée sur despreuves, de sorte que les protocoles sont testés sur leplan opérationnel à une échelle limitée, un suivi

rigoureux ayant été mis en place pour évaluer l’efficacité.On souligne la base solide de même que la culture de latransparence de la diffusion des résultats dont bénéficiel’approche tant au niveau international que par le biaisde forums nationaux d’apprentissage ; il s’agit d’unfacteur clé ayant sans aucun doute contribué à sonsuccès. Si l’on souhaite conserver l’intégrité de l’ap-proche, il est important de poursuivre cette culture, dedévelopper de nouvelles méthodologies d’évaluation decouverture, de mettre à l’essai de nouvelles formulesd’ATPE, de réaliser le pilotage opérationnel des méthodesnovatrices visant à renforcer les orientations en vue d’untraitement, la surveillance et la supervision ou pour testerde nouvelles modalités de gestion de la MAM.

Générer un engagement politique soutenu en matière dePCMAComme pour toutes les formes de sous-nutrition, la miseen œuvre effective et le déploiement de la PCMA exigentun engagement décidé et continu de la part dugouvernement. La présence de situations d’urgence créeun impact fort mais de courte durée quand il s’agit destimuler la PCMA, et ce même lorsque les pays n’ont pasla capacité d’intervenir. Cependant, sur le long terme,l’engagement politique est essentiel pour assurer la coor-dination du programme entre les organismesgouvernementaux et les bailleurs de fonds afin de garan-tir une mise en œuvre et une coordination efficaces entretous les niveaux de l’administration et afin de concevoiret de maintenir des programmes de financement trans-parents et efficaces. L’exécutif peut jouer un rôle essentieldans l’intégration de la PCMA au niveau local dans lesmesures de réduction de la pauvreté et les objectifs dedéveloppement nationaux.

Le leadership politique et la coordination dugouvernement sont déterminants pour assurer le succèsà long terme du déploiement de la PCMA. L’exécutif peut

24 A patent user agreement allows a company or an organi-sation (meeting specified criteria) to manufacture, market and distribute products covered by Nutriset/IRD patents in territories where a common patent has been registered.

25 Correct November 2011.

24 Un accord d’utilisation de brevet permet à une entreprise ou une organisation (répondant à des critères spécifiés) defabriquer, commercialiser et distribuer des produits couverts par des brevets Nutriset/IRD sur les territoires oùun brevet commun a été déposé.

25 correction - novembre 2011.

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In Malawi, policy direction and resource mobilisa-tion for nutrition falls under the Office of thePresident and Cabinet (OPC). A nutrition committeechaired by the OPC hosts technical working groupsfor different nutrition areas. The implementation ofnutrition policies sits under the MoH, i.e. the MoH isresponsible for the operational plans for implement-ing CMAM within the essential health packageincluding placing a line item in budgets of districtimplementation plans for CMAM. This allows MoH tofocus on implementation while the policy environ-ment is strengthened by being at a higher level.Similarly the recognition of nutrition as crosscutting, including plans in Malawi to have a nutri-tionist in every ministry, can help to bring nutritionissues firmly onto the agenda in multiple ministriesand facilitate cross-sectoral collaboration.

Box 6: Positioning of Nutrition in Malawi

jouer un rôle stratégique dans l’augmentation de l’impor-tance de la PCMA dans le programme national dedéveloppement, en renforçant le mandat du ministère dela Santé et en assurant le financement continu et coor-donné de tels programmes à partir de contributions dugouvernement ou de bailleurs de fonds (voir encadré 6pour l’exemple du Malawi). Les expériences d’étude decas suggèrent que l’exécutif a joué un rôle clef en situantla nutrition à un niveau élevé au sein des projetsnationaux des pays où les études de cas ont eu lieu, maissans pour autant toujours inclure le traitement de la MAS.

Pour le développement de programmes à long terme,il faut aborder la PCMA dans le cadre d’une stratégiegouvernementale plus vaste en termes de nutritionimpliquant une meilleure coordination entre lesdifférents secteurs gouvernementaux (santé, nutrition,éducation, développement social, agriculture), les

bailleurs de fonds et les acteurs et les fournisseurs deservices au niveau local s’attaquant aux causes fonda-mentales et sous-jacentes de toutes les formes desous-nutrition, y compris la MAS. L’exécutif joue un rôlecentral dans la coordination intersectorielle au sein dugouvernement, épaulé par les intervenants externes, etdans l’amélioration de la durabilité et de la qualité de laprogrammation en matière de PCMA.

Lorsque la programmation PCMA est isolée et séparéede priorités au niveau national ou lorsque les gouverne-ments n’ont pas la capacité de s’impliquer plusdirectement dans les efforts des organismes externeschargés de la mise en œuvre de la PCMA, il est fort prob-able que la programmation restera tributaire de ladisponibilité (incertaine) des fonds d’urgence. Cela nuiraalors à la planification à long terme et aux perspectivesde déploiement de la PCMA. Dans les situations où lespriorités du gouvernement ne sont pas énoncées, lesacteurs internationaux doivent faciliter l’articulation despriorités et des stratégies du gouvernement puiss’aligner sur ces dernières. Les bailleurs de fonds doiventquant à eux redoubler d’efforts afin que les acteurs inter-nationaux (ONU) s’alignent sur les stratégiesgouvernementales.

La décentralisation effective de la PCMALa décentralisation effective et la mise en œuvre de laPCMA au niveau local sont un autre facteur clé pour réus-sir le déploiement. S’il est important que l’exécutif resteimpliqué dans la programmation au niveau national, il estégalement essentiel que le gouvernement renforce lepotentiel d’adoption des programmes au niveau dudistrict. La mesure dans laquelle la PCMA peut effective-ment être mise en œuvre au niveau du district dépend,entre autres choses, du degré actuel de décentralisationdu gouvernement, de la disponibilité de l’expertise et desressources humaines à des échelons inférieurs dugouvernement et de la disponibilité de données de bonnequalité pour identifier les populations cibles, les zones àrisque et les indicateurs de progrès. Le leadership et l’au-torité nécessaires au déploiement de la PCMA doivent êtredécentralisés au niveau du district, de même que lesressources nécessaires à l’appui des plans décentralisés.

the MoH and in ensuring the continued and coordinatedfinancing of such programmes from government ordonor contributions (see Box 6 for a Malawi example).The case study experiences suggests that the executivehas played a key role in placing nutrition high onto thenational agenda of case study countries but this did notalways include the treatment of SAM.

Longer term development programming requiresCMAM to be approached as part of a wider governmentnutrition strategy involving broader coordination acrossdifferent government sectors (health, nutrition, educa-tion, social development, agriculture), with donors, locallevel actors and service providers to tackle the basic andunderlying causes of all forms of undernutrition, includ-ing SAM. The Executive has a pivotal role in facilitatinginter-sectoral coordination within government and withexternal stakeholders and improving the sustainabilityand quality of CMAM programming.

Where CMAM programming is isolated and separatefrom national level priorities or governments lack thecapacity to be more directly involved with the efforts ofexternal agencies implementing CMAM, there is a stronglikelihood that programming will remain dependent onthe (uncertain) availability of emergency funding. This inturn will undermine long term planning and prospects ofCMAM scale up. In situations where government priori-ties are not set out, international actors need to facilitatethe articulation of government priorities/strategies andthen align with these. Donors also need to increaseefforts that bring about alignment of international actors(UN) with government strategies.

Effective decentralisation of CMAMThe effective decentralisation and implementation ofCMAM at the local level is another key factor for success-ful scale up. Whilst it is important that the Executiveremains involved in national level programming, it is alsocritical that the government strengthens the potential forprogramme ownership at the district level The extent towhich CMAM can be effectively implemented at thedistrict level depends, among other things, on thegovernment’s existing degree of decentralisation, avail-ability of expertise and human capacity at lower tiers ofgovernment and the availability of good quality data toidentify target populations, risk areas and progress indi-cators. Leadership and authority for CMAM scale-up mustbe decentralised to the district level along with thenecessary resources in support of decentralised plans.

CMAM implementation is especially enhanced whenthe MoH has an effective presence throughout allgovernment levels or is already delivering other types ofprogrammes through a decentralised structure. Thereview of country case studies highlighted that there aremultiple drivers that can facilitate (and in some casesmake up for the lack of ) decentralisation structures, e.g.effective training and supervision, remuneration andcareer promotion schemes and reliable reporting. Total

With the devolution of the MoH in Pakistan (18thamendment), the sole responsibility of health andnutrition policy and planning now rests with theprovinces. This development has brought a numberof possibilities and concerns. On the plus side, itmay empower lower levels of government bygiving them more autonomy and enhance respon-siveness and efficiency allowing quicker actionwhere problems are identified. The devolution mayalso ensure greater equity within provinces.Concerns at the outset are around capacity (insuffi-cient technical, human and financial resources tomanage services well), emergency situations (suchas how provinces will manage to coordinate a largeresponse when national response has been chal-lenging), inter-provincial problems, especially dueto lack of routine health information collection, andlack of a provincial funding mechanisms. Nationallevel stewardship is needed to complement adecentralised approach.

Box 7: Decentralisation: pros and cons in Pakistan

Au Malawi, la direction politique et la mobilisationdes ressources pour la nutrition relèvent de l’Officedu Président et du Cabinet (OPC). Un comité denutrition présidé par l’OPC accueille des groupesde travail techniques pour différents secteurs de lanutrition. La mise en œuvre des politiques de nutri-tion relève du ministère de la Santé, c’est-à-direque le ministère de la Santé est responsable desplans opérationnels pour la mise en œuvre de laPCMA au sein de l’ensemble (« package ») des soinsde santé essentiels, y compris du placement d’unposte dans les budgets des plans de mise en œuvrede la PCMA au niveau des districts. Cela permet auministère de la Santé de se concentrer sur la miseen œuvre alors même que l’environnement poli-tique est renforcé en étant placé à un niveausupérieur. De même, le fait que la nutrition soitreconnue en tant que domaine transversal et quel’on compte disposer d’un nutritionniste danschaque ministère au Malawi peut aider à hisser laproblématique de la nutrition à l’ordre du jour deplusieurs ministères et à faciliter la collaborationintersectorielle.

Encadré 6 : Position de la nutrition au Malawi

Avec la délégation des compétences du ministère dela Santé au Pakistan (18e amendement), l’uniqueresponsabilité en ce qui concerne la politique et laplanification en matière de santé et de nutritionrevient maintenant aux provinces. Cette évolution aentraîné l’apparition de possibilités et de préoccupa-tions. Sur une note positive, cette délégation peutdéplacer les compétences vers les échelons inférieursdu gouvernement en leur donnant plus d’autonomieet améliorer la réactivité et l’efficacité en permettantune intervention plus rapide dès que les problèmessont identifiés. La délégation des compétences peutégalement assurer une plus grande équité au seindes provinces. Au départ, des inquiétudes sontapparues au sujet des capacités (insuffisance desressources techniques, humaines et financières pourgérer les services correctement), des situations d’ur-gence (telles que la façon dont les provincesparviendront à coordonner une intervention degrande envergure alors que l’intervention au niveaunational avait déjà été difficile), des problèmes inter-provinciaux, en particulier en raison d’un manque decollecte d’information de santé de routine, et au sujetdu manque de mécanismes de financement provinci-aux. Une gestion au niveau national est nécessairecomme complément à une approche décentralisée.

Encadré 7 : La décentralisation : avantages et inconvénients au Pakistan

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decentralisation, without a national framework and stew-ardship also carries risks (see Box 7).

As has been illustrated by studies on chronic malnu-trition, a greater involvement of concerned andcommitted government officials and local elites canproduce a more inclusive selection of beneficiaries, amore transparent use of resources, and greater commu-nity involvement. Local elites are in a privileged positionto shape decision making at the local level and influencepolicy making at the national level. Effective CMAMimplementation and scale up is likely to emerge wherethere is increased local ownership.

Financing CMAMThe provision of a continuous and predictable fundingstream is a key requisite for ensuring sustained CMAM

La mise en œuvre de la PCMA est particulièrementrenforcée lorsque le ministère de la Santé dispose d’uneprésence effective à tous les niveaux du gouvernementou administre déjà d’autres types de programmes àtravers une structure décentralisée. L’examen des étudesde cas par pays a souligné que plusieurs facteurspouvaient faciliter la mise en place de structures dedécentralisation (et dans certains cas, compenser l’insuff-isance de celles-ci), par exemple, une formation et unesupervision efficaces, des programmes de promotion decarrière et de rémunération et des rapports fiables. Ladécentralisation totale, sans cadre et sans gestion au niveaunational, comporte aussi des risques (voir encadré 7).

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scale-up. Ensuring a continuous and transparent flow offunds for CMAM scale-up poses two challenges forimplementing countries. The first is to shift away fromshort term emergency funding and the second is tomove away from donor dependency in a way thatgovernments are directly in charge of the allocation andmanagement of CMAM funds.

Overcoming the first financial challenge requires longterm development funded programmes rather thanshort term emergency funding windows. Donor supportis currently important both for the provision of SAMtreatment supplies, as well as the funding of relatedactivities such as distribution of supplies and capacitystrengthening. Whilst some donors are beginning tomake available longer term funding arrangements forCMAM as part of a wider nutrition package, these mech-anisms are currently only offered to UN agencies andinternational NGOs.

In order to promote consensus around a long termdonor funding strategy, governments and donors wouldneed to develop accurate funding estimates of CMAMinterventions and expected outcomes. To date, there arefew country specific cost benefit analyses of CMAM, anddonors and partner agencies keep separate estimates forthe funding of SAM treatments, nutrition therapeuticsupplies, as well as additional support activities, supplies,distribution and capacity strengthening. Governmentsand donors will also need to agree scale up targets, thefinancial implications of such targets, the percentage ofresources that can be provided by governments in theshort term, and a progressive and realistic funding strat-egy by government that would see them takingincreasing financial and accounting responsibility forfunding the programme.

At present, governments and their partners developshort term proposals to get specific funding from donorsfor CMAM scale up. There is a need to convince donorsthat support for RUTF provision, for example, shouldbecome part of disaster risk reduction (DRR) and thatefforts should be made to improve sustainability of RUTFprovision, as well as enable better planning and integra-tion of CMAM into health and other sectors. There is alsoa need for external partners to better align themselveswith government priorities. International NGOs shouldnot always capitalise on emergency funding windowswhen longer-term funding windows may serve the sameend. Donors, for their part, need to re-evaluate theappropriateness of their current funding mechanismsfor long-term scale up of CMAM. A conceptual shift inhow treatment of SAM is to be approached and fundedis needed so that the emphasis of external agencies,whether responding to emergencies or longer-termdevelopment needs, is to strengthen governmentcapacity (including funding capacity) to at least be ableto treat endemic levels of SAM in non-emergency years(see Box 8).

Comme cela a été illustré par des études sur la malnu-trition chronique, une plus grande implication de la partdes responsables gouvernementaux concernés etengagés et des élites locales peut mener à une sélectionplus inclusive des bénéficiaires, une utilisation plus trans-parente des ressources et une meilleure participationcommunautaire. Les élites locales sont dans une positionprivilégiée pour façonner la prise de décision au niveaulocal et influencer les décisions politiques au niveaunational. La mise en œuvre et le déploiement efficaces dela PCMA sont susceptibles d’émerger lorsque la recon-naissance locale augmente.

Le financement de la PCMALa création d’un volet de financement continu et prévisi-ble est une condition clé pour assurer un déploiementdurable de la PCMA. Assurer un flux continu et transpar-ent de fonds destinés au déploiement de la PCMA posedeux défis pour les pays de mise en œuvre. Le premierconsiste à s’éloigner du financement d’urgence à courtterme et le second de se soustraire à la dépendance àl’égard des bailleurs de fonds afin que les gouverne-ments soient directement en charge de l’allocation et dela gestion des fonds destinés à la PCMA.

Surmonter le premier défi financier exige desprogrammes de développement financés à long termeplutôt que des guichets de financement d’urgence àcourt terme. Le soutien des bailleurs de fonds estactuellement important aussi bien pour la fourniture dematériel de traitement de la MAS que pour le finance-ment des activités connexes comme la distribution defournitures et le renf0orcement des capacités. Certainsbailleurs de fonds commencent à mettre à dispositiondes mécanismes de financement à long terme pour laPCMA dans le cadre d’un vaste programme de nutrition,or, ces mécanismes sont actuellement offerts unique-ment aux agences de l’ONU et aux ONG internationales.

Afin de promouvoir un consensus sur une stratégiede financement à long terme de la part des bailleurs defonds, les gouvernements et les bailleurs de fondsdevraient établir des estimations précises de finance-ment des interventions en matière de PCMA et des

résultats escomptés. À ce jour, on compte peu d’analysescoûts-avantages de la PCMA spécifiques aux pays et lesbailleurs de fonds et les organismes partenaires maintien-nent des estimations chacun de leur côté pour lefinancement des traitements de la MAS, de fournituresthérapeutiques nutritionnelles ainsi que des activités desoutien, des fournitures et des distributions supplémen-taires et pour le financement du renforcement descapacités. Les gouvernements et les bailleurs de fondsdevront également se mettre d’accord sur le déploiementdes objectifs, les incidences financières de ces objectifs, lepourcentage de ressources qui peuvent être fournies parles gouvernements à court terme et aussi sur l’adoptiond’une stratégie de financement progressif et réaliste parle gouvernement qui permettrait à celui-ci d’avoir uneresponsabilité financière et comptable croissante quantau financement du programme.

À l’heure actuelle, les gouvernements et leurs parte-naires développent des propositions à court terme pourobtenir un financement spécifique de la part desbailleurs de fonds pour le déploiement de la PCMA. Il fautconvaincre les bailleurs de fonds que le soutien de lafourniture d’ATPE, par exemple, devrait faire partie de laréduction des risques de catastrophes (RRC) et que desefforts devraient être faits pour améliorer la durabilité del’approvisionnement en ATPE, ainsi que pour permettreune meilleure planification et une meilleure intégrationde la PCMA dans la santé et les autres secteurs. Il fautégalement que les partenaires externes s’alignent davan-tage sur les priorités gouvernementales. Les ONGinternationales ne devraient pas toujours capitaliser surles guichets de financement d’urgence lorsque lesguichets de financement à long terme peuvent remplir lemême objectif. Les bailleurs de fonds, pour leur part,doivent réévaluer la pertinence de leurs mécanismes definancement actuels pour le déploiement de la PCMA àlong terme. Il faut procéder à un changement conceptueldans la façon dont le traitement de la MAS doit êtreabordé et financé afin que les organismes externes, qu’ils’agisse de répondre aux situations d’urgence ou à desbesoins de développement à plus long terme, mettentl’accent sur le renforcement de la capacité du gouverne-ment (y compris la capacité de financement) pour que

celui-ci soit au moins en mesure de traiter des niveauxendémiques de MAS lors des années où il n’y a pas decatastrophes (voir encadré 8).

Les gouvernements doivent présenter une élabora-tion claire des coûts liés à la PCMA, démontrer unengagement financier progressif (par exemple par lebiais de fonds gouvernementaux affectés) et identifier leséléments de soutien en matière de PCMA qui ont besoinde ressources supplémentaires. En cas d’urgence, lesgouvernements doivent être préparés en disposant deplans clairs et chiffrés pour un déploiement accélérévisant à répondre à la demande accrue. Cela peut aider àlimiter la baisse d’appropriation par le gouvernement, cequi arrive souvent en cas de catastrophe. En outre, lesbailleurs de fonds et les autres partenaires de coopéra-tion (par exemple les agences de l’ONU et les ONGinternationales) doivent mieux aligner leur financementet leurs politiques et stratégies de mise en œuvre de laPCMA sur les politiques à plus long terme du gouverne-ment en matière de PCMA et de nutrition.

Pour surmonter le second défi lié au déploiement, ilfaut se soustraire à la dépendance à l’égard des bailleursde fonds et incorporer des fonds aux budgets gouverne-mentaux. La ligne de financement la plus coûteuse est lafourniture d’ATPE, composante clé de la PCMA. Unegrande partie du défi que pose le renforcement de l’im-plication du gouvernement consiste à trouver desmoyens alternatifs pour la production et le financementdes ATPE. Ce n’est que dans une seule étude de cas que leministère de la Santé a commencé à fournir des ATPE deson propre budget afin de compléter l’approvision-nement externe (Malawi). Dans d’autres cas, une plusgrande participation du gouvernement a été demandéedans les budgets de santé, cependant, ces derniers neconstituent toujours qu’une faible portion du budget desgouvernements dans l’ensemble, et la plupart de cesfonds sont destinés à couvrir les ressources humaines(salaires).

Les études de cas illustrent le manque dramatique dedonnées cohérentes et comparables en matière de coûtsà tous les niveaux. Au niveau général, il est difficile demesurer l’ampleur des investissements requis pour

Governments need to present clear costing of CMAM,demonstrate progressive financial commitment (forexample, through earmarked government funds), andidentify the elements of CMAM support that need furtherresources. In the event of emergencies, governmentsshould be prepared with clear, costed plans for surgescale-up to meet increased demand. This can help to limitthe loss of government ownership frequently seen inemergencies. Furthermore, donors and other cooperat-ing partners (e.g. UN agencies and INGOs) need to betteralign their funding and implementation policies andstrategies for CMAM with longer-term government nutri-tion and CMAM policies.

Overcoming the second challenge for scale-uprequires moving away from donor dependency andincorporating funds into government budgets. Themost expensive funding line is the provision of RUTF, akey component of CMAM treatment. Much of the chal-lenge to enhance government ownership is to findalternative means for the production and funding ofRUTF. In only one case study has the MoH startedprocurement of RUTF from its own budget to supple-ment external procurement (Malawi). In other cases,greater government ownership has been soughtthrough health budgets, however, health budgetsremain a small share of the governments’ overallbudget, and most of these funds are destined to coverhuman resources (salaries).

The case studies illustrate the dramatic lack of consis-tent and comparable costing data across the board. Atthe macro level, it is difficult to gauge the magnitude ofthe required investment to significantly reduce SAM andMAM in a given period of time. Similarly, there are nocomparable figures about CMAM coverage or rate ofCMAM expansion per country. This lack of data is espe-cially problematic to identify the size of scale upchallenges and the strategy to overcome these.

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Volunteer Health Workersat the Sai training, Gokwe

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26 Bryce, J., Coitinho, D., Darnton-Hill, I., Pelletier, D. and Pinstrup-Andersen, P. For the maternal and child undernutrition study group., 2008. Maternal and child undernutrition: effective action at national level. The Lancet, Vol. 371, Issue 9611, pp. 510-526.

Concern is supporting the MoH in the Karamojaregion of Uganda to implement CMAM. Support isfocused on capacity development of the districthealth teams to manage the programme and on theprocess of integrating CMAM within existing super-vision, monitoring, reporting and supply systems.Concern has employed a flexible system designed toprovide minimal, adequate additional staff andresource support from Concern on an as-neededbasis to MoH health facilities during times whenSAM levels spike beyond existing MoH capacity tomanage.

Concern and the district health teams have workedtogether to define the maximum numbers of SAMcases that each facility is able to deal with on aweekly basis. Gaps in clinical capacity and resourcesat each participating facility should these thresholdsbe exceeded have also been identified. This hasallowed support needs to be outlined and agree-ment to be reached as to the stage at which thisadditional support can be withdrawn. Concern, thedistrict health teams and the participating healthfacilities have signed agreements outlining roles andresponsibilities of each party in the event thatConcern is called upon to implement this emergencyresponse system. For example when agreed thresh-olds are exceeded, Concern provides additionalclinical staff and supplies to participating facilities asagreed. Where access to existing facilities provesproblematic for patients, Concern is prepared toopen additional outreach clinics on a temporary, as-needed basis. Concern is also prepared to providetemporary, as-needed staff to support mobilisationefforts, management of facilities, HMIS and logisticssystems. (Source: Concern Uganda Project Report)

Box 8: Concern’s experience of applying thresholds to CMAM support in Uganda

réduire la MAS et la MAM de manière significative dansun laps de temps donné. De même, on ne dispose pasde chiffres comparables sur la couverture de la PCMAou les taux d’expansion de la PCMA par pays. Cemanque de données rend particulièrement difficiled’identifier l’ampleur des défis rencontrés par ledéploiement et la stratégie pour surmonter cesderniers.

Améliorer la qualité et la disponibilité desrenseignements sur les coûts liés au déploiement de laPCMA est une condition sine qua non pour aider àaméliorer la capacité des gouvernements à gérer lefinancement de la PCMA. L’amélioration des renseigne-ments sur les coûts permettrait également d’identifieret d’optimiser les avantages des synergies existantesentre la PCMA et d’autres interventions sauvant desvies et améliorant les conditions nutritionnelles, parexemple, en reliant les activités dans le cadre de laPCMA au travail quotidien du personnel de santé depremière ligne travaillant dans le domaine de l’ANJE, dela PCIME, du VIH, de la tuberculose et de l’interactionentérovirale-nutritionnelle (Enteroviral- NutritionalInteraction – ENI). En outre, afin d’éviter la tendance àchiffrer les activités liées à la PCMA en tant quecomposants verticaux des programmes, les exercicesd’établissement des coûts doivent essayer de déter-miner des stratégies critiques rentables d’activités pourla survie de l’enfant auxquelles la PCMA peut êtrecombinée pour accroître la durabilité de celle-ci.

Bien que la MAS soit maintenant presqueuniversellement reconnue comme étant une causemajeure de mortalité des enfants, la PCMA ne semblepas se trouver au sommet de tous les projets mondiauxen matière de déploiement de la nutrition. La princi-pale raison invoquée est la fragilité de nombreuxsystèmes de santé lorsqu’il s’agit de prendre en chargeun nouveau service, bien que cette raison puissesembler injustifiée si une approche globale visant à aiderles pays en matière de nutrition est adoptée. Comme l’af-firme la série de The Lancet portant sur la nutrition de lamère et de l’enfant, « le débat......se dirige vers uneapproche plus rationnelle qui reconnaît la nécessité d’inten-

sifier les interventions à fort impact et de renforcer en mêmetemps le système de santé26 ».

Malgré ce débat continu, les preuves parlent d’elles-mêmes. Les pays eux-mêmes adoptent une approchemesurée. Même sans soutien financier à long terme nigaranti, les gouvernements, motivés par la charge decas de MAS et les résultats positifs visibles, déploient laPCMA. Les défis qui se posent sont multiples, en partic-ulier quand il s’agit de financement et de renforcementdes capacités nationales. Cependant, on note des réus-sites et des exemples extrêmement encourageantsd’approches créatives et innovatrices pour résoudrecertains de ces défis. Les défis n’ont pas empêché laPCMA de se forger une place dans les projets au niveaunational. Toutefois, ces expériences des pays soulèventun certain nombre de questions destinées à tous ceuxqui s’occupent de la mise en place et du financementdes projets et des plans mondiaux, en ce qui concerneles intentions à plus long terme et les modalités definancement et de soutien pour que les gouverne-ments deviennent moins dépendants des bailleurs defonds extérieurs et des dons d’ATPE.

Le rapport complet, Government experiences ofscale-up of Community-based Management of AcuteMalnutrition (PCMA). A synthesis of lessons (lesexpériences du gouvernement pour le déploiementde la prise en charge communautaire de la malnutri-tion aiguë (PCMA). Une synthèse des enseign-ements), ENN, janv. 2012, peut être téléchargée surwww.ennonline.net. Un nombre limité de copiesimprimées est disponible, communiquez avec lebureau ENN pour en demander.

Improving the quality and availability of costing infor-mation for CMAM scale up is a key prerequisite to helpimprove governments’ ability to manage CMAM funding.Improved costing information would also help to identifyand maximize the benefits of existing synergies betweenCMAM and other life-saving and nutrition enhancinginterventions, for example, by linking CMAM activitywithin the day to day work of frontline health staff work-ing on IYCF, IMCI, HIV, TB, and ENI. Furthermore, in orderto avoid the tendency to cost out CMAM activities asvertical programme components, costing exercises needto consider where CMAM can be ‘piggy-backed’ ontoother critical cost effective child survival strategies toincrease sustainability.

Though SAM is now recognised almost universally asa major cause of childhood mortality, CMAM does not

Concern soutient le ministère de la Santé dans la régionde Karamoja en Ouganda pour la mise en œuvre de laPCMA. Le soutien est axé sur le développement descapacités des équipes de santé de district à gérer leprogramme et sur le processus d’intégration de la PCMAau sein des systèmes existants de supervision, desurveillance, d’élaboration et de communication derapports et d’approvisionnement. Concern emploie unsystème flexible conçu pour fournir du soutien supplé-mentaire en personnel et en ressources en quantitéminimale et adéquate sur une base ponctuelle et à l’at-tention des établissements de santé du ministère de laSanté pendant les périodes où les niveaux de MASculminent au-delà de la capacité de gestion existantedu MS.

Concern et les équipes de santé de district ont travailléde concert pour définir le nombre maximum de cas deMAS que chaque établissement est en mesure de traitersur une base hebdomadaire. On a également identifiéles lacunes dans les capacités et les ressources cliniquesdans chaque établissement participant au cas où cesseuils seraient dépassés. Cela a permis de définir lesbesoins en soutien et de parvenir à un accord sur lestade auquel ce soutien supplémentaire devrait êtreretiré. Concern, les équipes de santé de district et lesétablissements de santé participants ont signé desaccords précisant les rôles et responsabilités de chaquepartie dans le cas où Concern serait appelé à mettre enœuvre ce système d’intervention d’urgence. Par exem-ple, lorsque les seuils convenus sont dépassés, Concernfournit plus de personnel et de fournitures cliniques auxétablissements participants, comme il a été convenu.Lorsque l’accès aux installations existantes s’avère prob-lématique pour les patients, Concern est prêt à ouvrird’autres cliniques de sensibilisation sur une basetemporaire, selon les besoins. Concern est égalementprêt à fournir du personnel temporaire selon les besoinspour soutenir les efforts de mobilisation, la gestion desinstallations, les SGIS et les systèmes logistiques.(Source : Rapport de projet Concern Ouganda)

Encadré 8 : L’expérience de Concern en ce qui concernel’application des seuils pour le soutien de laPCMA en Ouganda

26 Bryce, J., Coitinho, D., Darnton-Hill, I., Pelletier, D. et Pinstrup-Andersen, P. For the maternal and child undernutrition study group., 2008. Maternal and child undernutrition : effective action at national level.(Pour legroupe d’étude sur la sous-nutrition maternelle et infan-tile, 2008. La sous-nutrition maternelle et infantile : une action efficace au niveau national) The Lancet, Vol. 371, édition 9611, pp. 510-526.

Editorial Éditorial

appear at the top of all global nutrition scale-up agendas.The main reason given is the fragility of many healthsystems to take on a new service, yet this reason is ques-tionable if a comprehensive approach to supportingcountries for nutrition is being adopted. As the Lancetmaternal and child nutrition series asserts ‘thedebate……..is moving toward a more rational approachthat recognises the need to scale-up high impact interven-tions and strengthen the health system simultaneously’26 .

Despite this continued debate, the evidence is clear.Countries themselves are taking a measured approach.Even without long term financial backing or guaranteedsupport, governments, motivated by the burden of SAMand the visibly positive results, are scaling up CMAM. Thechallenges that arise are multiple, particularly when itcomes to financing and building national capacities.However, there are successes and there are extremelyencouraging examples of creative and innovativeapproaches to addressing some of these challenges. Thechallenges have not prevented the agenda for CMAMmoving forward at national level. However, these countryexperiences raise a number of questions to those settingand resourcing global agendas and plans in relation tolonger-term intentions, funding modalities and supportfor governments to become less dependent on externaldonors and RUTF donations.

The full report, Government experiences of scale-upof Community-based Management of Acute Malnutrition(CMAM). A synthesis of lessons, ENN, Jan 2012, is avail-able to download at www.ennonline.net. A limitednumber of print copies are available, contact the ENNoffice with requests.

Filling RUTF jars in the RUTFfactory In Mozambique

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IntroductionGlobally, more than 3.5 million children under the age of fiveyear die each year due to the underlying causes of malnutrition.It is also estimated that 13 million infants are born each yearwith low birth weight (LBW), 55 million children are wasted (ofwhich 19 million are severely wasted) and 178 million arestunted. Of the estimated 178 million stunted cases, 90% live in36 high burden countries that include Ethiopia1. The conse-quence of the many adverse interacting elements in Ethiopia isthat although malnutrition rates among children are steadilydecreasing, they remain at unsatisfactorily high levels. The 2010Ethiopian Demographic Health Survey (EDHS)2 estimated thenational prevalence of Global Acute Malnutrition (GAM) at9.7%, with 44.4% of children estimated to be stunted and 28.7%underweight. Encouragingly, both underweight and stuntingprevalence was reducing by 1.34% per year over the pastdecade. While this trend is clearly progressing in the right direc-tion, Ethiopia will only reach the Millennium DevelopmentGoal (MDG) target of halving the number of underweight chil-dren if the percentage reduction is increased to at least 1.6

Field Article

Dr Ferew Lemma is Senior Nutrition Advisor to the StateMinister (Programs), Federal Ministry of Health, andREACH Facilitator, based in Addis Ababa, Ethiopia.

Dr Tewolde has over nine years of experience in the areaof nutrition with particular focus on management ofacute malnutrition. He has been a Nutrition Specialistwith UNICEF Ethiopia since June 2005, previously work-ing with Save the Children and World Vision. He hastaken part in the development of Ethiopian nationalprotocol and training materials for management of

severe acute malnutrition and development of national guidelines forHIV and Nutrition.

Dr. Habtamu Fekadu is Chief of Party for ENGINE (inte-grated nutrition programme), Save the Children US,Ethiopia. He has worked in health, nutrition, andacademics in Ethiopia for the last 16 years. His consider-able portfolio of experience includes Federal Ministry ofHealth nutrition lead on the five year National NutritionProgramme (NNP) of Ethiopia, amongst a broad range

of other activities including strategy development, training and evalua-tion, and working with other agencies, notably UNICEF and Save theChildren.

Emily Mates is a public health professional with a focusin nutrition. She was lead researcher with ENN on theCMAM Conference based in Addis Ababa, where she hasworked for many years in emergency and developmenthealth and nutrition programming

The authors would like to mention in particular the support of DrAbdulaziz and Mesfin Gose (Federal Ministry of Health), Sylvie Chamois(UNICEF), Pankaj Kumar and Israel Hailu (Concern Worldwide) IassackManyama and colleagues (ENCU/ DRMFSS) and the many other partnersimplementing CMAM in Ethiopia.

Acronyms:

ASRI Accelerated Stunting Reduction Initiative

CBN Community Based Nutrition

CHD Community Health Day

CMAM Community Management of Acute Malnutrition

EDHS Ethiopian Demographic and Health Survey

DRMFSS Disaster Risk Management and Food Security Section

EHNRI Ethiopian Health and Nutrition Research Institute

ENCU Emergency Nutrition Coordination Unit

ENA Essential Nutrition Actions

EOS Enhanced Outreach Strategy

FFA Food Fortification Alliance

FMoH Federal Ministry of Health

GAM Global Acute Malnutrition

GMP Growth Monitoring and Promotion

GoE Government of Ethiopia

HEP Health Extension Programme

HEW Health Extension Worker

ICCM Integrated Community Case Management

IMNCI Integrated Management of Neonatal and Childhood Illnesses

INGO International NGO

IRT Integrated Refresher Training

IYCN Infant and Young Child Nutrition

LBW Low Birth Weight

MAM Moderate Acute Malnutrition

MDG Millennium Development Goal

MOH Minstry of Health

MUAC Mid Upper Arm Circumference

NCHS National Centre for Health Statistics

NGO Non-Governmental Organisation

NNP National Nutrition Programme

NNS National Nutrition Strategy

OTP Outpatient Therapeutic Programme

RHB Regional Health Bureau

RUTF Ready-to Use Therapeutic Food

SAM Severe Acute Malnutrition

TFP Therapeutic Feeding Programme

UNICEF United Nations Children’s Fund

VAS Vitamin A Supplementation

WFP World Food Programme

WHO World Health Organisation

WoHO Woreda Health Office

ZHD Zonal Health Department

CMAM rollout in Ethiopia:

the ‘way in’ to scaleup nutrition

By Dr Ferew Lemma, Dr Tewoldeberhan Daniel,Dr Habtamu Fekadu and Emily Mates

1 Black, R, Allen, L. H, Bhutta, Z. ., Caulfield, L. E, De Onis, M, Ezzati, M, Mathers,C, and Rivera, J. For the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. Published online Jan 17 2008. DOI:10.1016/S0140-6736(07)61690-0

2 This data is not yet official until the full EDHS report 2010 is issued (expected December 2011).

Seven month oldAynadis has herMUAC measured

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the weekly OTP atGeter MedaHealth Post

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percentage points per year. This implies theneed to intensify and scale-up known highimpact nutrition interventions and those thataddress wasting. Figure 1 describes thechanges in malnutrition prevalence from2000-2010.

The Government of Ethiopia (GoE) hasdeveloped a five-year development plan, theGrowth and Transformation Plan (GTP), forthe period 2010/11 to 2014/15. The mainobjectives of the GTP include: i) Maintain an average real Gross Domestic

Product (GDP) growth rate of 11% and attain the MDGs

ii) Expand and ensure the quality of educa-tion and health services and achieve MDGs in the social sector

iii) Establish suitable conditions for sustain-able nation building, through the creation of a stable democratic and developmentalstate

iv) Ensure the sustainability of growth by realizing all of the above objectives withina stable macro-economic framework.

Under the umbrella of the GTP, the GoElaunched the fourth Health SectorDevelopment Programme (HSDP-IV). Thenew (and final) HSDP IV (2010 – 2015) placesa strong focus on maternal health issues andhas considerably more focus on nutrition thanthe three previous plans. There are 16 nutri-tion indicators within HSDP-IV, examples ofwhich include reducing the stunting preva-lence from 46% to 37%, reducing theprevalence of wasting from 11% to 3%, andincreasing household utilisation of iodisedsalt from 4% to 95%3.

During the course of implementation ofthe previous health sector developmentprogramme (HSDP-III 2005/6 – 2009/10), aNational Nutrition Strategy (NNS) was devel-oped and launched in 2008. The NNS isoperationalised through the NationalNutrition Programme (NNP), a 10- yearinitiative aiming to reduce the levels of stunt-ing, wasting, underweight and LBW infants.The first phase is for five years (2008–2013), atan estimated cost of 370 million USD andconsists of two main components:‘Supporting Service Delivery’ and‘Institutional Strengthening and CapacityBuilding’. The overall objective is betterharmonisation and coordination of the vari-ous approaches to manage and preventmalnutrition.

The service delivery arm of the NNP hasfour sub-components: a) Sustaining EnhancedOutreach Strategy (EOS) with TargetedSupplementary Food (TSF) and transitioningof EOS into the Health Extension Package(HEP), b) Health Facility Nutrition Services,c) Community Based Nutrition (CBN) and d)Micronutrient Interventions.

A process of revision and extension of theNNP has recently commenced (October 2011)for two main reasons: i. To align the end of the first phase with the

HSDP IV and MDGs, i.e. extend the first phase by 2 years to 2015

ii. To strengthen initiatives that were not adequately addressed in the original document and include initiatives that have emerged since the NNP was devised. For example:

Field Article

• Accelerated Stunting Reduction Initiative (ASRI) - inclusive of maternal nutrition, Infant and Young Child Nutrition (IYCN)

• Food Fortification Alliance (FFA), goals and objectives for improving micronu-trient status

• Strengthening of multi-sectoral linkages– key sectors include; agriculture, educa-tion, water and energy, labour and socialprotection, finance and economic devel-opment, women’s children and youth affairs

• Social protection policy and nutrition related indicators

• Moderate acute malnutrition (MAM) programming and the development of improved linkages between preventive and treatment programming

• School health and nutrition (SHN)

CMAM/TFP roll-out in EthiopiaThe term Therapeutic Feeding Programme(TFP) is used in Ethiopia to describe the treat-ment of Severe Acute Malnutrition (SAM).Much has already been written aboutEthiopia’s scale up experience to date5, so thehistory and development of the TFP inEthiopia is only briefly summarised here.Community based management of acutemalnutrition (CMAM) in Ethiopia tradition-ally does not include the management ofMAM. Hence the discussion below focuses onSAM management only.

A small pilot for CMAM was firstconducted in Southern Ethiopia in 2000. Aresearch programme in three countries(Malawi, Ethiopia and South Sudan)followed, implemented from 2002 by ValidInternational and Concern Worldwide, to testthe efficacy and safety of the CMAMapproach.

A food security crisis due to droughtdeveloped across many areas of the countryduring 2003/4. This crisis was the catalyst formany international non-governmental organ-isations (INGOs) to adopt the CMAMapproach of treating the majority of cases asoutpatients, as they became overwhelmedtrying to manage the high caseloads ofmalnourished children arriving at theTherapeutic Feeding Centres (TFCs).6

From 2004/5, the Federal Ministry ofHealth (FMoH), alongside partners includingUNICEF and others, commenced scale-up ofSAM treatment services. This involved devel-oping guidelines and establishing morein-patient and out-patient services across thecountry. In 2007, following internationalendorsement of the CMAM approach,7 thenational protocol for SAM treatment wasrevised to include detailed guidance for theOutpatient Therapeutic Programme (OTP)and community mobilisation activities.

70

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Underweight Stunting Wasting

Percentage

Figure 1: Nutrition indices EDHS 2000*, 2005* and 2010

* Recalculated using World Health Organisation (WHO) GrowthStandards4 for 2000 and 2005

3 Recalculated by Tulane University.4 As the DHS 2010 was not out during the HSDP-IV

preparation, DHS 2005 was used as a benchmark.5 Field Exchange issue 40. Emergency Nutrition Network.

http://fex.ennonline.net/40/contents.aspx6 TFCs were often established in a health centre compound

with erection of a large tent, and heavy presence of NGO staff to manage the cases on a daily basis.

7 WHO/WFP/UNSCN/UNICEF. Community-Based Managementof Severe Acute Malnutrition. A Joint Statement by the World Health Organization, the World Food Programme, theUnited Nations System Standing Committee on Nutrition andthe United Nations Children’s Fund, 2007. http://www.who.

int/nutrition/topics/statement_ combased _malnutrition/en/8 Sylvie Chamois (2009). Decentralisation of out-patient management

of severe malnutrition in Ethiopia. Field Exchange, Issue No 36,July 2009. p12. http://fex.ennonline.net/36/decentralisation.aspx

9 See Footnote 8 for details of the rapid decentralisation process in 2008.

10 Of 27,739 SAM children treated, rates of 77.6% recovery, 0.7%mortality and 4.2% defaulter. The Sphere Project recommends recovery >75%, mortality < 10%, defaulter < 15%, coverage of >50% in rural communities, >70% in urban populations and >90% in a camp situation. The Sphere Project. Humanitarian Charter and Minimum Standards in Disaster Response. Geneva,2011 Edition. Sphere Project.www.sphereproject.org

The TFP combines in-patient and out-patient care forchildren suffering from SAM (mid upper arm circum-ference (MUAC) <11.0 cm, weight for height (WFH)<70%, and/or bilateral pitting oedema). Recovery isachieved through provision of Ready to UseTherapeutic Food (RUTF) most commonly the prod-uct Plumpy’nut®, according to their body weight. Aminority of children with additional complicationspass through an in-patient treatment using therapeu-tic milk and continue follow up as outpatients withRUTF to complete their recovery at home.

It is recommended that there is at least one in-patient unit located in a health centre of each district(woreda). An OTP site is established in the healthposts located in each village/kebele, staffed by twoHealth Extension Workers (HEW).

TFP implementation includes extensive communitymobilisation, through supervised community volun-teer networks. The success of OTP is dependent on awell-informed and responsive community.

Box 1. Overview of the TFP in Ethiopia

In 2008, a dramatic and rapid increase of SAMcases was seen across Oromia and SouthernNations, Nationalities and People’s (SNNP)regions as food security deteriorated due todrought. Responding to this emergency bymaximising access and coverage of these life-saving services, the FMoH reviewed the evidenceof CMAM effectiveness when implemented athealth centre level and made the decision to decen-tralise CMAM services to primary health care(health post) level. This involved OTP managed bythe Health Extension Workers (HEWs)8, as outlinedin Box 1.

To achieve the rapid decentralisation of OTP, theFMoH led the development of simplified quickreference materials in July 20089. This was immedi-ately followed by a national level master trainingfor nutritionists from NGOs and Regional HealthBureaus (RHBs) to enable cascading of training in100 districts (woredas) in Oromia and SNNPregions. The master trainers facilitated regionallevel Training of Trainers (ToT) sessions. Thetrained staff then provided two-day training fordistrict and HEW staff. By November 2008, 455health posts in the two affected regions weremanaging OTP, with results reaching InternationalSphere recommendations for selective feedingprogrammes.10 These good results prompted majorand accelerated efforts for scale-up of the TFP

17

across the other two main regions (Amhara andTigray). The pace of scale up has continued,with > 8,000 health facilities currently offeringOTP services across Ethiopia. Table 1 shows thenumber and coverage of health facilitiesproviding CMAM services in Ethiopia.

The FMoH has guided the roll-out of theTFP. It is no longer viewed as a response neces-sary in times of emergency only. Instead it hasbecome part of the integrated nationalapproach of decentralising primary health careservices across the country, through the HealthExtension Programme (HEP). This is describedfurther below.

Results of national TFP scale-upA total of 731,238 severely malnourished childrenwere admitted to the TFP between January 2008and September 2011, as outlined in Figure 2.

Figure 2 clearly illustrates that the number ofchildren admitted each month continued toincrease with the increasing number of OTPsites, while at the same time showing theseasonal variation of caseloads in Ethiopia.

The performance of the TFP has been highlysuccessful with impressive programme results:an average recovery (cure) rate of 82.3%,mortality rate of 0.7% and defaulter rate of 5.0%.All results are well above the Sphere interna-tional recommendations, a major achievementfor this government-led national public healthinitiative.

Consistently low mortality rates provideevidence of the ability of primary health careworkers to identify and refer sick children -those with a lack of appetite or additionalmedical complications that require higher-levelhealth care. Note that the low mortality rate isalso related to the early case detection thatcomes from having massively decentralisedservices. Caregivers can access assistance early-on in the disease process of their child, reducingthe need for referrals of complicated cases forin-patient care as well as the risk of death.

The low default rates also confirm thereduced opportunity costs for caregivers whenservices have been decentralised at scale. Theselow default rates (for a programme thatrequires more than one visit to the health facil-ity) also demonstrate broad communityconfidence in the programme.

The wide-scale roll out of TFP/CMAM inEthiopia allowed for early detection of the dete-riorating nutrition situation during the 2011Horn of Africa crisis, through identification ofthe rapidly increasing admission trends inSNNPR and Oromia regions. The country wasbetter prepared to mobilize resources andfurther develop the capacity already built, wellbefore the crisis was declared globally. Mostimportantly, the efforts made over the past fewyears to decentralise TFP/CMAM in Ethiopiaensured that many deaths related to SAMduring this current crisis have been averted.

An enabling context for the national TFP scaleup – The Health Extension ProgrammeHSDP III has been a triumph for primary healthcare in Ethiopia, with massive roll-out of theHealth Extension Package (HEP). The HEPinvolved the training and deploying of 33,000female HEWs to strengthen the primary healthsystem (1 HEW per 2,500 population, 2 HEWsworking together at each village health post).The HEP is well-established across the countryand some evidence of its success can be seen inthe preliminary results of the EDHS 2010,showing a sustained decrease in infant andunder-five mortality rates.12

The HEP was originally designed forpreventative activities only. The health leader-ship in Ethiopia has proven to be adaptablewhen presented with solid evidence, e.g.TFP/CMAM programming (that was decen-tralised to health post level from 2008) andearly treatment of diarrhoea, malaria and AcuteRespiratory Infections (ARI). The role of theHEWs has now been formally widened toinclude basic treatment services as outlined inthe Integrated Community Case Management(ICCM), which has been included in theIntegrated Refresher Training (IRT) package

11 A ‘hot-spot’ classification system has been introduced in Ethiopia where woredas are classified using concepts from the IPC (Integrated Phase Classification) approach. The emergency affected woredas are ranked based on the levelof existing hazards including current food security, disease outbreak, flooding, CMAM admissions, nutrition survey results and other related indicators. Emergency affected woredas are classified as priority 1, 2 and 3 woredas, whilenon-emergency woredas are classified as priority 4.

12 Since 2005, infant mortality has decreased by 23%, from 77 to 59 deaths per 1,000 live births. Under five mortality

has decreased by 28%, from 123 to 88 deaths per 1,000 births. EDHS preliminary results, 2010.

13 A considerable effort was also placed on establishing a monitoring system for the TFP. Independent field monitor-ing officers worked alongside RHB and woreda officials using standardised checklists and scorecards. A detailed description of this is provided in Field Exchange issue 40, pages 38-42. See footnote 10 for full reference.

14 Development partners providing support include the World Bank, UNICEF, CIDA, Dutch Government and JICA.

45,000

40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000

0

Jan-08

Mar-08

May-08

Jul-0

8Sept-08

Nov-08

Jan-09

Mar-09

May-09

Jul-0

8Sept-09

Nov-09

Jan-10

Mar-10

May-10

Jul-1

0Sept-10

Nov-10

Jan-11

Mar-11

May-11

Jul-1

1Sept-11

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Admission% Death

Number of sites% Default

% Cure% Report completion

Figure 2: Numbers of OTP sites, SAM children admitted, percentage recovery(cure), death and default rate, and percentage of report completion(January 2008 – September 2011)

Figure 3: Progression of TFP expansion and reporting rates

10,000

9,000

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Jan-08

Mar-08

May-08

Jul-0

8

Sept-08

Nov-08

Jan-09

Mar-09

May-09

Jul-0

8

Sept-09

Nov-09

Jan-10

Mar-10

May-10

Jul-1

0

Sept-10

Nov-10

Jan-11

Mar-11

May-11

Jul-1

1

Sept-11

Number of sites % Report compleation

Table 1: District level coverage of TFP/CMAM inEthiopia, October 2011Hotspot prioritynumber11

Number ofdistricts

Number ofOTPs

Number ofSC/TFU

1 175 3,106 192

2 138 2,677 147

3 40 655 32

4 269 1,662 102

TOTAL 622 8,100 473

Field Article

currently being delivered in a phased approachto HEWs across the country. This heralds thefull integration of TFP/CMAM into the publichealth system in Ethiopia where a severelymalnourished child can access treatment in anyhealth facility in the same way as a child withmalaria.

The TFP reporting systemThe rapid expansion of the TFP (from 1,240 sitesat the end of 2008 to 4,325 by the end of 2009, a240% increase) ensured that the focus needed toremain on training and capacity building ofHEWs and supervisory staff in managing SAMtreatment at health post level. Partners werewell aware that the reporting system (designedto monitor the number of sites implementingthe programme and the quality of care, throughtracking recovery, death, default) was poorlyfunctioning during the first two years, but thefocus was necessarily on the capacity buildingof health staff. At the beginning of 2010, as thenumbers of TFP sites continued to expand, itbecame a priority to improve the reporting rate.

UNICEF recruited a TFP Reporting Officerfor each region (initially for three months butextended to 11 months of 2010), operatingunder the Emergency Nutrition CoordinationUnit (ENCU). The reporting rates significantlyimproved, in part due to the TFP ReportingOfficers who worked to identify the bottlenecksin the reporting system. In the short term, theyalso acted as ‘couriers’ for the data early in2010. See Figure 3 for the progression of TFPexpansion and reporting rate.

In order to sustain this improved reportingrate from the regions, the ENCU conducted areview in 2011 to document the lessons learnedof how the TFP reporting rate improved. Someof the key lessons included the need for:• Continuous advocacy on the importance of

timely and accurate TFP reports at regional and woreda levels, by all nutrition staff in the regions.

• Training of zonal and woreda Maternal and Child Health (MCH) experts in use of the TFP data base and completion of monthly reports and providing supportive supervi-

interventions through the HEP. The EOS waslaunched in April 2004 with the aim of reducingmortality and morbidity in 6.8 million childrenunder 5 years, as well as pregnant and lactatingmothers in 325 drought prone woredas acrossEthiopia. This was to be achieved through theimplementation of key child survival initia-tives, including Vitamin A Supplementation(VAS), de-worming, measles vaccination andscreening for malnutrition and subsequenttreatment of malnutrition. A major success ofthe EOS programme has been Vitamin A cover-

age consistently recorded as over80% since 2005.

The EOS has transitioned intoChild Health Days (CHD) in the228 Woredas where the CBNprogramme is currently beingimplemented. To facilitate the tran-sition of more EOS woredas intothe CHDs, an operational plan fortransition has been prepared and isunder discussion between theFMoH and key partners.

Using the opportunity pres-ented by the six-monthly VAScampaigns, screening for acutemalnutrition using Mid-UpperArm Circum- ference (MUAC) indrought- affected woredas is alsoundertaken. Children and preg-nant and lactating women (PLW)identified as moderately malnour-ished receive 3-monthly supplem-entary food rations through theTSF, while those identified asseverely malnourished are referredto the nearest health facilityproviding TFP/CMAM services.The number of woredas imple-menting the TSF component of theEOS has been reduced to 167drought affected woredas in sixregions. This is largely due to thelack of sufficient resources avail-able to procure and supplysupplementary rations. A conceptnote has been developed by theFMoH, DRMFSS, UNICEF andWFP regarding the transition ofTSF into a programme for manage-

ment of MAM in the medium to long term.

RUTF in Ethiopia: supply, importation,local production and distribution mechanismsThe development and use of RUTF has been thecritical factor that helped to revolutionise themanagement of SAM, through enabling out-patient treatment for the vast majority ofmalnourished children. From 2003 to 2005,INGOs generally provided their own suppliesfor the projects they implemented.

By 2005, the OTP was slowly being scaledup. During the hunger gap in the same year,UNICEF was required to air-lift approximately400 metric tons of RUTF from their Europeansupplier. In addition to the extra costs associ-ated with air-freight, complicated andtime-consuming customs clearance processespresented a challenge for the importation ofRUTF. UNICEF took on the role of central

sion for relevant staff. • Including reporting rates as one of the

performance evaluation indicators amongst health workers.

• Discussion of reporting rates in the monthlyand quarterly review meetings held at regional level, including analysis of report-ing submission to encourage the close follow up for those facilities/woredas not reporting.

• Continuous follow up and regular commu-nications with woredas an health facility level experts, using all available means (telephone, e-mail, fax and other networks).

The benefits of the efforts towardsimproving the reporting rate(consistently above 80%), is thatthere is now trend data whichshows the impressive expansionand successful performance of theTFP at primary health care level.13

Additionally, widespread coverageand accurate reporting of the TFP isproviding invaluable trend moni-toring data. In the absence ofroutine nutrition information (seebelow, challenges) reports ofincreasing numbers of admissionsto the TFP have become crucial dataalerts for authorities to deterioratingsituations, as seen in the lowlanddrought affected areas during 2011.

There remain on-going chal-lenges for the TFP reporting andnutrition information systems.Although the reporting rates haveremained consistently above 80%,there is often a delay in timelycompilation and submission ofreports. The information oftencomes late, reducing its efficacy for‘early warning’ of deterioratingsituations. Also, the standardiseddatabase for TFP monitoring is onlyat regional level and has not yetbeen implemented at woreda level.With the expanding numbers of TFPsites, there is increased importancefor this trend monitoring data to beaccurate and timely.

There are also opportunities for the report-ing systems. The HMIS has been revised andnow includes TFP data in a manner that enablestracking performance standards against theSphere indicators. Moreover, HMIS reportingfrom woreda to regional levels will soon changefrom a quarterly to monthly basis. This willcreate a solid opportunity to fully integrateTFP/CMAM reporting into the national HMIS.

Linkages with other programmesTFP/CMAM in Ethiopia has developed somelinkages with other nutrition programmes thatare implemented under the umbrella of theNNP including:

Community Based Nutrition (CBN)CBN is the preventative arm of the nutritionservice delivery outlined in the NNP. It aims touse community capacity to assess and analysethe nutrition situation of its own communityand take appropriate action. Monthly GrowthMonitoring and Promotion (GMP) sessions,followed by community conversations andcounselling, are used as tools to elicit the triple-

18

15 See article regarding UNICEF global supply of RUTF includ-ing Ethiopia in Field Exchange 42. Increasing access to RUTF. Jan Komrska, UNICEF.p46-47.

OTP training is provided as part of CBNtraining in the 343 CBN woredas where CBN isimplemented, creating an opportunity for bothprogrammes to benefit from this linkage. Thecommunity conversations within the CBN areproving useful in assessing and analysing whya child is malnourished and what behaviouralchanges could foster improved nutritionalstatus for the children in a family, using theirexisting resources. Additionally, the presence ofTFP/CMAM in all CBN woredas provides goodopportunities for referrals and behaviouralchange messaging for severely malnourishedchildren.

Enhanced Outreach Strategy (EOS)The Enhanced Outreach Strategy/TargetedSupplementary Food Programme (EOS/TSF)was designed and initiated jointly by the FMoH,the Disaster Risk Management Food SecuritySector (DRMFSS) (former Disaster Preventionand Preparedness Agency), UNICEF and WFP,to address some of the most critical childsurvival and malnutrition problems in Ethiopiaand to provide a bridge to sustained nutrition

Field Article

Seta Temesgen with her seven month old baby, Aynadis,during weekly OTP (Geter Meda Health Post, Lasta

District, North Wollo Zone, Amhara Region)

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A cycle of assessment, analysis and action. Theprogramme has been gradually expanded,training over 90,000 Community HealthVolunteers (CHVs). CBN has been scaled-up to228 woredas in the four main regions ofEthiopia (SNNP, Tigray, Amhara, Oromiya)supported by development partners of theFMoH.14 In 2012, the CBN will be rolled-out toan additional 115 woredas bringing the totalnumber of woredas to 343. UNICEF providestechnical assistance and support for govern-ment implementation.

19

procurer and distributor of RUTF for most organisa-tions to facilitate the importation processes. UNICEFprocured and distributed a total of 11,472 metric tonsof RUTF between January 2008 and September 201115.

Small scale local production of RUTF was pilotedfrom 2004/5 by Concern and Valid Nutrition, using asmall scale local producer and locally produced rawmaterials, except for the Dried Skimmed Milk (DSM)and mineral/vitamin mix which had to be imported.However, these pilots were unsuccessful as it proveddifficult to ensure the quality of the product usingsmall-scale producers.

Success factors for local productionIn early 2007, larger-scale production was establishedfollowing an initial investment from a US-basedphilanthropist (donating over 300,000 USD, to berepaid back to UNICEF through in-kind contributionby the local manufacturer once the production was upand running). Through the use of Nutriset’s franchisenetwork (plumpyfield), a local company HILINAreceived the transfer of technology and skills fromNutriset that enabled local production of RUTF, of aquality that passed the expected standards of bothMédecins Sans Frontières (MSF) and UNICEF.

While the local producer was gradually scaling-up

production, it was not enough to meet theneeds of the expanded TFP during nutritionstress years (such as 2008). A large amountof RUTF still needed to be imported,although the proportion supplied by localproduction is encouraging.

Between January 2008 and June 2011,approximately 39.3 million USD had beeninvested in the procurement of RUTF. Thiscost does not include the freight and distri-bution expenses. RUTF remains the mostexpensive component of the TFP; a costanalysis is currently being undertaken(together with the CMAM evaluation),which is expected to provide more informa-tion of the costing associated with the TFP inEthiopia.

Challenges with local productionThe local producer continues to procure allpeanuts and oil from the local market, whichpositively contributes to the local economyand livelihoods of farmers. However, some-times the quality of the RUTF has beencompromised, with unacceptably highlevels of aflatoxin contamination from poorhandling and storage of peanuts. The localproducer has taken several steps to ensurethat levels of aflatoxin stay within accept-able recommendations. UNICEF has alsoinstituted a system of testing each and everybatch of RUTF for contamination. This hasresulted in a two week lead time aftercompletion of the production until aflatoxintest results are received from an independ-ent laboratory in the UK. These efforts bythe producer to improve the quality of thelocally sourced raw materials have beenshowing results. Over the past 12 months,only one batch of RUTF has failed to complywith acceptable levels of aflatoxin in thefinal product.

Distribution systems and structures forRUTFThe in-country distribution of RUTF usesvarious routes to reach the health facilities.The bulky nature of the RUTF in bothvolume and weight that is required to ‘cure’each severely malnourished child is consid-erably larger than the drug supplies usuallyneeded for routine treatment of other life-threatening conditions. As a result,pre-positioning several months worth ofRUTF supplies has often been beyond thewarehousing capacity of the health system.Additionally, the seasonal and sometimesdrought-related rapid increases in admis-sions to the TFP, intensifies the pressure onthe health service logistic system for ensur-ing timely deliveries of large volumes ofRUTF.

The FMoH uses the Pharmaceutical Fundand Supplies Agency (PFSA) logistic systemfor most medicines and supplies usedwithin the health system. As described,RUTF is a bulky and heavy product, whichhas meant that it is beyond the currentcapacity of the PFSA system to handle distri-bution and storage. As a result, UNICEF andpartners have been required to deliver theRUTF through the RHBs and ZHDs, indi-cated in Figure 6.

UNICEF has distributed an average ofapproximately 2,800 metric tons of RUTFper year since 2008 to health facilities across

16 This is equivalent to over 217,000 cartons or over 32.5million sachets per year

1800

1600

1400

1200

1000

800

600

400

200

02008 2009 2010 2011

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Figure 4: Quarterly distribution of RUTF to TFP from 2008-mid 2011, in metric tons. (Source: UNICEF)

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Figure 5: Source and amount (MT) of RUTF for TFP inEthiopia (2008-2010)

Figure 6: Delivery flow chart of RUTF for TFP/CMAM /TFP inEthiopia

UNICEF bonded warehouse NGO importedRUTF

RHB Warehouse

ZHD Warehouse

WoHO Warehouse

Health Facilities (health posts,health centres and hospitals

NGO warehouse/transport assistance

Field Article

Ethiopia.16 Mostly it is delivered directly tothe RHB warehouses although in times ofemergency, UNICEF sometimes delivers tothe zonal level or direct to woredas (dottedlines in Figure 6), to minimise the risk ofdamaging stock-outs. Re-supplying of theRUTF is based on official requests from theRHBs using the TFP reporting system, withre-supply levels based on the monthlyreported caseloads.

Major successes of the RUTF supplyand distribution systemThe system has enabled rapid expansion ofCMAM capacity to over 7,000 health posts.It is flexible and able to respond to emer-gency needs. Performance is strongly relatedto the technical persons implementing theprogramme, as they take the lead in requisi-tioning and distributing the RUTF. NGOscan access the RUTF from ZHDs or RHBsand support its delivery to health post level.UNICEF acting as the central procurementchannel has considerably eased the burdenon partners for importation and customsclearance

Major challenges of the RUTF supplyand distribution systemThe limited warehousing capacity of theregional and zonal health offices can some-times affect the quantity of RUTF that can bedelivered and stored safely. Late requestsand inadequate forecasting of projectedconsumption compromise programming.Some misuse/ leakage of RUTF by clientshas been reported (selling and sharing),using for moderately malnourished childrenand at times, adults. Some duplication canoccur between partners, e.g. UNICEF, theFood By Prescription programme (FBP) andGOAL, creating difficulties for some facili-ties to track records of clients versuscommodities. Coordination meetings havebeen established to assist with reducingduplication.

CMAM transition in emergencies anddevelopmentManagement of SAM has traditionally beenconsidered an emergency response, oftenimplemented by NGOs. In the context ofchronic food insecurity and seasonal hunger,programmes open based on emergencythresholds of SAM and GAM rates and thenclose as the situation improves, only toreopen in the next hunger season. The impli-cations of this traditional emergency focus ofCMAM include irregular and short-livedfunding, inadequate resources for capacitybuilding of the health system and delays inthe emergency response. These delays havemostly been linked with the time needed toidentify the affected woredas and conductnutrition surveys, in order to justify the poorsituation and hence access emergency fund-ing from the various donors. This paradigmhas resulted in additional costs of repeatedlyphasing in and phasing out of programmesfor the management of acute malnutrition inchronically affected woredas. The timelinessand adequacy of RUTF provision can behostage to the declaration of emergency situ-ations and resulting donor pledges. Hencethere is a need for improved funding mech-

RHB: Regional Health Bureau, ZHD: Zonal Health Department, WoHO:Woreda Health Office

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anisms, especially for on-going situations thatmay not be characterised as a humanitarianemergency.

The extensive CMAM rollout in Ethiopia hasenabled unusual access to longitudinal infor-mation on admissions of severelymalnourished children to public health facili-ties over the past few years. Instead of waitingfor nutrition surveys to be planned, undertakenand compiled, humanitarian actors can easilyidentify the progress or deterioration of a givennutrition situation, through surveillance of themonthly admissions to CMAM. The massiveincrease in coverage of CMAM services acrossthe country has allowed access to first-handinformation from wide areas. These constitute aconsiderable proportion of the country, espe-cially if compared to the handful of woredasthat were being reached through nutritionsurveys. However, it must be noted that routineprogramming data, reports and anthropometricmeasurements will likely be of lower qualitythan standard nutrition survey data. Therefore,while the use of nutrition survey data remainsrelevant in specific situations, it is not necessar-ily the only tool available for decision makingfor action.

In addition to nutrition surveys, hot-spotclassification has been introduced in Ethiopia.The ‘hot-spot’ priority list provides the basis forthe Relief Requirement Plan released by theDRMFSS in collaboration with all sectorministries and the UN. The use of the ‘hot-spot’classification system has been a step forwardfrom the sole reliance on the use of GAM andMAM thresholds, to decide when to start andstop interventions.

Ways forward Integrated management of acute malnutrition at scaleCMAM has integrated very well into theprimary health care system of Ethiopia and isundoubtedly saving the lives of many vulnera-ble children. There has been demonstratedsuccess when linking CMAM with theIntegrated Management of Neonatal andChildhood Illnesses (IMNCI) and ICCM initia-tives. Encouragingly, many opportunities forthe capacity building of frontline health work-ers continue to present themselves in Ethiopia.What is less clear is how the level of funding forintegrated treatment for SAM will be sustainedover the longer-term, since the supplies areexpensive. There is an urgent need to strategisethe possibilities of funding sources beyondhumanitarian mechanisms. This could not onlyprovide funding sources for ongoing needs, butwould enable more equity of services, ifseverely malnourished children in ‘non-emer-gency’ woredas were able to have the sameaccess to treatment as those living in identifiedhot-spot woredas. The cost analysis of theUNICEF/MOH CMAM evaluation (currentlyunderway) is expected to provide usefulinsights on the cost effectiveness of investing inthe management of severe acute malnutrition.

The implementation of TFP/CMAM at scalecalls for concerted efforts and investment inquality monitoring and improvement. CMAMquality improvement is contingent on many ofthe health system pillars17 including servicedelivery, information systems, the health work-force, medical products, health financing andleadership. As a result, efforts to improve

CMAM quality should be viewed from thehealth system’s perspective, and thereforecontribute to overall improvements in thesystem.

In addition, there is a need for improvedlinkages between TFP/CMAM, CBN and otherdirect nutrition interventions currently beingimplemented in Ethiopia to ensure that themaximum gains are being leveraged from theconsiderable investments being made by bothgovernment and partners.

Operational research prioritiesUnder the NNP, operational research is identi-fied as crucial for developing ourunderstanding of effective preventive and cura-tive nutrition interventions. A number ofresearch possibilities have been identified byFMOH/ EHNRI and partners, with priorityoperational research areas as follows: • Cost effectiveness study of TFP/CMAM in

Ethiopia• Determinants of successful and lasting

management of SAM through community based nutrition activities

• Assessment of quality of nutrition data; flow, data utilisation, and validation

• Study on the effectiveness, feasibility, acceptability and compliance of micronutri-ent powders (e.g. Sprinkles) to improve complementary feeding practices and reduce micronutrient deficiencies in childrenunder 2 years of age.

ConclusionThe large numbers of severely malnourishedchildren successfully treated over the last fewyears testifies to Ethiopia’s success in fully inte-grating the out-patient management of SAMinto all levels of the routine health system.Importantly, across this vast land, services have

17 WHO. Everybody’s Business: Strengthening health systemsto improve health outcomes: WHO Framework for action. 2007. (accessed at http://www.who.int/healthsystems/ round9.2.pdf

Field Article

Health Extension Worker, Habtam Byabel,attends to Seta Temesgen and her baby,

Aynadis, inside the Geter Meda Health Post

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been decentralised to primary health care levelto improve access and coverage.

Based on our successful experience of scal-ing up TFP/CMAM in Ethiopia, countries thatare considering starting TFP/CMAM could tryto scale-up services to national level. Suchactions save lives, both during emergency situ-ations and as part of routine nutritioninterventions. It is clear that the implementa-tion of TFP/CMAM at-scale not only putspressure on the health system, but also stimu-lates it to respond to the additional demands.This could be due to the fact that theprogramme is so visibly successful; it createsdemand from within communities because ofthe rapid improvement in their sick malnour-ished children; when able to access appropriatetreatment, the transition of their children - fromlistless and lethargic, to playful and energetic –can provide a powerful motivating force for thecommunity.

Ethiopia has learned that to successfully roll-out TFP/CMAM, it is vital to ensuregovernment commitment and to develop goodcoordination between government and devel-opment partners (especially for resourceallocation). It is also crucial to create a well-established logistics system and wellthought-out monitoring and evaluationsystems, to ensure both quality and continuityof services.

For more information, contact: Dr FerewLemma, email: ferew.lemma@yahoo.com

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CHIM Centre for Health InformationManagement

CHO Community health officer

CHN Community Health Nurse

CHPS Community Health Planning Services

CHVs Community health volunteers

CMV Combined Mineral and Vitamin mix

CSO Civil society organisation

DHMT District Health Management Team

FANTA2 Food and Nutrition Technical AssistanceProject II

GDHS Ghana Demographic and Health Survey

GHS Ghana Health Service

GPRS II Ghana Poverty Reduction Strategy II

GSGDA Ghana Shared Growth and DevelopmentAgenda

HIMS Health Information Management System

HSMTDP Health Sector Medium Term DevelopmentPlan

ICD Institutional Care Division

IMNCI Integrated Management of. Neonatal andChildhood Illness

IYCN Infant and Young Child Nutrition

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Field Article

Effectiveness of public healthsystems to support nationalrollout strategies in Ghana

BackgroundNational nutrition and health situationLike most developing countries, Ghana isfaced with high rates of malnutrition.According to the Ghana Demographic andHealth Survey (GDHS) 2008, 14% of childrenunder five years are underweight, 28% arestunted and 9.0% wasted. Severe wasting is2.0% with the highest proportion of severelywasted in the Upper West (3.9%), Eastern(3.7%) and Northern (3.4%) regions of thecountry (see Figure 1 for map of Ghana). Interms of micronutrient deficiencies, the preva-lence of anaemia is very high among womenof reproductive age (59%), pregnant women(70%) and lactating women (62%). It is equallyhigh among children under-five at 78% withno improvement seen when compared to the2003 GDHS. Encouragingly, infant mortalityhas dropped from 64/1000 live births (GDHS20031) to 50/1000 live births (GDHS 20082)whilst under-five mortality has dropped from111/1000 live births (GDHS 2003) to 80/1000live births (GDHS 2008).

Over recent years, the country has devel-oped and implemented a number of strategiesto combat malnutrition. Progress has beenmade, with an increase in exclusive breast-feeding rate among infants less than 6 monthsfrom 53% (DHS 2003) to 63% (DHS 2008).Progress has also been made towards theachievement of the MDG 1 target of halvingunderweight by 2015. The prevalence ofunderweight has reduced from 23% in 1993 to14% in 2008, however, major challengesremain. There has been limited progress inreducing stunting (chronic malnutrition), theprevalence of which has fallen by only 6percentage points since 1988. Ghana is amongthe 36 countries with a stunting prevalenceabove 20%3. Whilst levels of wasting haveremained relatively constant, it is also ofconcern that the rate of overweight amongchildren under five years is on the increase(from 1% in 1998 to 5% in 2008), indicating adual burden of malnutrition.

By Michael A. Neequaye and Wilhelmina Okwabi

Wilhelmina Okwabi is DeputyDirector of Nutrition of theGhana Health Service (GHS), aposition she has held for 2 years.Her previous positions includeProgramme Manager of

Nutrition and HIV/AIDS, National Coordinator forInfant and Young Child Feeding, AssismstantProgramme Manger (Supplementary FeedingProgramme) and Nutrition Course Coordinator ina Rural Health Training School.

Michael A. Neequaye works withthe Ghana Health Service as theNational Programme Manager,Nutrition Rehabilitation, and theNational Coordinator for theCMAM programme since 2007.

Previously he was the Regional Nutrition Officerof the Ministry of Health in the Eastern region ofGhana before joining World Vision Ghana as theProject Manager for the Micronutrient andHealth (MICAH) Project for 10 years.

1 Ghana Demographic and Health Survey, 20032 Ghana Demographic and Health Survey, 20083 Black et al, 2008. Maternal and Child Undernutrition 1.

Maternal and child undernutrition: global and regional exposures and health consequences.

MOH Ministry of Health

MUAC Mid Upper Arm Circumference

NACS Nutrition Assessment Counselling andSupport

NHI National health insurance

NID National Immunisation Day

NMCCSP Nutrition Malaria Control for ChildSurvival Project

NRC Nutrition Rehabilitation Centre

PLHIV People living with HIV

RCH Reproduction and Child Health

RHMT Regional Health Management Team

RUTF Ready to Use Therapeutic Food

SAM Severe acute malnutrition

SAM ST SAM Support Teams

SAM SU SAM Service Unit

SAM TC SAM Technical Committee

SBCC Social Behaviour Change andCommunication

SFP Supplementary Feeding Programme

PPME Policy Planning and Monitoring andEvaluation

TMPs Traditional medicine practitioners

The authors gratefully acknowledge thesupport of WHO, USAID/FANTA-2, and UNICEF inwriting this article. The Nutrition Departmentwould like to mention in particular the follow-ing people for their invaluable contributionsand comments during the development of thearticle: Dr. Isabella Sagoe-Moses and CynthiaObbu, Ghana Health Service (GHS),Reproductive and Child Health Department,Samuel Atuahene-Antwi GHS, Ga SouthMunicipal Health Directorate, Akosua Kwakye,WHO/Ghana, Alice Nkoroi, USAID/FANTA-2,Catherine Adu-Asare, USAID/FANTA-2, ErnestinaAgyapong, UNICEF/Ghana, Maina Muthee,UNICEF/Ghana. Special thanks also to theDirector General, Director of Family Health andother Divisional and Departmental Directors ofGHS for their support in the integration ofCMAM into the health service delivery in Ghana.Last but not least, GHS wishes to thank allDirectors and staff working in the 31 districtsimplementing CMAM in Ghana.

Group 1 region: Upper West, Upper East, Northern, Central and Greater AccraGroup 2 region: Western, Eastern, Volta, Ashanti and Brong Ahafo

Acronyms: Figure 1: Administrative map of Ghana

Medicalexamination

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Health and nutrition policiesThe National Nutrition Policy is currently beingdrafted4. Prior to the development of thenational nutrition policy, a strategic document‘Imagine Ghana free of Malnutrition5’ wasdeveloped by a multi-sectoral group of stake-holders. The document set out strategicnutrition objectives and provided costing forimplementing nutrition interventions to meetthe set objectives. This document is currentlybeing used as the basis for the nutrition policy,updating and aligning Ghana’s nutrition prior-ities to address under-nutrition usingevidence-based nutrition interventions.

The Ghana Health Sector Medium TermDevelopment Plan (HSMTDP) 2010–2013 andthe Ghana Shared Growth and DevelopmentAgenda (GSGDA), which is a follow on docu-ment to the Ghana Poverty Reduction StrategyII (GPRS II), identify nutrition and food securityas critical and cross-cutting issues in addressingoverall human resource development. TheGSGDA sets out policy objectives to addressissues relating to nutrition and food security.Both aforementioned documents expressparticular concern regarding the persistent andhigh undernutrition rates among children,particularly male children in rural areas and innorthern Ghana. The HSMTDP identifies thescale up of CMAM as an important interventionfor helping to reduce under five mortality ratesand also for improving the nutrition status ofwomen and children.

Vulnerability to emergenciesThe Comprehensive Food Security andVulnerability Analysis conducted by the WorldFood Programme (WFP) in May 2009 showedthat, although Ghana is generally less affectedby food insecurity compared to other WestAfrican and sub-Saharan countries, about 1.2million Ghanaians are food insecure. A further2 million people are vulnerable and could expe-rience food insecurity during adverse weatherconditions, such as floods or droughts, and as aresult of post-harvest losses. Although theprevalence of acute undernutrition is belowemergency thresholds, nutritional challengesthreaten Ghana’s overall social and economicdevelopment. There are regional variations infood security and undernutrition in the country.The Northern regions (Upper East, Upper West,and Northern) have a higher prevalence ofunderweight and wasting that are closelylinked to food insecurity. Lack of access to foodis also a determining factor for acute undernu-trition in the coastal zone.

Organisation of the Ghana Health System(GHS)The Ministry of Health (MOH) is the govern-ment ministry in Ghana that is responsible forthe formulation of national health policies,resource mobilisation, and health service deliv-ery regulation. The MOH has a number ofagencies, including the Ghana Medical andDental Council, the Pharmacy Council, GhanaRegistered Nurses and Midwives, AlternativeMedicine Council, Food and Drugs Board,Private Hospitals and Maternity Homes Board,National Health Insurance Secretariat, GhanaNational Drugs Programme, teaching hospitalsand the Ghana Health Service (GHS). SeeFigure 2 for an overview of the GHS structure.

The GHS is an autonomous body under theMOH, responsible for healthcare provision inaccordance with MOH policies through public

NRCs provide residential nutrition care. NRCstend to be clustered in more urban areas.Administratively, the GHS is managed at theregional and district level by health direc-torates.

Beyond the sub-district level, communitylevel health services are provided throughdifferent mechanisms. Two of the more devel-oped mechanisms include child welfareoutreach points (run from health centres) andCHPS zones. The CHPS zones comprisecommunities of 3,000 to 4,500 people (generallytwo to five villages), to which a communityhealth officer6 (CHO) is assigned to provideprimary health care services from the CHPScompound (the nurse’s home and office, builtby the community) and through frequent homevisits. The CHO is supported by a number ofcommunity health volunteers (CHVs) selectedby a community health committee, comprisedof village leaders, women’s and youth groups,traditional birth attendants and others.

Across the different levels of service deliv-ery, health staffing is generally adequate withexceptions in newly formed districts. TheNorthern regions also tend to have fewer physi-cians and nurses compared to the southern andcentral parts of the country because theseregions are less developed.

CMAM integration and scale up in GhanaIntroduction of CMAMCMAM was first introduced in Ghana in June2007 at a workshop organised by the GHS incollaboration with UNICEF, WHO and USAIDfor selected health care providers throughoutthe country. See Table 1 for an outline of keyevents in the development of CMAM in Ghana.Prior to 2007, the GHS had addressed the needsof children with severe acute malnutrition(SAM) in paediatric wards or NRCs, whichprovided nutrition counselling and foodscooked using locally available ingredients.However, these NRCs did not follow the WHO1999 treatment protocol for the management ofSAM7 or provide any specialised therapeuticfoods for children with SAM.

hospitals, health centres, and CommunityHealth Planning Services (CHPS) compounds.The GHS provides in-service training and devel-ops guidelines and plans for implementation ofnational health policies. Private and faith-basedhealth facilities, such as mission hospitals,administer approximately 40% of healthcareservices in the country. While independent,these facilities are bound by national MOH poli-cies and GHS guidelines and are required tosubmit statistics and reports to the GHS.

The Family Health Division under the GHShas three departments: Reproductive and ChildHealth, Nutrition, and Health Promotion. TheNutrition Department assigns ProgrammeOfficers for the various nutrition programmessuch as Infant and Young Child Nutrition(IYCN), Nutrition Malaria Control for ChildSurvival Project (NMCCSP), MicronutrientControl Programme, which covers vitamin A,iron deficiency anaemia, iodine deficiencydisorders and food fortification, NutritionRehabilitation, which includes CMAM andNutrition Assessment Counselling and Support(NACS) for PLHIV, and the SupplementaryFeeding Programme (SFP) in Northern Ghana.At the regional and district levels, there areassigned nutrition officers, while at the sub-district levels a health manager (PhysicianAssistant or Public Health Nurse) overseesnutrition activities along with other healthactivities.

Health services deliveryThere are three semi-autonomous referralteaching hospitals, one each in the northern,central and southern parts of the country. Thereare ten regions of Ghana, divided into 170districts, and each region has a regional referralhospital. All districts are expected to have adistrict hospital, which serves as the first refer-ral level. However, some of the newly createddistricts have upgraded health facilities ratherthan hospitals, due to variations in levels ofstaffing and equipment. Districts are furtherdivided into sub-districts, which have healthcentres headed by Physician Assistants andstaffed with clinical and public health nursesand other auxiliary staff. Some of the largerurban health centres, referred to as polyclinics,are staffed with physicians in addition to thepersonnel mentioned above. Additionally, thereare 42 Nutrition Rehabilitation Centres (NRCs)that were established to manage malnutritionprior to the introduction of CMAM. Ten of the

Figure 2: Ghana Health Services organisation structure

Family HealthDivision

Reproductiveand ChildHealth

Department

Diseasecontrol

Department

DiseaseSurvillanceDepartment

PolicyDepartment

Planning andBudgetingDepartment

Clinical engineeringDepartment

EstateManagementDepartment

TransportManagementDepartment

GeneralAdministrationDepartment

HealthPromotionDepartment

NutritionDepartment

Public HealthDivision

Policy, Planning,monitoring andevaluation

HealthAdministrationand supportservices

Director General

Deputy DirectorGeneral

HumanResource

InstitutionalCare

InternalAudit

Finance Research andDevelopment

SuppliesStores and

DrugManagement

Office ofDirectorGeneral

4 As at November 2011.5 ‘Imagine Ghana Free of Malnutrition’, NMCCSP Programme

supported by the World Bank6 A Community Health Officer is a Community Health Nurse

or Midwife who receives additional training, upgrading his/her skills to manage a CHPS zone.

7 WHO. 1999. Management of severe malnutrition: A manualfor physicians and other senior health workers.

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Field article

the regional level, support teams workingunder the regional health director oversee theroll-out of CMAM within their regions.

CMAM services and supplies were madeaccessible in a sustainable manner, in order thatquality services could be provided to childrenwith SAM. To ensure quality service provision,each region initiated CMAM in one or twodistricts with a limited number of outpatientand inpatient sites. These facilities acted aslearning sites for the region, with services thengradually scaling-up to the rest of the districtsin the region. Decisions to expand CMAM tonew districts were based on the quality of serv-ice delivery at the learning sites, the availabilityof qualified technical personnel to provide tech-nical support and the availability of resourcesand supplies to ensure continuous servicedelivery in all new districts.

A five-year National Scale up Strategy iscurrently being developed. It is expected thatthe National Strategy for CMAM will bediscussed and endorsed in a national work-shop.

PartnershipsThe MOH/GHS is responsible for the overallcoordination of CMAM services, creating anenabling environment and providing CMAMservices. The MOH/GHS health care providersmanage SAM cases in outpatient and inpatientcare and collaborate with health volunteers toconduct community outreach activities. OtherGHS human resources at managerial and auxil-iary levels support CMAM services as part ofexisting routine health services. MOH/GHSnational, regional and district technical officersare responsible for building the capacity of theimplementing health care providers.

The GHS is also responsible for distributingand storing CMAM supplies through the exist-ing GHS logistics system. The GHS alsoprovides routine medication (antibiotics andmalaria prophylaxis) free to children with SAMin some facilities.

Partners currently supporting the integra-tion and scale-up of CMAM in Ghana areUSAID, USAID/FANTA-2, UNICEF and WHO.The partners provide technical assistance thatincludes facilitating the development of guide-lines, training materials, monitoring, reportingand quality improvement tools, and supportingthe review of the learning sites that informdesign of the CMAM services. UNICEF andUSAID also procure CMAM supplies for thegovernment and provide financial support tothe GHS to conduct trainings and other capac-ity building activities.

Implementation of CMAM in GhanaEnabling environment for CMAMThe MOH/GHS has taken the lead role in theintegration of CMAM into the national healthsystem. In December 2007, the GHS establishedthe SAM TC to coordinate and oversee imple-mentation and integration of CMAM activitiesinto the service delivery system at all levels inGhana. The SAM TC is chaired by the GHSNutrition department and is composed of arange of representatives, including other GHSDepartments, Institutional Care Division (ICD),Child Health, Policy Planning and Monitoringand Evaluation (PPME), Korle-Bu TeachingHospital (representing the academic institu-tions), and partners (UNICEF, WHO, USAIDand FANTA-2).

The SAM Service Unit (SAM SU), which is acore team of the SAM TC, is housed in theGHS/Nutrition Department and receives tech-nical and financial support from USAID,FANTA-2, UNICEF and WHO. It is responsiblefor providing day-to-day technical guidance,coordination and advocacy for CMAM.

At the regional level, SAM Support Teams(SAM STs) were established in January 2010.Their role is to plan and coordinate CMAMimplementation within the region and providetechnical support to the districts and facilities.The regional SAM STs comprise of GHS staffspecifically the Regional Nutrition Officer,Regional Public Health Nurse, RegionalDisease Control Officer, Regional Clinical CareOfficer (from the ICD) and an appointed clini-cian/paediatrician trained and experienced ininpatient care. The Regional SAM STs report tothe Regional Health Director.

Integration and scale-up of CMAM is a keycomponent of nutrition in the HSMTDP2010–2013. The SAM TC prepares nationalannual CMAM work plans and also supportsthe regions to prepare region-specific CMAMscale up plans. These work plans are then inte-grated into the overall regional and nationalGHS annual work plans in line with the healthsector plan. The nutrition policy under devel-opment will include policy guidance onimplementation and scale up of CMAM inGhana.

The MOH/GHS has developed and dissem-inated the Interim National Guidelines forCMAM in Ghana that are widely used withinthe implementing regions. CMAM has alsobeen integrated into the new IMNCI

Following recommendations from the June2007 workshop, the MOH/GHS adopted theCMAM approach for the management of SAMwith the establishment of learning sites in twodistricts, Ashiedu-Keteke sub-metropolitanarea (Greater Accra region) and Agona District(Central region) in April 2008. The learningsites were later expanded to Ga South district inMarch 2009. These learning sites providedaccessible practical experience and an opportu-nity to refine the strategy for the scaling-up ofCMAM in phases.

Integration and scale up of CMAMCMAM integration and scale up within Ghanahas been planned in a two-phased approach.Phase 1 targeted five regions: Upper West,Upper East, Northern, Central and GreaterAccra. The second phase will target the fiveremaining regions of Western, Eastern, Volta,Ashanti and Brong-Ahafo, which is expected tostart in 2012.

The Phase 1 scale-up of CMAM began in2010, with a limited number of districts and agradual expansion to additional districts in2011. CMAM scale-up activities have specifi-cally focused on strengthening the capacities ofthe GHS and nutrition partners and developingcompetencies for sustainable, quality servicesfor the management of SAM. An enabling envi-ronment for CMAM was created andcompetencies strengthened in partnership withUNICEF, WHO, USAID, the USAID-fundedFood and Nutrition Technical Assistance ProjectII (FANTA-2), national training institutions, andother partners in health and nutrition.

In Ghana, the operational strategy forCMAM is managed by the SAM TechnicalCommittee (SAM TC) at the national level. At

Date Activities

June 2007 - Workshop organised to introduce CMAM into Ghana.

December 2007 - Severe Acute Malnutrition Technical Committee (SAM TC) formed to plan and coordinate theintegration of CMAM into the health delivery system.

March 2008 - Sensitisation of regional and district health directorates on CMAM in Central and Greater Accraregions where learning sites were selected.

April 2008 - Training for health staff in the learning sites on outpatient and inpatient care.- Training of volunteers in community outreach.- Initial outpatient care facilities established in the learning sites of Ashiedu Keteke (2) and Agona

Districts (7).

July 2008 - Field testing of the generic community outreach module conducted in Ghana. This is part of theFANTA, VALID, UNICEF, Concern Worldwide and other partners CMAM training modules developed in 2008.

March 2009 - CMAM activities scaled up within the learning sites to provide district-wide coverage in AgonaWest Municipality and Agona East District.

May 2009 - Field test of the global CMAM costing tool.

July 2009 - Conducted a CMAM training of trainers workshop for regional health staff from Phase 1 regions(Northern, Upper East, Upper West, Central and Greater Accra).

August 2009 - Conducted the first expanded WHO training of facilitators and clinicians workshop on themanagement of SAM in inpatient care. The expanded WHO training included the management of SAM in the context of CMAM.

January 2010 - Initiated the review and adaptation of the generic CMAM training materials developed by FANTA, VALID, UNICEF, Concern Worldwide and other partners in 2008 to the Ghana context. This included recent global developments and best practice in the management of SAM.

- Initiated the review and adaptation of the generic WHO training materials for inpatient manage ment of SAM in the context of CMAM in Ghana.

May 2010 - Scale up of CMAM started in the Phase 1 regions (Upper West, Upper East, Northern, GreaterAccra and Central).

Feb 2010 - The SAM TC approved the Interim National Guidelines for CMAM and Job Aids.

August 2010 - Review of the integration of CMAM services into the health system.

January 2011 - Consolidated feedback from the regions and districts implementing CMAM on the Ghana adapted CMAM training materials.

- Consolidated the feedback from clinicians and other trainers on the adapted Ghana inpatientcare training materials.

January 2011 - Conducted regional SAM STs refresher training and annual planning workshop.

January 2011 todate (Aug 2011)

- Ongoing scale up of CMAM within Phase 1 scale up regions.

Table 1: Key events timeline

(Integrated Management of. Neonatal andChildhood Illness) chart booklet and trainingmaterials. In addition, the WHO pocket bookletis currently being updated to reflect Ghana-specific adaptations and will provide guidanceto clinicians on the management of SAM in thehospitals.

Competencies for CMAMIn order to integrate and scale-up CMAM inGhana, it has been necessary to conduct in-service training for health care providers toimprove their knowledge and skills in recentglobal developments and best practices in themanagement of SAM. Since 2008, the SAM SUand regional SAM STs have spent considerabletime conducting training to build the capacityof health care providers at the national,regional, district and facility levels. Traininghas also been provided to CHVs on active casesearch, follow up and referral of SAM cases. Todate, approximately 1,473 health care providersand 6,555 CHVs have been trained on themanagement of SAM. Table 2 provides detailsof health care providers and CHVs trainedsince initiation of CMAM in Ghana.

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In addition to in-service training, the SAMSU and regional SAM STs provide continuoussupportive mentoring and supervision to theDHMT and facilities implementing CMAM.Interns from tertiary institutions assigned to theNutrition Department and within the imple-menting districts receive training andorientation to provide support in the manage-ment of SAM cases. Medical and Dieteticsstudents from the University of Ghana on rota-tion at Princess Marie Louise (PML) Children’sHospital (one of the learning sites) are alsoorientated and participate in the managementof SAM.

Access to CMAM servicesIn 2008, CMAM service provision started inlimited learning sites with one district in each oftwo regions, Central and Greater Accra. In 2009,new learning sites were set up in Ga SouthDistrict of Greater Accra region to provide alearning experience within a peri-urban setting.Gradual expansion to other facilities withinthese districts and expansion to new districts in2009 increased access to services.

In 2010, the SAM TC and SAM SU initiatedPhase 1 scale up within Central, Northern,Greater Accra, Upper East and Upper WestRegions (See Table 3). Each region followed thesame process of implementing a limitednumber of outpatient and inpatient care sites inone or two districts, which served as learningsites, before gradually scaling up to otherdistricts. Selection of initial districts was basedon prevalence of malnutrition, availability ofstaff and geographical accessibility.

CMAM services are provided within exist-ing MOH/GHS service delivery structures.Health facilities providing outpatient careinclude hospitals, polyclinics, health centres,community clinics, CHPS and communityoutreach points. Inpatient care services areprovided solely in hospitals.

CHVs, Community Health Nurses (CHNs)and CHOs undertake the community outreachcomponent of CMAM. Existing volunteers used

Region Number trained inoutpatient care (OPC)*

Number trained ininpatient care (IPC)

Community HealthVolunteers (CHV)

Greater Accra 330 38 515

Central Region 294 79 579

Upper East Region 156 37 304

Upper West Region 190 28 1816

Northern Region 213 83 3641

National Level Trainers 23 25 -

Total 1183 290 6555

*District nutrition officers, disease control officer, CHN (Community Health Nurse)/CHO trained on CMAMprovide training to community volunteers

Table 2: Number of health care providers and community volunteers trained (as of August 2011)

Region Totalnumber ofdistricts

Number ofdistricts imple-menting CMAM

Total number offacilities inimplementingdistricts

Total numberof outpatientcare facilities

Total numberof hospitals inimplementingdistricts

Total numberof inpatientcare facilities

Central 17 7 71 71 9 8

Greater Accra 10 6 62 62 7 4

Northern 20 8 78 78 12 9

Upper West 9 6 119 119 6 4

Upper East 9 4 73 73 3 4

Ashanti* - - - - - 1

Total 65 31 403 403 37 30

Table 3: Summary of health facilities implementing CMAM (as of August 2011)

* Staff in one hospital in Ashanti (a phase 2 region) was trained because of the high case load.

for other public health outreach activities, suchas National Immunisation Days (NIDs), vita-min A supplementation, communitysurveillance and guinea worm eradication, arebeing used for CMAM community assessmentand mobilisation. This ensures the efficient useof volunteers and takes advantage of additionalmotivation as these volunteers are given anincentive package to support the NIDs. Thevolunteers generally support one communityeach, although some support two or threecommunities if they are relatively close to eachother.

CHVs screen children at the household levelby measuring Mid Upper Arm Circumference(MUAC) and checking for oedema. They referSAM cases to the nearest health facility. Activecase finding of children with SAM is alsoconducted during the child welfare clinics(usually once per month) and during childhealth weeks. In communities where there areCHPS zones/compounds, the CHVs work inclose collaboration with the CHOs.

Some strong links have been establishedbetween identification of SAM and other publichealth programmes. For example, assessmentof MUAC and oedema has been incorporatedinto the World Bank supported NMCCSP(Nutrition and Malaria Control for ChildSurvival Project) training modules.Additionally, the Ghana IMNCI has adoptedthe new algorithm, which uses MUAC, bilateralpitting oedema and appetite test to diagnoseSAM with and without medical complications.The IMNCI chart booklet and training materialsalso provide guidance on how children withSAM without medical complications should bemanaged in outpatient care, and explains howto refer children with SAM with medicalcomplications to inpatient facilities.

There is a linkage also between HIV servicesand CMAM. Children with SAM who fail tothrive are referred for further investigation,which includes HIV testing and counsellingand referral to HIV services if necessary.

Follow up visit on a SAM child toprevent defaulting

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Appetite test being conducted

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cards or tally sheets for supplies, supervisionchecklists for regional and district levels. Thereis generally good record keeping and reportingby the service providers. CMAM serviceperformance is reviewed monthly at all levels:sub-metropolitan area, municipality, district,regional and national levels. CMAM data arecurrently managed by the nutrition officers andnot yet integrated into the Health InformationManagement System (HIMS). Discussions areongoing with the Centre for Health InformationManagement (CHIM) to review existing nutri-tion indicators in the system to also includeCMAM indicators. CMAM data are collated atthe district level and the data are then sent tothe regional level where they are entered intoan Excel database before being submitted to thenational GHS/Nutrition Department.

CMAM service performanceTable 4 and Figure 3 provide a summary of thetotal number of children who were managedand some service performance indicators (frominception to August 2011).

Cure rate: Overall, 71% of children weredischarged cured, which is below the recom-mended Sphere target of >75%. The cure ratewas offset by the high default explained below.

Death rate: Overall, 2% of children died, whichis an acceptable rate for the management ofSAM and below the Sphere standard of <10%.Many of the children who died had presentedto the health facility at a very late stage orrefused referral to the inpatient care for socialreasons.

Default rate: The number of children whodefaulted treatment was high (21%) and abovethe recommended Sphere standards of <15%.The high default rate can be explained by:• Caregivers default treatment as soon as the

child starts to improve. RUTF is quite effec-tive and children will start to show signifi-cant improvement in the third week. The health workers are urged to provide inten-sive counselling to caregivers to ensure that children continue to come for treatment until they are fully recovered.

• Cases where children are coming from neighbouring districts that do not have CMAM established. As soon as the child starts to show improvement, the mothers discontinue treatment. It is assumed as scaleup continues and there is more access to CMAM services, the default rate will decrease.

• Seasonal migration of caregivers of childrenwith SAM already receiving treatment, especially during planting and harvest seasons.

Non-recovery rate: Overall, 1% of children weredischarged as non-recovered.

Average length of stay (LoS) and average dailyweight gain: A total of 515 cards of childrendischarged as cured were used to analyse theaverage length of stay and weight gain. Theaverage length of stay was 60 days and weightgain reported at 6.0 g/kg/day.

Promising practices (successes)The following are notable promising practicesand successes in the Ghanaian experience ofrolling out CMAM:

Consensus building prior to rolling outCMAM between development partners (WHO,UNICEF, USAID), and the GHS was the keyfactor that enabled the principal stakeholders tobecome active members of the SAM TC. Thegood coordination established prior to roll outfacilitated access to the funding required to hiresufficient external technical expertise and topurchase supplies. Selection of learningdistricts from regions already supported bypartners made funding more easily accessiblefor CMAM.

The decision by the GHS to request externaland in-country technical support at the plan-ning stage allowed the existing nationalexpertise to quickly gain confidence and toensure the implementation of good practicesfrom the start. It also facilitated the process ofadapting guidelines and training materials tothe Ghanaian context.

Exposure of the CMAM Coordinator to theexperience of CMAM scale-up in other coun-tries was key to building confidence in CMAM.This enabled effective advocacy for CMAMwithin the GHS Nutrition Department at thenational level, District Health ManagementTeams (DHMTs) and Regional HealthManagement Teams (RHMTs).

The lead role taken by the GHS during theplanning and implementation resulted in therapid uptake of services at all levels (national-,regional- and district-level structures), whichfacilitated the institutionalisation of CMAM.

The establishment of a SAM TC as a forumfor guidance and coordination of CMAMimplementation and scale-up was an importantstep in a number of ways. It helped to speed upthe understanding of CMAM, the developmentof interim guidelines and the strengthening ofnational competencies.

The learning site approach to implementingCMAM generated lessons learned and promis-ing practices informed the process of scale-up.

The integration of CMAM outpatient careinto the Reproduction and Child Health (RCH)service package, which mostly includes preven-tive activities, was very successful. The publichealth teams responsible for delivery were

Children with HIV who are severely malnour-ished are also treated using the national CMAMprotocols.

Access to CMAM suppliesUNICEF procures and provides anthropometricequipment, Ready to Use Therapeutic Food(RUTF), therapeutic milk (F-75, F-100),Rehydration Solution for Malnutrition(ReSoMal) and Combined Mineral and Vitaminmix (CMV) for the programme. USAID is alsoprocuring RUTF, F-75 and F-100 to support tworegions and has committed funds for procuringCMAM supplies to support scale up in 2012.

The RUTF and equipment are stored at theNational MOH/GHS warehouse. The suppliesare then requested by facilities at national,regional and district level and distributedthrough the existing GHS supply chain system.Stock reporting has been incorporated into theweekly tally sheets and monthly reports tosystematise and improve stock control andreduce the risk of ‘stock-outs’ due to delayedrequests for re-supply. Health care providershave been trained to use the system, wherebythey report on inventory levels on a monthlybasis and make requests to the DHD forsupplies when they reach a minimum stocklevel.

Quality of CMAM servicesStandardised treatment protocols and job aidshave been developed and are being used at allCMAM operational districts, facilities andcommunities. Adherence to the protocols ishigh, although there are variations betweenindividuals and facilities. Experience to datehas indicated that the main determinants ofgood adherence to standardised treatmentprotocols are the intensity of supervision andsupport received during the initial two to threemonths of setting up inpatient and outpatientcare facilities from the national SAM SU andregional SAM STs, and the level of trainingreceived by the implementers.

The national SAM SU and regional SAM STsprovide monthly and quarterly supportivesupervision to the regions, districts and facili-ties. The DHMT also carries outweekly/bi-weekly supportive supervision. Thefocus of the support and supervision is onadherence to CMAM protocols, admissionprocedures, use of the action protocol, the qual-ity of screening and assessment of malnutritionusing MUAC tapes, testing for bilateral pittingoedema, and the quality of individual and serv-ice data recording and reporting. The quality ofthe management of SAM is high partly due tothis intensive supportive supervision.

The CMAM monitoring tools for careinclude outpatient care treatment cards, tallysheets, client registers and reporting forms, bin

Region Totaladmissions

Totaldischarges

Cured Died Defaulter Non-recovered

N N N % N % N % N %

Greater Accra 658 592 308 52 13 2 268 45 3 1

Central 516 476 244 51 19 4 213 45 0 0

Northern 1295 952 655 69 11 1 281 30 5 1

Upper East 958 902 709 79 13 1 180 20 0 0

Upper West 1504 1295 954 74 23 2 310 24 8 1

Ashanti 1042 916 771 84 16 2 102 11 27 3

Total 5973 5133 3641 71% 95 2% 1354 26% 43 1%

Table 4: Summary of CMAM performance data (to August 2011) Figure 3: CMAM performance indicators; cured, defaulted, died and non-recovered

Died 2%

Defaulted 26%

Non-Recovered 1%

Cured 71%

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highly motivated by the rapid clinical improve-ment of children with SAM.

The approach of training most CHNs at thelearning sites, as opposed to training only twoor three CMAM focal people, enhanced teamwork and support for the programme. Itmaximised the chances of continuity of care andhelped to convince implementers that CMAM isa government-owned intervention with a long-term perspective that requires the involvementof all health care providers.

Ensuring intensive and close monitoring andmentoring of implementers by adoptingfrequent supportive supervisory visits at initia-tion of services was a successful approach. Itcontributed to good quality service provisionand also proved to be an effective motivator forstaff implementing the programme.

Distribution of RUTF during the start of theprogramme used the same channels as otherhealth supplies (employing the same transportand warehouse). This reinforced GHS owner-ship, minimised perceptions of the interventionas ‘vertical’ and increased the likelihood of thedistribution system being sustained.

The CMAM programme did not select newvolunteers, but used the same CHVs as forother health programmes. This minimised therisk of volunteers requesting a special motiva-tion scheme and enhanced the integration ofactive SAM case finding with their activities.

Mother-to-mother sensitisation was usedsuccessfully, based on the ideas of ‘positivedeviance’ whereby mothers/caregivers ofrecovering children are encouraged to sensitisecaregivers of malnourished children to the exis-tence and effectiveness of CMAM.

The CHNs initiated the use of new informa-tion technology (SMS messages and telephones)to communicate with the CHVs promptingthem to conduct follow-up activities. Thishelped to increase the proportion of defaulterswho returned.

At the district level, collaboration betweenmanagers of different interventions within the

DHMT ensured the integration of trainings andsensitisation meetings. For example, resourcesfor the National TB programme and NIDs wereused to sensitise community workers onCMAM and/or provide refresher training tocommunity volunteers. This kind of synergyoptimised the output of the programme, ensur-ing that more communities were sensitised andmore volunteers trained than the availableCMAM budget allowed.

ChallengesDespite the successes of CMAM implementa-tion, some challenges and/or weaknesses havebeen identified (either through the CMAMreview or through internal review) that need tobe addressed:• There is a lack of funding to support scale

up to all the Phase 2 regions.• Community mobilisation did not specifically

target the traditional medicine practitioners (TMPs). As such, children with SAM who are taken to these informal providers first, due to the belief that SAM is a spiritual problem (‘evil eye/curse’), are not identifiedand referred.

• The defaulter rate is high. This is because some of SAM cases come from districts that have not initiated CMAM, making follow-up difficult once clients go back to their districts of origin.

• It has been observed that volunteer fatigue sets in after a while, particularly in the urban areas. There is a need to find ways of sustaining the enthusiasm and commitment of volunteers.

• Not all SAM cases being managed at the outpatient care facilities receive routine medication. This is because although treat-ment is supposed to be free to children under-five years, some health facilities are not able to provide free treatment to the children who are not registrants of the national health insurance (NHI) scheme.

• Initial attempts to produce RUTF in-countryfailed after management issues with the selected company led to the inability of the company to meet conditions for start up.

MINISTRY OF HEALTH

Risks to scaling upAt present, there are a number of risks to thescale up of CMAM in Ghana. Althoughregional and district SAM STs help to reducethe workload of the national SAM SU, asCMAM expands nationally, the SAM SU willnot have sufficient staff to successfully managethis phase of scale up. Inadequate funding fortraining, mentoring and supervision is aconstraint, especially in Phase 2 regions that arenot the focus of development partners. Thiswill require continuous advocacy for resourcemobilisation to support the scale up. Ensuringadequate and sustained availability of CMAMsupplies (RUTF, F-75, F-100) remains a chal-lenge. The high quality of CMAM service mightbe compromised if initial supportive supervi-sion is not maintained during Phase 2 scale up.

Way forwardThe next steps for CMAM activities in Ghanaare to:• Develop a five-year CMAM scale-up strategy

(2012–2016). • Integrate CMAM into pre-service training

curricula for medical, nutrition, dietetics and nursing students.

• Conduct a coverage survey to determine the extent of SAM within the community, the current access and uptake of CMAM services and the barriers to access and uptake that exist.

• Include CMAM supplies, especially RUTF and CMV, into the national essential medi-cines list and hence the NHI drug list.

• Develop linkages between CMAM and informal health systems such as the TMPs.

• Conduct a capacity assessment to identify and prioritise the introduction of CMAM activities within Phase 2 regions (Western, Eastern, Volta, Ashanti and Brong-Ahafo).

• Strengthen Social Behaviour Change and Communication (SBCC) for CMAM and link with IYCN, using quality improvementtools and systems at the community level.

• Facilitate the involvement of civil society organisations (CSOs) to strengthen the community outreach component of CMAM.

• Continue to advocate for national produc-tion of RUTF.

For more information, contact: Mr MichaelNeequaye, email: mikeneeq@yahoo.co.uk

Ghana Health Service: http://www.ghanahealthservice.org/

MUAC measurement of a child withSAM in Nyakrom hospital, Ghana

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By Leo Anesu Matunga and Anne Bush

Leo Matunga is currently the nutrition clustercoordinator for Somalia. He has over 12 yearsexperience working in nutrition in emergencies inSomalia, Zimbabwe, Sudan and Pakistan. He hasexperience working in government, internationalNGOs and UN agencies. He holds a Masters in

Public Health from University of Western Cape, South Africa, aMasters in Development Studies from Leeds University (UK) and aBSc in Nutrition Studies from the University of Zimbabwe.

Anne Bush is a freelance consultant, engaged bythe ENN to support write up of this article for theCMAM Conference. She has over 15 years experi-ence working in the field of international publichealth nutrition in Kenya, Somalia, Tanzania,Ethiopia, the DR Congo, and Indonesia. She

holds a Masters in Public Health from the London School ofHygiene and Tropical Medicine and a BSc in Dietetics.

The authors acknowledges the immense contributions of UNICEFSomalia, WFP Somalia, Ministry of Health officials in theGovernment of Somaliland, Ministry of Health officials inGovernment of Puntland, Ministry of Health Officials in TheTransitional Federal Government, local and international organi-sations working in Somalia and the Nutrition Cluster team.

BSNP Basic Nutrition Services Package

CAP Consolidated Appeals Process

CERF Central Emergency Response Fund

EPHS Essential Package of Health Services

FSNAU Food Security and NutritionAnalysis Unit

HIS Health Information Systems

HSS Health System Strengthening

IDP Internally displaced persons

IMAM Integrated Management of AcuteMalnutrition

MCH Maternal and Child Health

MOH Ministry of Health

NWZ North-west zone

NEZ North-east zone

OTP Outpatient Therapeutic Programme

PCAs Programme CooperationAgreement

SCZ South Central zone

SC Stabilisation centre

ToT Training of Trainers

TSFP Targeted Supplementary FeedingProgramme

Acronyms:

IntegratedManagement ofAcute Malnutrition(IMAM) scale up: Lessons fromSomalia operations

Brief history and backgroundSomalia has been in a state of armedconflict since 1988, and has been with-out an effective government since thefall of Siad Barre in 1991, representingthe longest case of state collapse inmodern times1. Two decades after thecollapse of the unified state, Somaliacontinues to endure protracted armedconflict and a major humanitariancrisis, currently exacerbated by asevere drought and floods. The recentfailure of the deyr 2010/11 seasonalrains and the lighter than normal gurains has resulted in an estimated 32%of Somalia’s 7.5 million people beingin need of humanitarian assistance,including approximately 910,000 inter-nally displaced persons (IDPs).

Somalia is an arid country of250,000 square miles, consisting ofthree main zones with varied social,livelihood and economic structures.These are:• the North-west zone (NWZ), also

known as Somaliland, comprising Woq Galbeed, Awdal, Togdheer and Sool/Sanaag regions

• the North-east zone (NEZ) also known as Puntland that includes Bari and Nugal regions

• the South Central zone (SCZ) comprising Mudug, Galgadud, Hiran, Bakool, Bay, Shabelle, Juba and Gedo regions.

Somaliland and Puntland both recog-nise themselves as independent statesand are pushing for internationalrecognition as such. Somaliland andPuntland border each other across thecontested regions of Sool and Sanaagand occasional border clashes dooccur. The SCZ, by far the biggest zonein the country, has an estimated popu-lation of 4,810,837, more than 60% ofthe whole country population.Continued displacement as a result ofthe ongoing civil conflict in the SCZ

has resulted in IDPs from the epicentreof the conflict in Mogadishu andneighbouring areas dispersing overthe country, with many returning totheir ancestral clan homeland.Although Somalia is formed of apredominantly single ethnic block, theelaborate clan system holds the checksand balances of the country.

The country’s main livelihoods arepastoral (sheep, goats, camels), agro-pastoral, riverine, fishing, urban andIDP livelihoods. It is estimated that thecountry receives roughly in excess of 1billion dollars in remittances fromdiaspora annually.

Southern and central Somalia havesome of the worst social indicators inthe world, with over 43% of the popu-lation living on less than $1/day,2 aswell as some of the worst rates ofunder-five and maternal mortality.Despite the extensive need, a narrow-ing of humanitarian space has made itvirtually impossible for aid organisa-tions to reach many of the people inneed.3 The lack of central governmentmeans in effect working with threedifferent health authorities and to anextent, involves three differentapproaches.

Socio-political operating environmentSince the collapse of central govern-ment in 1991 and the resulting civilwar, there have been many efforts torestore a central government inSomalia without sustained success. In1991, the NWZ declared the independ-ent state of Somaliland, with itsgoverning administration in the capi-tal Hargesia. The region isautonomous, holding democratic elec-tions in 2010, but is not internationallyrecognised. The NEZ declared itself asthe autonomous region of Puntland in1998. Although governed by its admin-istration in its capital Garowe, itpledges to participate in any Somalireconciliation and reconstructionprocess that should occur. In SouthCentral Somalia, political conflict andviolence continue to prevail, despiteattempts to establish and support acentral governing entity.

National nutrition and healthsituation – some historyTwenty years of war and insecurityhave had devastating effects on thenutrition and health status of thepeople of Somalia. The combination ofconflict, insecurity, mass displacement,recurrent droughts and flooding andextreme poverty, coupled with verylow basic social service coverage, hasseriously affected food security and

1 For a more detailed analysis of the history of instability and humanitarian access in Somalia, see Ken Menkhaus (2010). Stabilisation and humanitarian access in a collapsed state: the Somali case, 34 Disasters 320 (2010).

2 Mark Bradbury. State-building, Counter-terror-ism, and Licensing Humanitarianism in Somalia.(Briefing Paper). Sept 2010 Feinstein International Centre (2010).

3 Human Rights Watch, supra note 9.

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livelihoods and greatly increased vulnerabil-ity to disease and malnutrition. TheMillennium Development Goal (MDG)health-related indicators are among theworst in the world. Life expectancy is 45years. One child in every twelve dies beforethe age of one year, while one child in sevendies before the age of five.

Pre-1991The pre-war period (before 1991) in Somaliahas little background information on thehealth and nutrition status among represen-tative populations in Somalia. Studiesduring this period tended to focus ondistressed populations, usually in droughtaffected areas. Various methods and report-ing formats were used and a lot of healthand nutrition records were lost during thefighting, making it difficult to trace surveyreports so it is difficult to establish any base-line data for this period4. From 1980 to 1990,nutrition assessments conducted by differ-ent agencies in Somalia indicated varyinglevels of global acute malnutrition (GAM)based on weight-for-height % of median(WHM). Most surveys found a GAM preva-lence of below 15% (WHM < 80% oroedema) although there were fluctuationswith regular reports of a worrying nutritionsituation.

Post-1991The collapse of the government in the earlynineties and the subsequent conflict markeda severe deterioration in the nutrition situa-tion. The highest ever levels of GAM inSomalia were recorded in numerous surveysconducted in 1991 and thereafter.

With the civil conflict and the famine in1991/92, coping strategies were severelyeroded for the majority of the population. In1991- 1992, a devastating famine hit south-ern Somalia and led to mass starvation,resulting in rates of acute malnutrition(WHM) of 55-70% in Bay-Bakool and Gedoregions and 45% in Hiran region. Theseregions that were most affected by thefamine are still the regions where the highestrates of acute and chronic malnutritioncontinue to be reported.

A note on GAM thresholdsAll nutrition surveys conducted in the pre-war period estimated prevalence of acutemalnutrition based on percent of the referencemedian. Z scores, which estimates prevalenceof acute malnutrition based on standarddeviations from the mean, were introduced

by WHO globally in 1992. The application ofthe >15% GAM threshold to classify anemergency nutrition situation is only rele-vant for nutrition surveys conducted usingthe Z score reference. However, even thoughdirect comparison between assessmentsconducted before and after the introductionof the concept of Z scores is not intended,trends of malnutrition between 1993 to 2000demonstrate a persistent poor nutrition situ-ation with results of >15% GAM, beingreported in many parts of the country.

Development of the Food Security andNutrition Analysis Unit (FSNAU) Following the collapse of the central govern-ment in 1991 and the persistent conflict inSomalia, the country’s institutional capacityhas been lost, with little to non-existent fieldmonitoring systems in place. The FSNAU5,which is based in Nairobi and has beenfunded by a variety of donors including UNagencies, was formed in 1994 initially toprovide food security situation updates tohumanitarian response agencies. From 2000,the nutrition component was incorporatedto provide up to date information on theevolving nutrition situation, to guideresponse within the context of a complexemergency (see Box 1). The FSNAU hasadapted to the situation in Somalia over theyears by developing an extensive network oftrained Somali national enumerators andskilled Somali national field analysts spreadthroughout the country to reduce thedependence on international staff. FSNAUhas also spearheaded adoption and imple-mentation of standard assessmentguidelines and an analytical framework bythe Nutrition Cluster.

The FSNAU analysis can inform thetargeting and nature of response, but does notnecessarily have the capacity to monitor theeffectiveness or impact of that response –these tasks therefore fall under the mandateof response agencies. FSNAU internationalstaff have limited access to parts of Somaliabecause of UN security regulations andwhere access is permitted, essential securitymeasures and methods of travel are oftencostly and time-consuming.

Results from FSNAU meta analysis ofdata from 2001 to 2009 show that over this

FSNAU provides evidence-based analysis of Somalifood, nutrition and livelihood security, to enable bothshort-term emergency responses and long-termstrategic planning in food security and nutrition well-being. FSNAU works to develop the capacity of otheragencies (both governmental and non-governmental)to collect evidence-based information and focusmore on the overall analysis. FNSAU analysis alsocontributes to policy and strategy development

FSNAU/Nutrition collects primary data, undertakeshousehold surveys and conducts assessmentsacross different regions and livelihoods, dependinglargely upon its own field capacity and thecontributions of collaborating organizations thatalso have a field presence in country.

Box 1: Outline of the Food Security and Nutrition Analysis Unit (FSNAU)

The FSNAU analytical framework forms the basis for thenutrition situation classification and the EstimatedNutrition Situation maps. It is based on internationalthresholds (WHO, Sphere and FANTA (Food andNutrition Technical Assistance) where available andcontextually relevant analysis where these are notavailable. The current version of the analysis framework(July 2010) has three sections: core outcome indicators(mainly anthropometry related information andmortality), immediate causes and driving/underlyingfactors.

Where representative nutrition surveys are conducted,the GAM is the core outcome reference indicator,denoting the prevalence of acute malnutrition. Inaddition, a minimum of two anthropometric indicators

are required to make an analysis and classification ofthe situation into one of the five different phases(Acceptable, Alert, serious, Critical and Very Critical).Information from the season in progress only isused. Historical data are used for overall contextualand seasonal trends analysis.

To provide a three month outlook, the immediateand driving factors are analysed, and theconvergence of the evidence of the projectedscenario classified as Stable, Uncertain, Potential toDeteriorate or Potential to Improve. This information,including projected trend, is presented in theEstimated Nutrition Situation Map.

For more information: www.fsnau.org

40%

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Figure 2: Annual national median rates of stunting for theperiod 2001 to 2009

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2001 2002 2003 2004 2005 2006 2007 2008 2009Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr Gu Deyr

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Seasonal trends in national median rates acute malnutrition 2001-2009

Figure 1: Results from FSNAU meta-analysis of data from2001 to 2009

source FSNAU

source FSNAU

35%

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Figure 3: Malnutrition rates* by zone in Somalia (2001-2009)

*Based on WHO Growth Standards.

13.315.8

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Figure 4: Prevalence of nutritional anaemia and vitamin A deficiency among women and children

Source: Micronutrient survey, 2009

pregnant womennon-pregnant women

all women

4 Cambrezy, 1997. Unpublished report.5 The FSNAUs technical and management support is

provided by the UN Food and Agricultural Organisation (FAO)

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Rates of malnutrition also vary according tothelivelihood system. Results of the FSNAUmeta-analysis of data 2001-2009 revealed thatriverine and agro-pastoralist groups had thehighest median rate of wasting, stunting andunderweight. This suggests a higher nutritionalvulnerability to shocks such as floods, drought,displacement and disease outbreak. Rates ofmalnutrition among the urban populationtended to be lower, reflecting better access to adiversified diet and to public services, includ-ing health.

The 2009 National Micronutrient andAnthropometric Nutrition Survey, conducted inall three zones, highlighted that micronutrientmalnutrition is a significant public health prob-lem throughout Somalia. The prevalence ofboth nutritional anaemia and vitamin A defi-ciency among women and children of all age

groups was found to be above WHO thresholdsfor classifying a severe situation in each of thethree zones (see Figure 4).

Emergency situations: frequency andseverityThe food security and nutrition situation inSomalia is characterised by chronic and recur-ring emergency situations resulting fromrepeated episodes of drought, flooding, conflictand displacement. Communities have littlechance to recover between crises. The frequencyand severity are exacerbated by the absence ofstrong government and lack of humanitarianspace. The maps in Figure 5 show the progres-sion of the estimated nutrition situation fromDeyr 2006/07 to Gu 2011.

Political will and policy environmentPolitical will and support for nutrition is rela-tively strong in Somaliland and, to a lesserextent, Puntland. It exists for the Ministry ofHealth (MOH) SCZ but control is largelylimited to Mogadishu (see later).

There is no national nutrition policy but theSomali Nutrition Strategy for 2011 to 2013 hasbeen developed. The strategy identifies keypriorities and the need for a shift to a more inte-grated multi-sectoral approach to addressingmalnutrition in Somalia. Integrated manage-ment of acute malnutrition (IMAM) isidentified as a key approach and asprogrammes for the management of acutemalnutrition are reasonably well funded, it ishighlighted as an important delivery platformthrough which to deliver complementary activ-ities. The strategy defines overall goals for theentire country and has been endorsed by theMOH of all three zones. Zonal action plans forthe implementation of the strategy are to bedeveloped and costed and will boost compli-ance at sub-national level. Funding remains achallenge.

period, median rates of GAM have remained atserious (10 to <15%) or critical (15 to <20%)levels (WHO Classification 2000) throughoutwith a national median rate of 16% (see Figure1). Furthermore, annual national median ratesof stunting were above 20% i.e. at serious levelthroughout the period 2001 to 2009, accordingto WHO classification (2000), as shown inFigure 2.

Results of the meta-analysis also highlighthow the situation has been consistently worsein SCZ than Puntland or Somaliland. In SCZ,median rates of stunting were found to be29.7% and wasting 18%. This compares to 20%stunting and 17% wasting for Puntland and18% stunting and 13% wasting for Somaliland(see Figure 3). This reflects the devastatingeffect of chronic political conflict and insecurityin SCZ in particular.

Figure 5: Deterioration in the nutrition situation from Deyr 2006/07 to Gu 2011

Deyr ‘06/07

Deyr ‘09/10 Deyr ‘10/11

Gu ‘07

Gu ‘09 Gu ‘10 Gu ‘10

Gu ‘08Deyr ‘07/08 Deyr ‘08/09

Source: FSNAU website. Note: To see the detail, download from http://www.fsnau.org/downloads/Prgrogression_of_Estimated_Nutrition_Situation_Deyr_06_10_to_Gu_11.pdf

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Nutrition outcomes are not yet included insectoral policies and programmes but theSomali Nutrition Strategy is trying to high-light nutrition issues at policy level.

Somali specific IMAM guidelines weredeveloped through the Nutrition Cluster in2010 and a Basic Nutrition Services Package(BSNP) has been defined and encouraged, alsothrough the Nutrition Cluster. However,whilst many agencies are adopting theapproach and include it within activitiesoutlined at proposal level, many organisationsfind it difficult to conceptualise or lack thecapacity to deliver.

MOH systems and structures – wherenutrition fitsAfter twenty years of conflict, the health caresystem in Somalia remains underdeveloped,poorly resourced, inequitable and unbalanced.The public health care delivery system oper-ates in a fragmented manner, maintainedlargely by medical supplies provided byUNICEF and other agencies. In the absence ofan efficient and adequate public healthsystem, the private sector has flourished butremains unregulated with poor quality ofservices and poor access to the rural popula-tion. Over half of the estimated healthworkforce is unskilled and unsupervised andstaff are paid a below subsistence wage. Mostpublic facilities operate at a level far belowtheir intended capacity and are poorly organ-ised, with very low utilisation rates (estimatedas on average, one contact every eight years6).

In Somaliland there is a functioning MOHand political will exists. Nutrition has beenidentified as a key priority area by theMinister of Health and the nutrition focalperson within the ministry is motivated andactive. Key staff have been appointed atHargeisa level, and at regional and districtlevels. Thus a ‘traditional’ MOH structure is inplace but remains financially dependent onsupport from UNICEF and other agencies. InSomaliland, 34 outpatient therapeuticprogrammes (OTPs) and four stabilisationcentres (SCs) are delivered through govern-ment health facilities.

In Puntland, political will and support ispresent to a lesser extent, with health receivinga greater focus than nutrition, primarily due tothe qualifications and background of the nutri-tion focal person. There is willingness to workwith UNICEF support on nutrition and govern-ment will respond if funding is available. TenOTPs operate through government healthfacilities.

In SCZ, the MOH recognises nutrition and‘allows’ UNICEF and its partners to imple-ment programmes but the public healthstructure and functioning is largely confinedto Mogadishu. Delivery of IMAMprogrammes through government health facil-ities is limited to one SC in Mogadishu wherehospital staff support the implementation ofan otherwise independent centre.

Where OTP services are operating throughgovernment health facilities, the services aredelivered by MOH staff but they are givenfinancial incentives by humanitarian players.Where MOH is implementing with little staffsupport, reporting is provided by MOH alone.Where greater levels of support are provided,

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Figure 6: Scale up of UNICEF support to nutrition services, 2006 - 2011.

6 Rossi and Davies, 2008. Rossi L and Davies A. Exploring Primary Health Care in Somalia: MCH Data 2007. UNICEF Somalia Support Centre Report 8.

Map 1: Nutrition services, September 2007

reports are provided by the supporting NGO.Whether reporting is conducted by MOH or ahumanitarian agency, reports are generallydelayed. Efforts are currently underway totrain staff to strengthen reporting.

Implementation of IMAM in SomaliaThe implementation of all four components(community mobilisation, SCs, OTP andtargeted supplementary feeding programme(TSFP)) of programmes for the managementof acute malnutrition in an integrated way isnot always feasible in Somalia. Existence ofand access to SCs is limited, such that the idealprogramme set up of OTP with SC servicesavailable (either attached to a hospital orstand alone) are usually only seen in towns inSomalia. The more common set up is anetwork of several OTPs with limited possi-bility of referring complicated cases to SCs.The lack of SC services may be due to distanceto the nearest facility, or due to lack of accessfor other reasons (e.g. transport, clan issues,inability to leave the family for a full week orinsecurity). OTPs may or may not be integratedwith SFP. In some areas, SFPs are implementedin the absence of OTPs or SCs. In these cases,the centres may admit all malnourished chil-dren regardless of their severity.

During the initial expansion of IMAM,programmes were implemented according tooperational guidance developed by NutritionCluster partners in 2005. In 2010, new guide-lines were developed and endorsed by theNutrition Cluster. These guidelines, initiallypromoted by UNICEF and the SomaliNutrition Cluster, have been written inconsultation with all organisations, depart-ments and agencies implementingprogrammes to manage acute malnutrition inSomalia. This was done with the intention ofcapitalising on best practices and experiences,so that lessons learnt by one can be applied byall partners. The guidelines intend to facilitatethe process of training new staff and to helpwith the opening of new centres. These guide-lines try to take specifics of the Somali contextinto account, whenever possible, and givepractical suggestions for often difficultcircumstances e.g. lack of SC referral site.Field cards have been developed with the aimof being laminated for use in the field. So far,the application of the 2010 guidelines has beenlimited due to problems in the process of trans-lation into Somali. Some sections have beentranslated for training purposes.

Some of the specific challenges that IMAMfaces in Somalia are:• Conflict• High insecurity• High mobility of population (including

health staff)• Spread of the population, with long

distances and isolation• Difficult transport and communications• Population displacement (and the inability

of IDPs to access services in some host areas)

• Regular migration among pastoralists• Difficult social environment related to

complex clan structure• Specific conflicts between clans

Map 2: Nutrition services, July 2011

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selected for CERF underfunded emergenciesallocation.

Donors are doing all they can to provide fund-ing to UN agencies and NGOs. Little fundinggoes to the government in SCZ but quitesubstantial amounts are directed through thegovernments in Somaliland and Puntland.

The CHF funding pool has been establishedby donors to provide funding to humanitarianplayers, especially local NGOs managedthrough the cluster system. CHF funding isavailable to high priority projects includedwithin the CAP. Proposals are prioritised by theNutrition Cluster Review Committee accordingto a set of criteria. These criteria include regionof priority, the presence of complementarypreventive activities, inclusion of capacitybuilding activities and cost per beneficiary. Theavailability of CHF has increased considerablythe amount of funding being accessed by localNGOs. Some international NGOs are alsoaccessing bilateral aid directly from donors.

In Somalia, there are risks associated withscale-up. With the current crisis, funding isavailable and rapid expansion of services isongoing. However, funding is usually 6 to 12months maximum with no guarantees ofcontinued funding thereafter. To date, there areno programmes that have been stopped due tothis but it remains a concern.

The short term nature of funding for IMAMpresents several challenges. First, it can lead tothe ‘start-stop’ approach and disruption of serv-ices and limits the development of moresustained services for IMAM in Somalia. Shortterm funding mechanisms limit the possibilitiesfor taking a longer term approach to themanagement and prevention of acute malnutri-tion. Malnutrition in Somalia is both an acuteand chronic problem with multiple underlyingcauses that cannot be addressed through shortterm programmes. Even outside years of crisis,GAM rates remain high suggesting the impor-tance of longer term underlying causes, forexample inappropriate infant and young child

the coming month to cover some of the identi-fied gaps. Services are supported primarily byUNICEF and WFP, implemented in partnershipwith local NGOs and also by internationalNGOs. The number of sites continues to changewith scale up plans in response to the currenthumanitarian emergency. The current rapidscale up has been able to build on the success ofthe expansion over the previous three to fouryears and includes greater emphasis on the useof mobile teams and community health workers.

Figure 6 demonstrates the extent of expan-sion of UNICEF Nutrition services throughoutSomalia since IMAM was first implemented in2006.

Maps 1 and 2 illustrate the scale up of IMAMservices, comparing services provided inSeptember 2007 with those of July 2011, inresponse to the changing food security andnutrition situation.

There are currently 96 Nutrition Clusterpartners providing nutrition services through-out Somalia, 65 are local Somali NGOs and 23are international NGOs7. The remaining partnersare UN agencies or MOH centres. In addition toNutrition Cluster partners, nine OTP sites arebeing implemented by MSF operations.

FundingCurrently, most funding for IMAM services isshort term, although there are some donorsnow looking at multiple year funding. There islimited development funding for nutrition inSomalia.

Funding mechanisms available are: • Bilateral donors – ECHO8, DFID (UK

Department for International Development)and UNICEF fund agencies to run projects directly.

• Common Humanitarian Fund (CHF) emer-gency reserve – 20% CHF allocation is set aside for unexpected emergencies arising.

• CHF second allocation – funding mechanismfor high priority projects within the CAP (Consolidated Appeals Process) that have not received bilateral funding. It is not available to projects not included in the CAP.

• The Central Emergency Response Fund (CERF) –Somalia is one of six countries

7 Numbers taken from latest Nutrition cluster membership list as of October 2011

8 European Commission for Humanitarian Aid and Civil Protection

• Rigid traditional family structures that rely heavily on women's work

• Lack of health infrastructure• Lack of training infrastructure and there

fore chronic lack of qualified health staff• In some areas, the need to pay fees to access

the health system and consequently, lack of access to services.

These challenges result in many problemsincluding:• Inadequate number of centres to have good

geographical coverage of programmes• Low coverage, even in areas that are

theoretically served by a centre• Lack of referral of complicated cases to SCs

for life-saving treatment• Frequent and unpredictable break-downs in

the supply chain• Discontinuity of programmes in some areas,

with regular closure and re-opening of programmes

• Irregular and often inconsistent community mobilisation

• Overall fragmentation of aid and of otherinterventions to prevent malnutrition

• Low qualification of staff and difficulty to hire new health staff when needed

• High turn-over of staff• Difficulty in supervision, on-site monitoring

or on-the-job training• Costs for families attending health and

nutrition services regularly• Fear of mothers to attend due to insecurity

and volatility of the situation.

Scale up of IMAM in SomaliaIMAM first began implementation in Somaliain 2005/6 with several international agenciesadopting the approach in line with increasingglobal recognition of the benefits and effective-ness of community based management of acutemalnutrition. Since then, an impressive expan-sion of IMAM services has been achieved, withno particular Somali specific trigger or strategyto the scale up. In 2006, around 30 OTP andTSFP sites were providing IMAM services,increasing to around 250 OTPs in 2010. At thetime of writing (Sept 2011) there are currently25 SCs, 461 OTPs and 662 TSFPs being imple-mented throughout Sosmalia. There are plansto add nine new SCs, 58 OTPs and 138 TSFPs in

Figure 7: UNICEF Somalia logistics hubs Table 1: Monthly performance indicators for OTP throughout Somalia

Month (2011) Cure rate (>75%) Default rate (<15%) Death rate (<10%) Non cure rate

January 88.8% 8.9% 1% 1.6%

February 90.4% 5.2% 1% 3.2%

March 88.2% 6.1% 1% 4.7%

April 91% 4.7% 1.1% 3%

May 84.7% 8.6% 1% 5.6%

June 85.7% 7.8% 1.4% 5%

July 85% 7.7% 1.7% 5.6%

August 84.8% 8.5% 1.4% 5.4%

Table 2: Monthly performance indicators for TSFP throughout Somalia

Month (2011) Cure rate (>75%) Default rate (<15%) Death rate (<3%) Non cure rate

January 65.5% 33% 0.2% 1.1%

February 93% 4.8% 0.4% 1.8%

March 96.1% 2% 0.1% 1.7%

April 75% 14.7% 2.8% 7.3%

May 90.1% 8.2% 1% 0.5%

June 38% 33.6% 0.7% 27.8%

July 40.2% 19.5% 0.6% 39.6%

August 58.7% 7.8% 0.4% 33%

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feeding (IYCF) practices. Capacity is a majorissue that requires longer term commitment toaddress in a more sustainable manner.

Secondly, it affects the way programmes areimplemented and results in a tendency fororganisations to try to implement as manyactivities as possible in the shortest time, ratherthan engage in a more gradual process of estab-lishing a programme and introducing differentcomponents as needs and capacities are fullyunderstood and realised. This is not necessarilythe best way of achieving maximum impact.Trying to do everything at once may be toomuch, in particular where local implementingpartners lack capacity.

Sources and opportunities for self funding inthe future are limited and remain a long wayoff. In Somaliland and Puntland, the regionswhere stronger governance structures are inplace and self funding could one day be morerealistic, the governments are not recognisedinternationally. Furthermore, the governments’revenue base is very dependent on taxes to civilservice and exports of livestock to the MiddleEast. With the drought having affected live-stock, this revenue base has dwindledsignificantly, thereby squeezing the alreadycash strapped governments.

Supplies and logisticsChallengesThe Somalia operation has experienced prob-lems with suppliers of RUTF resulting in theneed to switch supplier, causing some pipelinedelays. Local production in Somalia is not anoption. Furthermore, there are logistical chal-lenges in sending nutrition supplies, especiallyCorn Soya Blend (CSB), to various parts of thecountry due to numerous difficulties includingactive conflict, mines, rains, and multiple andchanging authorisation requirements of localauthorities. Logistics are further complicated bythe control of access to many areas by Al Shababand the closure of the border between Somaliaand neighbouring countries. Figure 7 maps theUNICEF logistics hubs. In the insecure environ-ment, looting of stocks in country meanspre-positioning in Somalia is not possible.

For SFPs, the current crisis places demandson implementing agencies facing pressuresfrom the local community, resulting in moreCSB being distributed than planned so thatstocks run out. Some partners are contractuallyready to start activities but are awaitingsupplies of CSB to do so.

The suspension of WFP activities in Southand Central Somalia has had a serious impact.By 2009, WFP had delivered the logisticalsupport for delivery of food in Somalia whileUNICEF delivered only on therapeutic nutri-tion programmes. In January 2010, WFPsuspended operations in South Somalia. Asprovider of last resort, UNICEF picked up their400 programmes, signing agreements withpartners they had not previously worked with.Delays were inevitable in this context and withthe lack of adequate notice, supplies orresources. A problem with drug supplies hasalso been experienced.

Nutrition Information SystemThrough considerable focus and effort, thecompleteness of reporting of nutrition informa-tion by partners has improved tremendously.With regular follow up, 95% reporting coverage

has been achieved on a monthly basis, however,the quality of reporting needs to be furtherstrengthened (see section on performance indi-cators below). Problems with the currentdatabase mean cross checking of this month’sprogramme information against the previousmonths has to be done manually.

One challenge for nutrition information isthe discrepancy between caseloads from projectreporting and FSNAU estimated caseloads.Numbers of beneficiaries identified throughproject data are often significantly higher thanFSNAU estimates for the same area, resulting incoverage rates of greater than 100%. This maybe due to a problem with population denomi-nators arising from the use of out of datepopulation statistics. It may also be due to theincidence rate of acute malnutrition used. Inview of the multitude of problems and theseverity of the situation in Somalia, an inci-dence rate of 1.6 may not be appropriate – itcould even be as high as 8. (Even in Somaliland,an incidence rate of 4 or 5 may be applicable).

There is a positive move to the increasing useof SQUEAC9 surveys to triangulate reportingresults. Most organisations have includedSQUEAC in their proposals. UNICEF will facil-itate this through engaging external consultantsto accelerate the process.

Performance indicatorsMonthly reporting data are collated for IMAMprogrammes in Somalia. The data indicate thatOTP programmes are performing well andmeeting SPHERE standards (see Table 1).However, there is recognition that according tothe data, programmes are performing betterthan might be expected given the challengesand constraints of implementation in manyareas of Somalia. Efforts are now underway tofollow reporting more closely to check the reli-ability of the data presented by partners.

Community mobilisationIn Somalia, where there is limited access to SCs,community mobilisation is a very importantcomponent of IMAM. Promotion of the earlydetection and diagnosis of cases of acutemalnutrition can reduce the numbers that dete-riorate into a severe condition prior topresentation. In general, the level of community

mobilisation has improved. Some challengesremain. For example, in SCZ, CHW are, ineffect, salaried through the incentives they arepaid. This system encourages CHWs to take onlarge areas (for which they are paid more) butthat they may not be able to cover effectively.

Coordination systemsWith the lack of effective central government,the Nutrition Cluster plays a significant role inthe coordination of nutrition programmesthroughout Somalia. Due to securityconstraints, the cluster is based in Nairobi.Traditionally, regular monthly NutritionCluster coordination meetings have been heldwith excellent participation. However, withsuch a large number of nutrition programmesimplemented by local NGOs, the resultingnumber of Nutrition Cluster partners meansthat it has become increasingly difficult to focuson operational issues at these meetings. Toovercome this, the general Nutrition Clustercoordination meeting is now held once a quar-ter to include partners and members, whilst themonthly coordination meeting is held forimplementing partners only. In reality, atten-dance is still too large to be able to discussimplementation issues in a useful way. So, inaddition to a monthly cluster meeting, regionalmeetings are held at Nairobi level. These forabring together all partners working in a partic-ular region to meet and discuss operationalissues. This has proved very helpful to theimproved coordination of activities, who isdoing what and where and identifying thegaps. There are also thematic working groupsfor infant and young child feeding (IYCF),micronutrient supplementation and capacitybuilding for more specific technical discussions.Furthermore, field cluster coordination fora atregional level are gradually being established(see Figure 8). This has proved useful in areas ofSCZ, in particular where there is a problemwith geographical coordination of activities andpossible duplication. Regular field cluster coor-dination meetings allow organisations todiscuss and agree issues such as programmecoverage amongst themselves at field level. Akey aim for strengthening overall coordination

Nutrition Cluster Somalia – Zonal and regional focal points, July 2011

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Figure 8: Field cluster coordination

9 Semi- Quantitative Evaluation of Access and Coverage

33

not capture the extent of provision of comple-mentary services systematically e.g. number ofimmunisations or soap distributions. HealthInformation Systems (HIS) are supposed tocapture this information. Third party monitorsdo report on level of integration but a questionremains as to whether this information iscollated in any way.

Inter-cluster linkagesGood coordination and collaboration existsbetween WASH, Health, Agriculture andLivelihoods and Nutrition Clusters at Nairobilevel. Clusters share information on thestrengths and weakness of potential partnersand which organisations are capable of scalingup a more integrated approach to delivery. InSCZ, the Agriculture and Livelihoods andNutrition Clusters work closely together toensure any agriculture and livelihoodsprogrammes, such as cash for work, includenutrition beneficiaries.

An inter-cluster strategy was developed inJune 2011 to address the acute food insecurityand nutrition crisis in SCZ. This defines whichinter-cluster activities are to be delivered ateach target location (e.g. nutrition centres,health centres, transit points, IDP settlements)and includes nutrition, health, livelihoods andWASH cluster activities.

Capacity, training and supervisionCapacity is an important issue for the scale upof IMAM throughout Somalia. As highlightedabove, the vast majority of nutrition services forthe management of acute malnutrition areimplemented by UNICEF and WFP in partner-ship with local NGOs. There is wide variationin the capacity of these local organisations.There has been notable improvement andcapacity development amongst organisationsthat first started implementing IMAM twoyears ago. However, in South and CentralSomalia, many of the most efficient and reliablepartners have been expelled from Al Shababcontrolled areas, resulting in a need to workwith less experienced partners. For many localpartner organisations new to nutritionprogramming, commitment is strong but tech-nical knowledge, experience or understandingmay be more limited. This applies not just fortechnical nutrition capacity but also projectcycle management, funding mechanisms,proposal writing, audits reporting, etc. In theSomalia context, training and supervision areoften difficult or challenging, given the limitedaccess of senior (and particularly international)staff to the centres. Innovative ways of trainingand supervising staff need to be developed forthis purpose.

Capacity has been a limiting factor in scaleup but to what extent is not clear. The followingare some examples of impact of capacity limita-tions on scale up. A local partner organisationeffectively implementing OTP at five sites maylack the capacity to scale up to six more sites,resulting in the need for another partner to bebrought in. Other agencies may agree to scaleup without the capacity to deliver, resulting indelays or problems with the quality of service.Others have asked for expansion but haveunderestimated the funding implications withthe result that the project is underfunded.

Lack of capacity also limits the extent towhich nutrition services are integrated with

is to get the field cluster coordination meetingsworking more effectively.

Integration and linkagesIntegration with MOHIn Somaliland and Puntland, IMAM servicesare linked with Maternal and Child Health(MCH) and health posts. In Somaliland, 34OTPs and 4 SCs are delivered through govern-ment health facilities, whilst in Puntland 10OTPs are operating through government struc-tures. In practice this means the services aredelivered by MOH staff with financial incen-tives paid by the humanitarian community. InSCZ integration with MOH is very limited.

Linkages with Essential Package of HealthServices (EPHS) and Health SystemStrengthening (HSS)The EPHS for Somalia was developed in 2008and defines the four levels of health serviceprovision (primary health care unit, healthcentre, referral health centre and hospital) andthe six core and four additional healthprogrammes to be implemented throughout thecountry. According to the EPHS, nutrition inter-ventions are integrated across the tenprogrammes. Overall there is a drive to ensurethat nutrition is considered a significant part ofthe EPHS. This is being achieved in partthrough the review of job descriptions andtraining packages of health professionals. Thereare however, disparities across the three zonesdue to differences in the presence and capacityof local government, the presence of interna-tional staff and the implementation of thecluster approach.

Integration of the Basic Nutrition ServicesPackage10 (BNSP), IYCF and nutrition educationIntegration of BSNP activities into IMAMprogrammes is a gradual process. It is includedin UNICEF’s standard proposal format butmany agencies struggle to understand theconcept of BNSP. The level of integration islimited by supervision, capacity, supplies andlogistics.

The IYCF and nutrition education activitiesare linked to IMAM programmes. Their inte-gration as components of IMAM programmesis encouraged at proposal level and issupported by UNICEF through to implementa-tion stage. Each IMAM programme has an IYCFpromoter supported through funding fromUNICEF. To date, a total of 100 IYCF counsel-lors have been trained and the programme isongoing. Furthermore, some IMAMprogrammes have set up community supportgroups for IYCF within the community to offeradvice to each other. However, with the magni-tude of the problem in Somalia, the clusterrecognises other approaches to improving IYCFpractices also need to be considered to achievesignificant behavioural change.

Nutrition education activities are also deliv-ered on a routine basis through IMAMprogrammes. This may be through groupeducation sessions with mothers attendingIMAM sites and/or through sessionsconducted within the community. Furtherstrengthening and exploration of differentapproaches is required to improve impact. Inrecognition of this, nutrition and WASH clus-ters have started to work together onnutrition/WASH promotional messages andhow best to deliver them. UNICEF has signed acontract with BBC World Trust for the develop-ment of drama, where promotional messagesare delivered via the radio. Other options to beexplored include the use of mobile phone tech-nology in sending promotional messages viatext messaging.

Inter-sectoral integrationIn such a challenging operating environment,the use of existing programmes and structuresas a delivery mechanism for integrated activi-ties across sectors is crucial. Furthermore, theabsence of integrated services can prolongrecovery and increase relapse rates. At proposalstage, the current format of CAP proposals,UNICEF Programme Cooperation Agreement(PCAs) and WFP Flash Appeals requires thathealth and water, sanitation and health (WASH)activities, e.g. immunisation or soap distribu-tion, are integrated within nutritionprogrammes. However, it is recognised thatimplementation of an integrated response atfield level needs strengthening, particularly inSCZ. Capacity may be a limiting factor in this.Current reporting requirements for nutrition do

10 The BNSP for Somalia provides guidance and justification on what nutrition services should be included at various levels of the health system and throughout the lifecycle. The essential components are defined as: management of acute malnutrition, micronutrient supplementation, immu-nisations, deworming, promotion and support for optimal IYCF, promotion and support for optimal maternal nutritionand care, prevention and management of common illnesses, fortification (home based and food vehicles) and monitoring and surveillance.

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On the job training where trainees from a lowercapacity organisation spend a block of timewith a higher capacity organisation (mentor) atthe mentor’s work site. This provides theadvantages of having an experienced mentor athand to address questions and difficulties andreinforces information provided during thedidactic course. The challenge to using thisapproach is the availability of quality sites witha mentor.

Twinning, where a relationship between twoorganisations is established to provide a plat-form for sharing of expertise and experience.

Consultation using call centre allows newly trainedstaff to ask questions of experienced providersthrough direct phone calls to the centre andprovides a support network that builds the confi-dence of newly trained providers.

Distance learning schemes can be run usingdifferent technology depending on theresources available to the trainees. It may bethrough internet or audio tapes combined withwritten materials. Distance learning has theadvantage of reaching a wide geographicallydisparate audience and allows trainees toremain at their workplace with training in theirlocal language. There can be a call centre toprovide technical back up.

On site mentoring using mobile teams is whereexperienced professionals are sent to sites ofless-experienced providers for a few days tooffer on-site mentoring. This allows the traineeto practice skills and raise questions and diffi-culties specific to the trainee’s work situationand means. The use of mobile teams, with atechnically strong team leader and supportedby a technically strong NGO, reduces therequirement for large numbers of skilledmentors.

MonitoringApproaches to monitoring vary across the threezones, reflecting the level of security and accessin each.

SCZWith the current lack of access to internationalstaff in SCZ, the monitoring of programmedelivery by partners is a major challenge.

34

other cluster activities. The promotion of anintegrated approach is undoubtedly somethingto be strived for. However, where capacity isstill being strengthened, the tendency of localpartner organisations to take on activities fromother clusters, particularly in the context ofshort term emergency funding, may overstretchand overload some organisations.

In Somaliland and Puntland, capacity devel-opment within evolving local authorities isimportant for more sustainable effects.Appointments to the civil service are oftenlinked to clan association with the relevantminister, rather than technical know-how. Thismay mean that international staff members ulti-mately carry out the monitoring work typicallyundertaken by national civil servants. Thisamounts to gap filling rather than skills trans-fer. High staff turnover is also an issue. There isa shortage of technical NGOs capable of travel-ling to many areas and training localcommunities. However, compared with 2-3years ago, when many NGOs were establishedand collapsed within a short space of time,increased support from international NGOs,and improvement in partner capacity isevident.

One of the cluster’s primary roles is to givehands-on technical support and supervision topartners throughout the implementation cycle,not merely in terms of capturing final results.Capacity building is one of the objectives of theCluster Response Plan. From the first round ofCHF allocation, USD$500,000 went towardscapacity building at agency level. The impor-tance of this aspect to continuing the scale upprocess is highlighted by the investment in thecurrent capacity mapping exercise. This willprovide baseline information through themapping of capacity at three levels beingundertaken: i) Nairobi – general managementcapacity, ii) field level - technical and manage-ment capacity and iii) field level - nurses andCHWs. The aim is to gain a better understand-ing of the gaps and lead to formulation of aspecific capacity development strategy toaddress priority issues for the way forward.

Lessons learned on capacity developmentTo date, capacity building has mainly beenthrough Training of Trainers (ToT) at Nairobi orHargesia level. The focus has been mainly onlocal NGOs and MOH staff. This approach hasproved to be less effective when implementedalone and needs to be coupled with othercomplementary approaches, including on-the-job mentoring. Additional reasons why theToTs have not been an effective standaloneapproach include: the wrong people haveattending training held at Nairobi or Manderalevel, skills learned at training are not passeddown and weak capacity in delivering the ToT.

Increased commitment from internationalNGOs to train and mentor local partners hasproved successful. In 2008, Action Contre laFaim (ACF) acted as a training centre for organ-isations with lower capacity, which had positiveresults. Another encouraging example is OxfamNovib’s partnership agreement with local NGOSAACID, in which Oxfam oversees andmentors the activities of the local NGO.

Innovative ways forward for capacity developmentGiven the significant constraints, some innova-tive approaches under consideration include:

11 The Afgooye corridor is the largest single concentration of internally displaced people in the world. There are over 400,000 people along a 40 km stretch of road, which snakes out from Mogadishu heading eastwards.

Programmes tend to be managed remotely andrely on partners’ implementation reports.Verification in quantitative terms may be possi-ble but verification of programme quality ismore of a challenge. When experienced moni-tors are not available and senior staff cannotthemselves reach project sites, there is a seriousrisk that programmes may fall below a desiredstandard with no repercussions for the imple-menting partner or direction for improvement.Furthermore, absolute verification that no aidhas been diverted or misused is increasinglymore difficult when senior staff cannot visitproject sites. A further complication is that evenwhen agency (e.g. UNICEF or WFP) staff aresatisfied that monitoring activities are sufficientand suitable, donor organisations may continueto seek further verification and evidence of highquality project implementation.

With the challenging context of SCZ includ-ing restricted access, new and innovativeoperational modalities are constantly consid-ered and a number of monitoring proceduresare in place. These include the following:

• Programme support missions by technical staff

These are carried out whenever there is awindow of opportunity for access. Suchmissions may be rapid but can provide vitalopportunities to assess needs and monitorongoing activities and define necessary followup activities.

• Joint monitoring with communities/local authorities/partners

This approach relies on the network of partner-ships that have been established over the yearsand is dependent on the presence and capacityof partners to carry out monitoring activities.The expulsion of international partners hasreduced the pool of joint monitoring partners.

• Independent third party monitorsThird party monitoring is a new approach usedby both UNICEF and WFP who each contract adifferent independent organisation to monitor

Field article

Infant and young child feeding support

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their nutrition programmes by region. Theseorganisations are local NGOs, in the case ofUNICEF a local consulting group called CharityRelief Organisation (CRO). Programmes maybe visited either as part of a planned scheduleor ‘on spec’. A monitoring visit may berequested in response to reports of problemswith a particular programme, e.g. from otherorganisations. Monitors are provided with achecklist and monitoring tools. This includes aset of questions that are intended to flag anydiscrepancies in reporting and monitoring.Reports from third party monitors are crosschecked with partner reports and local commu-nity reporting. Third party monitoring providesindependent verification of the programmewith the contracted organisation acting onbehalf of UNICEF or WFP. The monitors are notperceived to be linked with either UNICEF orWFP, which gives them better protection andaccess in some locations. As well as monitoring,the visit is taken as an opportunity to provideon the job training as necessary. The possibilityof using third party monitoring more regu-larly/extensively for training and supervisionpurposes is being explored. Donors are notalways satisfied with the use of third partymonitors, however.

• Peer monitoringSomali staff members use family and friends indifferent areas to check up on project activities.There are limitations since friends and familiesmay not possess technical skills to assess thequality of programmes.

• Results monitoringNutrition surveys carried out by FSNAU canprovide independent verification of the effec-tiveness of assistance. A recent example is thepositive impact of SFPs for IDPs in the AfogoyeCorridor11.

• Triangulation of informationInformation reported by partners, differentsources at community level (e.g. communityelders, education committees, school clubs) andother key informants including other partners,UN agencies and information from third partymonitors.

• Direct beneficiary feedback Through the use of mobile phone technologyavailable in Somalia, there is potential to sourceadditional information from beneficiaries,

Field article

although lack of technical skills to assess qual-ity of programmes means the approach needscareful consideration.

SomalilandWith the exception of some areas of Sool andSanaag, where conflict persists, access to proj-ects in Somaliland is available. The primarychallenge with regard to monitoring is lack oftime to visit programme sites throughout theregion. Staff tend to be overstretched with ahigh volume of work and missions are difficult,covering long journeys on rough terrain.

PuntlandDirect monitoring is also feasible in Puntland.Agency staff can safely travel to all regions.Some of the monitoring activities in this zoneinclude third party monitoring, monitoring bythe relevant government ministry, quarterlymonitoring visits to sites and to implementingpartners by staff members, and periodic jointmonitoring with government (for example,where UNICEF sponsor officers from theMinistry to join UNICEF officers to monitorprojects together). However, administrativework often takes priority over site visits.Furthermore, some staff do not want to travel toremote areas due to fears around personalsafety or other reasons. In general, staff manageto undertake once a quarter visits instead of theoptimal once a month.

Impact and achievementsThe real success of nutrition programming inSomalia is the achievement of such rapid scaleup of IMAM services in a very difficult context,primarily through UNICEF and WFP partner-ships with local NGOs. The expansion ofservices over the last 3 to 4 years has provideda vital base for the current response to thehumanitarian emergency.

Working through local partners can be asuccessful model when government structuresare weak and access for international agenciesis limited. While estimates of population cover-age greater than 100% in some areas suggests aproblem either with population estimates orwith incidence rates, it does indicate very posi-tive results. With follow up, monthly reportingis now 95% although there may be some qualityissues. The introduction of SQUEAC coveragesurveys will allow the triangulation of results.

Even in this difficult environment, cure ratesare within the Sphere standards.

More recently, the use of mobile clinics ratherthan static clinics is being promoted. Localorganisations are being encouraged to look atthe population being served and whether dailyattendance warrants a static clinic or whether amobile team would be a better use of resources(staff time and infrastructure costs). One mobileteam would substitute five static sites, for exam-ple. Each mobile team provides a timetable ofservices to the surrounding community forweekly OTP visits and fortnightly or monthlyTSFP. Mobile services are not reflected in thenutrition services map (see earlier).

Ways forwardThe extent of the scale up of IMAM services overrecent years in the face of all the challenges of theSomalia context is a tremendous achievement.With the current emergency, geographical cover-age of services and the number of partnerscontinues to expand. In terms of the wayforward from here, the major focus is on improv-ing the quality of services through the following:• Innovative approaches to capacity building,

both for local NGOs and government staff, combining ToTs and instructive training withcomplementary approaches such as on-the-job training, mentoring of lower capacity NGOs by higher capacity NGOs, distance learning and use of mobile mentoring teams.

• Strengthening project management skills as well as technical capacity of local partners.

• The use of third party monitoring to provide on the job training and supervision.

• A move towards the greater use of mobile teams linked to one static site in order to increase programme coverage.

• Introduction of the use of SQUEAC surveys to triangulate reporting results.

• Strengthening of field coordination systems.

The Scaling Up Nutrition (SUN) initiativeprovides a framework for action to scale upefforts at country level for addressing undernu-trition through encouraging country ownednutrition strategies and programmes and takinga multi-sectoral approach that includes integrat-ing nutrition in related sectors. Without aneffective central government, Somalia is not anobvious candidate for SUN in the formal sense.However, a Somali Nutrition Strategy has beendeveloped and endorsed by the authorities ineach of the three zones. The strategy encouragesthe use of current IMAM to maximise opportuni-ties arising for a more integrated response. TheBNSP epitomises this. Scale up of a more inte-grated approach is in progress. The scale up ofIMAM can certainly benefit other nutrition inter-ventions. Particularly in a context like Somaliawhere IMAM program- mes are reasonably wellfunded, they can provide a platform throughwhich to deliver other nutrition and relatedinterventions. However, it is essential to recog-nise the critical role of capacity strengthening inthe expansion and effective integration of abroader spectrum of activities. Capacity of localpartners and longer term funding remain keychallenges, whilst the priority in the currentcontext is the continued rapid scale up of lifesaving interventions to prevent morbidity andmortality.

For more information, contact: Leo Anesu Matunga, email: lmatunga@unicef.org, tel: +254 728601202

A father accompanies his children to OTP

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IDENTIFYRUF target group

(type ofmalnutrition,age group,geographicalarea, etc.)

IDENTIFYCommoditiesand prices

SET UPComposition and prices

spread sheet for 100 g foods

SET UP and RUNLP spread sheet

OPTIMIZEDFormulation

COMPLETEFormulation

TRIALLEDformulation

MICRONUTRIENTREQUIREMENTSare available

No OK?

Yes

Yes No

PRODUCESmall amount of product

CHECKTexture

parameters

RUNSensitivity Analysis

CROSSCHECKMacro-nutrients withlaboratory analysis

UNDERTAKEAcceptability and

safety trialsWithout premix in the

formulation

With premix in theformulation

UNDERTAKEClinical trial

DESIGNMicro-nutrient premix

DETERMINEMicro-nutrient

specs

DEFINELinear Programming

(LP) elements

Phase A

Phase B

Phase C

Phase D

(objective function, decisionvariables, mathematical

linear constraints)

SELECTFood composition

data bases

Research

Ready to Use Therapeutic Food (RUTF) is not alwaysavailable where needed. In India, where the need isenormous, it has not been possible to legally import

RUTF from Europe since 2009. In this and other countries,the relatively high cost of Western brands and local policieshave prevented the widespread importation of RUTF, boost-ing the demand for regionally appropriate solutions. Thecurrent RUTF formulation is based on results from a limitednumber of studies, in a few settings, showing rapid weightgain. Consequently, in other settings, with different under-lying nutrient deficiencies and infectious disease profiles,similar weight gains would perhaps occur with nutrientlevels different from those in use. Furthermore, the currentcommercial formulation of RUTF is not acceptable to all thepatients in need of therapeutic nutrition in developingcountries, e.g. HIV positive wasted adults.

Evidence based nutrition research ideally relies on costlyrandomised clinical trials. Therefore a robust method isneeded to design the trial RUTF before such studies. Atpresent, there is no internationally endorsed protocol todesign products of this kind. Linear Programming (LP) is asuitable decision tool for designing novel food-basedformulations. The method helps by identifying the cheapestpossible combination of food ingredients that meet a set ofnutritional requirements, avoiding a ‘trial and error’approach.

The objective of a recent study was to test a LP-basedmethod for designing the cheapest formulation of a ready-to-use food (RUF) that fulfils predefined macronutrientsrequirements. It used region-specific foods that are cultur-ally acceptable and can be processed with locally availabletechnologies. The LP objective function and decision vari-ables consisted of the lowest formulation price and theweights of the chosen commodities (soy, sorghum, maize,oil and sugar) respectively. The LP constraints were basedon current United Nations (UN) recommendations for themacronutrient content of therapeutic feeds and includedpalatability, texture and maximum food ingredient weightcriteria. Non linear constraints for nutrient ratios wereconverted to linear equations to allow their use in LP. Theonly software needed is MS Excel, including a freely avail-able add-in called ‘Solver’ (see Figure 1).

The method was used to successfully design a prototypeRUTF for the rehabilitation of HIV/TB-wasted adults andchildren under five years of age with severe acute malnutri-tion (SAM) in East Africa. The safety and acceptability of theprototype RUTF was subsequently confirmed in a trial2.Laboratory analysis confirmed that the energy, protein andlipid values of the prototype formulation were within thepre-established cut-offs.

Some constraints were highlighted in applying LP todesign food formulations of this kind. These were mainly todo with the accuracy of the food composition data in rela-tion to local food ingredients, e.g. the oil descriptor used

Linear programming to design low cost, local RUTF

was palm oil but the actual commodityused was palm olein oil (an industriallyprepared fraction of palm oil). Theauthors concluded that the LP methodused was widely applicable for therational design of therapeutic food prod-ucts at minimum cost. The studyprovided a prototype formulation whichmet almost all the pre-defined require-ments (one had to be relaxed by 0.2%).One lesson learnt is the need forimproved methods to determine theingredient prices to use in the model thattakes into account seasonal/regional/national fluctuations. The RUTF cost(based only on food ingredients) wasapproximately 4 to 5 times cheaper thanthe current standard product (food ingre-dients and premix) – hence even with theaddition of micronutrient mix, stillsubstantially cheaper. Using the methodsdescribed in the paper, public healthnutritionists and food technologistscould apply these steps to design other

1 Dibari F et al (2012). Low-Cost, Ready-to-Use

Therapeutic Foods Can Be Designed Using Locally

Available Commodities with the Aid of Linear

Programming. The Journal of Nutrition. First

published ahead of print March 28th, 2012 as doi:

10.3945/jn.111.1569432 Owino, V. O., Irena, A. H., Dibari, F. and Collins, S.

(2012), Development and acceptability of a novel

milk-free soybean–maize–sorghum ready-to-use

therapeutic food (SMS-RUTF) based on industrial

extrusion cooking process. Maternal & Child

Nutrition. http://onlinelibrary.wiley.com/doi/

10.1111/j.1740-8709.2012.00400.x/abstract

Summary of research1

Figure 2: Proposed design and validation method for novel RUTF

Figure 1: Sample of the MS excel based analysis

RUF formulations, such as ready-to-usesupplementary or complementary foods.The authors do, however, caution that themacronutrient contents of LP prototypesalways need to be confirmed by foodcomposition analysis and the finalisedproducts trialled under field conditionsbefore they can be recommended forgeneral use.

For more information, contact: FilippoDibari, email: filippo@validinternational.org

Source: Filippo Dibari. Adapted from Dibari et al (2012).

37

UNICEF Global reporting update: SAM treatment in UNICEFsupported countries

UNICEF is one of the principal organisa-tions supporting the implementationand scale up of the community-based

management of acute malnutrition (CMAM1)approach with respect to managing severeacute malnutrition (SAM). UNICEF is the mainprovider of Ready to Use Therapeutic Food(RUTF), therapeutic milk (F-75, F100) and otheressential supplies in treating SAM. UNICEFalso provides technical guidance and supportscapacity building efforts of Ministries of Health(MoHs) and non-governmental organisations(NGOs) to improve both the quality and accessof SAM treatment.

A key component of UNICEF’s work ismonitoring and evaluation (M&E) to demon-strate impact. The need to have a standardisedmethod to compile, collate and compare infor-mation on impact and increase accountabilityrelated to the management of SAM has beenevident for some time. A Global MappingReview in UNICEF-supported countries wasconducted in 2010, based on 2009 data, to deter-mine the current situation of CMAMprogramming with a focus on SAM treatment,and the findings were shared in March 20112. Amajor finding of this CMAM Mapping Reviewwas the need to improve the quality andfrequency of SAM treatment performancereporting and one specific recommendationwas to develop a Global SAM reporting system.One step in addressing this has been the devel-opment of an annual summary, referred to asthe ‘Global SAM Treatment Update’ to reporton the status of SAM treatment for 2011 inUNICEF-supported countries. The purpose ofthis article is to summarise some of the keyinformation from the 2011 SAM TreatmentUpdate, including some comparison with the2009 data, and outline the way forward onglobal SAM treatment reporting.

Overview of the 2011 Global SAMTreatment UpdateBuilding on the 2010 Global Mapping Review,the data capture methodology for 2011 wasamended with the aim to improve the quality ofresponses. The original questionnaire3, basedon the World Health Organisation (WHO)health systems framework, was modified toincrease the specificity of both the qualitativeinformation (general CMAM programme back-ground/ context, country objective,bottlenecks) and quantitative information(caseloads, prevalence, access and coverage,performance indicators) being requested.

The questionnaire was sent out in December2011 to 614 UNICEF County Offices (COs),selected on the basis of previous orders for ther-apeutic supplies5. Fifty-seven UNICEF COsresponded (93 per cent response rate). Thisexercise has provided significant learning onhow to achieve a strengthened reporting systemfor the future and has yielded important SAMtreatment information, allowing for somecomparison of the progress in the quality andscale-up of CMAM programming over the lastfew years.

Main findings of the UNICEF Global SAMTreatment Update, 2011Number of countries reporting servicesAt the end of 2009, 536 UNICEF country officesreported community-based services for the

management of SAM7 and by the end of 2011this had risen to 618. In the 2011 questionnaire,countries were asked about their stage or objec-tive to scale up of services for management ofSAM. While the definition of classifying coun-tries requires strengthening to ensure countriesproviding inpatient services only are alsocaptured, Figure 1 gives some indication ofcountry objectives with regard to scale up.

Annual total admissions of children withSAM 6-59 monthsIn total, 1,961,772 reported cases of childrenaged 6-59 months with SAM were admitted fortreatment during 2011, compared with just over1 million reported during 2009. While this largeincrease in reported admissions reflects overallimproved reporting at national level, it is alsoindicative of the ongoing scaling up of treat-ment of SAM. The total reported admissionsstill represents between 10-15 per cent of the~20 million expected SAM cases annually.

National reporting ratesTwenty-nine countries (48%) reported that theyhad >75% reporting rate (i.e. they received>75% of the required monthly reports)compared with eight countries (15 per cent) in2009. The reporting rate demonstrated a largeimprovement in data collection at the nationallevel. However, given there is no standardisedsystem of national reporting, intra-countrycomparisons should be made with caution.Each country collects data differently, with the

1 Also known as Integrated Management of Acute Malnutrition (IMAM) or Community-based Therapeutic Care(CTC)

2 Global Mapping Review of community based management of acute malnutrition with a focus on SAM. March 2011. Valid International, UNICEF HQ Nutrition (long report with individual country/regional data: internal circulation only; summary report: external circulation)

3 For any additional documents pertaining to the review, please contact UNICEF New York Nutrition in Emergencies office.

4 Questionnaires were sent out to Guinea Conakry and Namibia later than the other country offices.

5 See data limitations section.

By UNICEF Nutrition in Emergencies Unit and Valid International

Countrywide service provision

Countrywide service provision

26.2%

26.2%

29.5%8.2%9.8%

Limited service provision/Emergency Response

Pilot

No data from country

Figure 1: Global breakdown of country status/objective with regard to CMAM scale up (2011)

≥75%

31.4%12.9%

40.0%

<75%

15.7%

No Response

Insufficient Reporting

≥75%

<15%

No Response

Insufficient Reporting

19.4%

29.9%41.8%

9.0%

6 Fifty-five countries by mid 2010, with Ghana and Hondurasstarting services.

7 Note: not all countries with inpatient services only may have been captured by the questionnaire. No definition of community-based management of SAM was provided and the existence of programming is from CO reports.

8 Cambodia, Comoros, Ghana, Guinea Bissau, Honduras, LaoPDR, Vietnam and Zanzibar reported starting community-based programmes subsequent to the 2009/2010 mapping exercise. Mainland Tanzania and Zanzibar counted separately due to the different nature of the SAM treatment programmes.

9 See news piece in this issue of Field Exchange.

Research

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Following the CMAM mapping exercises of 2009 and 2011, UNICEF andValid International are working together through a UNICEF-supportedProject Cooperation Agreement (PCA). Thanks to Erin Boyd (UNICEF),Nicky Dent (Valid International),James Hedges (UNICEF HQ), Gideon Jones(Valid International), and Rachel Lozano for contributing to this article.

Figure 2: Global Cure Rates (2011 Figure 3: Global Defaulter Rates (2011)

38

reporting rate sometimes reflecting the percent-age of reports received from health facilitieswith functional services for SAM, and some-times the percentage received fromimplementing partners.

Performance IndicatorsCure rate: Twenty-two countries (31.4%)achieved a minimum recovered rate of >75%(SPHERE standard for recovered) (47.1%response rate) (see Figure 2). Collection of thisspecific information was particularly challeng-ing given wide variance in performanceindicator calculation methods, often as differentdenominators were used. Further guidance inthis area is crucial for strengthening the qualityof this information.

Defaulter rate: Twenty countries (30%) achieveda defaulter rate of <15% (SPHERE standards -defaulted rate) where adequate reports wereavailable (50.2% of countries) (see Figure 3).Again, there is a need to support countries incollecting and collating these performance data.A benefit of this would be that default ratescould be used to identify which countries mightbenefit in receiving more technical assistance orinvestigation, for example through communityenquiries or specialised coverage surveys.

Geographical and treatment coverageDespite the current absence of a standardisedinternational way of illustrating geographicalcoverage for management of SAM, the datagathered from 2011 showed a marked increasein countries’ ability to track geographic cover-age. Attempting to strengthen the data from2009, which yielded very varied responses, for2011 a more precise question was posed, askingfor “number of health facilities integrating themanagement of SAM in country/total numberof health facilities in country.” Encouragingly28 countries (46 per cent) were able to respondto questions pertaining to geographic coveragebased on the existence of services at heath facil-ity level. Nevertheless, reporting challengeswere still apparent, illustrating continuing diffi-culties in measuring geographical coverage andthe range of methodologies used. For treatmentcoverage, while admissions data were strong,further clarity on the denominator is evidentlyneeded: the overall range of responses - from0.004 per cent to 150 per cent - was too wide(and sometimes questionable) to allow a mean-ingful comparison.

Integration into Health ServicesIntegration of management of SAM into thehealth system is a strategy gaining momentumas some MoHs adopt management of SAM aspart of the essential health package (note, notall countries are aiming for nationwide scaleup, as management of SAM is not always acountry health priority). Questions for the 2011Global SAM Treatment Update were poseddifferently in the 2010 mapping so directcomparison cannot be made, apart from a slightincrease in the number of countries incorporat-ing SAM indicators in the Health ManagementInformation System/HMIS (16 countries in2011 compared with 14 in 2009) and a greaterincrease in including community-basedmanagement of SAM in pre-service training (15countries in 2011 compared with 9 in 2009).

Procurement of RUTFIn 2011, UNICEF procured 27,000 MT – some 80per cent of the global supply. UNICEF contin-ues to support the local production of RUTFs

and has diversified its own supplier base toinclude manufacturers in Dominican Republic,Ethiopia, France, Haiti, India, Kenya,Madagascar, Malawi, Mozambique, Niger,Norway, Sierra Leone, South Africa, Sudan,Tanzania and USA.

Data limitationsThe different understanding of respondentswas evident in the data collection process, withmixed responses received for certain questions.It is evident that UNICEF staff have varyingunderstanding and experience of terminologyand standardisation of this understanding willbe crucial for strengthening future data collec-tion efforts. For the 2011 exercise, responseshave not been ‘eliminated’ if they appeared outof range, apart from obviously incompleteresponses for the geographical coverage ques-tion. COs were not requested to clarify orcorrect responses or add missing data, limitingthe reliability and completeness of the data set.Another limitation was the sending out of ques-tionnaires only to countries orderingSAM-related supplies, this measure led to somecountries being missed in the initial sending ofthe data collection tool. In addition, the statusof some countries said to be “planning” CMAMprogrammes from the mapping exercise is notknown and a comprehensive view of countrieswith inpatient management of SAM services isnot available.

Ways forwardThrough 2012, UNICEF and Valid Internationalhave been working together to develop a web-based data collection and analysis mechanismto capture key information related to themanagement of SAM at country level forsynthesis at global and regional level.Currently, the automated Global SAMTreatment Update mechanism is nearing thepiloting phase, but work is still being done toimprove the tool to ensure greater clarity andutility. This includes the incorporation of qual-ity checks and balances in the system tominimise inappropriate data submissions.

Much of the information to be insertedwithin the SAM Treatment Update tool isalready collected by countries currently, but theregular and systematic collation across coun-tries and regions at the global level has excitingpotential. Through the SAM Treatment Update,key data can be produced for the general healthand nutrition community, fulfilling a need atthe global level for big picture information onthe current situation of scale up of and manage-ment of SAM. Over time, this should enable thetracking of trends and changes from year toyear and country to country. This, in turn, willsupport the identification of gaps and guidingof advocacy efforts, decision-making, andresource mobilisation. The more detailed rawdata will be utilised by UNICEF for in-depthanalysis to inform its support to countries,strategic decision-making and fundraisingefforts, as well as supply forecasting andprogramme planning.

In terms of the immediate way forward onthis initiative to strengthen SAM treatmentrelated information for improving and expand-ing access to SAM treatment, there are certainkey actions to be undertaken:• Finalize outputs of Global SAM Treatment

Update: The major variable outputs of a web-based data capture tool need to be

finalised, as these will be reported on an annual basis for distribution internally to UNICEF management, field staff and exter-nally to stakeholders involved in the management of SAM (other UN agencies (WHO, WFP, FAO, UNHCR), donors, NGOs,technical bodies). Information will likely include the number of countries carrying out services for management of SAM, country caseload, admissions data and so on.

• Refine data capture tools and process: Based on learning from past data capture exercises, further work is needed in terms of how best to define and request specific information required at global and regional levels including linking with the supply aspect. Further work will also be needed onhow to ensure that information from all countries with services for SAM is captured,including those with inpatient services only.In addition, continued development of the web-based system for data entry with greater guidance on how to minimise errorsand missing data will be undertaken.

• Develop standardised definitions and methodology and refine content: as part of the tools development, efforts are needed tofurther refine definitions and methods to provide a common language and methodol-ogy to measure geographical and treatment coverage, and to define the classification/ stage of SAM services with international experts, stakeholders and health/nutrition technical bodies. To this end, the develop-ment of regional webinars is being planned for UNICEF staff to develop common defi-nitions and to strengthen country capacities to improve their existing information systems. Indicators designed to effectively capture information on the integration of SAM into national systems is being piloted with UNICEF East Africa regional office as part of the development of a framework to support integration of SAM management innational health systems.9

• Ongoing support: The weaker data from previous global capture exercises will be used to prioritize countries and identify areas that require additional support, to be linked to competency frameworks and capacity building strategies.

ConclusionsThe progress on SAM-treatment reporting overthe last few years has been significant and hasplayed an important role in highlighting theglobal achievements to date and the challengesremaining. This information is increasinglybeing utilised to inform a range of actions insupport of improving and expanding treatmentof SAM treatment at country level. This has ledto amendment of programmatic strategies andactions and provides an evidence base forstrategic decision-making, resource mobilisa-tion and advocacy. UNICEF remains committedto the nutritional well-being of children andmothers and it is envisaged that this mandatewill be increasingly strengthened throughimproved data reporting. The Global SAMTreatment Update initiative constitutes anotherimportant step towards this.

For further information, contact: Ilka Esquivel,Senior Adviser, Nutrition in Emergencies,iesquivel@unicef.org

Research

9 See news piece in this issue of Field Exchange.

39

By Ms Aminata Shamit Koroma, Faraja Chiwile, Marian Bangura,Hannah Yankson and Joyce Njoro

Capacity developmentof the national healthsystem for CMAM scaleup in Sierra Leone

ACF Action Contre la Faim

BeMOC Basic Emergency Obstetric Care

CHC Community Health Centre

CHV Community Health Volunteer

CMAM Community Management of AcuteMalnutrition

CSB Corn Soy Blend

DHMT District Health Management Team

DHS Demographic and Health Survey

EPI Expanded Programme ofImmunisation

FCHI Free Health Care Initiative

HMIS Health Management InformationSystem

ICC Interagency CoordinatingCommittee

INGO International Non-GovernmentalOrganisation

IRC International Rescue Committee

ITN Insecticide Treated Nets

IYCF Infant and Young Child Feeding

LQAS Lot Quality Assurance Sampling

MAM Moderate Acute Malnutrition

MCH Maternal and Child Health

MCHP Maternal and Child Health Post

MICS Multiple Indicator Cluster Survey

MOHS Ministry of Health and Sanitation

MSF Médecins Sans Frontières

NGO Non-Governmental Organisation

OTP Outpatient Therapeutic Programme

PHU Peripheral Health Unit

REACH Ending Child Hunger andUndernutrition partnership

RCH Reproductive and Child Health

RUTF Ready to Use Therapeutic foods

SAM Severe Acute Malnutrition

SC Stabilisation Centre

SFC Supplementary Feeding Centre

SFP Supplementary FeedingProgramme

SLEAC Simplified LQAS Evaluation ofAccess and Coverage

SMART Standardised Monitoring andAssessment of Relief andTransitions

SQUEAC Semi Quantitative Evaluation andAssessment of Coverage

TCC Technical Coordinating Committee

TFC Therapeutic Feeding Centre

UNICEF United Nations Children’s Fund

WFP World Food Programme

WHO World Health Organisation

Aminata Shamit Koroma is National Foodand Nutrition Programme Manager,Ministry of Health and Sanitation, basedin Freetown, Sierra Leone.

The authors would like to thank the members of the national nutrition technical committee, REACH secretariat, ACF,WHO, UNICEF, WFP for their time and effort and financial resources from UNICEF in putting this paper together. Weextend special thanks to all health and field workers in the CMAM programme for their unrelenting hard work andto the Government of Sierra Leone for its commitment to ending malnutrition.

Faraja Chiwile is NutritionManager with UNICEF SierraLeone.

Marian Bangura isNational NutritionProgramme Officerwith WFP SierraLeone.

Hannah Yankson isNational NutritionProgramme Officerwith WHO SierraLeone.

Joyce Njoro is theInternational UNREACH Facilitatorin Sierra Leone.

BackgroundSocio-economic statusThe Republic of Sierra Leone is situated on theWest Coast of Africa, bordering the North AtlanticOcean, between Guinea and Liberia. Its land areacovers approximately 71,740 sq. km. The estimatedprojected population for 2011 is 5,876,936 inhabi-tants1, of which approximately 37% reside in urbanareas. There are about 18 distinct language groupsin Sierra Leone, reflecting the diversity of culturesand traditions. Administratively, the country isdivided into four regions, namely Northern,Southern, Eastern regions and the Western areawhere the capital Freetown is located. The regionsare further divided into 14 districts, which are inturn sub-divided into chiefdoms that are governedby local paramount chiefs.

Sierra Leone has suffered from declines in socialand economic activities caused by a decade ofprotracted and devastating civil war, from 1991 to2001. That situation led to virtual collapse of socialservices and economic activities in most parts ofthe country. Sierra Leone is classified by the UnitedNations as one of the least developed countries. In2010, the country ranked 158 out of 169 in theUnited Nations Human Development Index.

Nutrition and health situationSierra Leone has some of the poorest health indica-tors in the world, with a life expectancy of 47 years,an infant mortality rate of 89 per 1,000 live births,an under-five mortality rate of 140 per 1,000 livebirths and a maternal mortality ratio of 857 per100,000 births (DHS 2008). The majority of causesof illness and death in Sierra Leone are preventa-ble, with most childhood deaths attributable to

nutritional deficiencies, pneumonia, malaria, anddiarrhoea. Malaria remains the most commoncause of illness and death in the country. Over 24%of children under the age of five years had malariain the two weeks preceding the 2008 householdsurvey. Prevention (Insecticide Treated Nets) andtreatment are both sub-optimal in Sierra Leone(DHS 2008). Diarrheal diseases and acute respira-tory infections are also major causes of out-patientattendance and general ill health in the country.The greatest burden of disease is in rural popula-tions, especially amongst the female population.Due to the unequal burden of ill health, women aremore likely to stop their economic activitiesbecause of illness than men.

While there has been some considerable reduc-tion in malnutrition rates in Sierra Leone since2005, it remains a serious problem in most parts ofthe country. According to the national SMART2

survey conducted in 2010, 34.1% (327,000) of chil-dren under the age of five years are stunted, 18.7%(179,000) are underweight and 5.8% (56,000) arewasted. Infant and young child feeding (IYCF)practices indicate that only 11% of infants under sixmonths of age in Sierra Leone are exclusivelybreastfed (DHS 2008). Only 52% of children 6-9months are given timely introduction of comple-mentary foods and amongst children 6-23 months,only 23% were fed with appropriate foods andaccording to recommended practices (DHS 2008).These inappropriate feeding practices are impor-tant contributors to child morbidity, whichexacerbates the already heavy burden of disease.

1 Government of Sierra Leone. 2004. Population and Housing Census, Census Tabulations.

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national, district level and partners,coalition building, resource mobilisa-tion, monitoring and oversight toensure effective implementation andquality programming. The MOHS alsoprovides both the infrastructure andthe bulk of the health sector personnelto implement CMAM.

Donors, UN agencies and NGOsThe main bilateral donors currentlyfunding the CMAM programme areIrish Aid and the UK Department forInternational Development (DFID).Their combined investment in CMAMin 2010 was almost $3 million. Donorsalso fund the UN agencies, whichhave specialised roles in supportingthe implementation of CMAM

through government, international or localNGOs. The roles of the different UN agenciesand NGOs are briefly described below:

UNICEF supports community mobilisation,OTP and SC components of CMAM. Theagency procures and provides supplies(Plumpy’Nut, F75, F100, routine medication),logistics, technical support and support fornational surveys (DHS, SMART, coveragesurvey, MICS). UNICEF has also engaged NGOpartners to undertake active screening ofunder-fives and social mobilisation for CMAMand IYCF at community level in each district.

WFP supports the SFP component of CMAMand SCs through provision of food to moder-ately malnourished children and mothers/caregivers of admitted SAM children. Theagency provides supplies, logistics, procure-ment (dry rations – Corn Soya Blend, oil andsugar). WFP NGO partners conduct the distri-bution and monitoring of the food commodities

Through twice yearly masscampaigns, Sierra Leone has achievedhigh coverage of under-five Vitamin Asupplementation and de-worming at91% and 85% respectively (SMART,20103). Anaemia is still highly preva-lent at 76% and 46% in children underfive years and women of child bearingage, respectively (DHS 2008). Thiscould be due to the high rates ofmalaria and other parasitic infections,poor dietary intake of iron-rich foods,or a combination of reasons.

According to the Sierra LeoneDistrict Health services baselinesurvey (2009), 66% of pregnant womenhad four or more antenatal care visitsas recommended, which is encourag-ing. The same study indicates that 40%subsequently delivered in a health facility.Currently, insufficient numbers of health facili-ties are equipped and staffed to acceptablestandards to provide emergency obstetric care.The referral system in many districts is notfunctional, often leading to dangerous delays inthe provision of comprehensive emergencyobstetric care.

Political will and policy environmentThe government recognises that issues ofmaternal and childhood health are key for ahealthy society and is committed to reducingthe high rates of maternal and child morbidityand mortality. The government has taken stepsthrough the ‘President’s Agenda for Change’and has developed a Basic Package of EssentialHealth Services. An important initiative hasbeen the introduction of the Free Health CareInitiative (FHCI) in April 2010 for all pregnantwomen, lactating mothers and children of lessthan five years. This initiative has considerablyimproved access to care as follows: • Increased consultations of children under 5

years from 933,349 to 2,926,431 after the first 12 months of the FHCI (2009-2010)4

• A 45% increase in institutional delivery (87,302 pre FHCI to 126,477 one year after)4

Sierra Leone is fortunate that the First Lady is achampion of children and women’s affairs. Shehas presided over a number of nutrition andhealth advocacy events in the country. In arecent National Nutrition and Food SecurityForum, the President (in a speech read on hisbehalf by the Minister of Information)expressed his concern at the current highnumbers of children affected by malnutritionand he affirmed his government’s commitmentto firmly address the problem, by putting inplace dedicated policies and strategies toreduce child hunger and undernutrition. Thereis therefore a high level of political will at pres-ent, ready to tackle the long standing problemsof malnutrition in-country.

The Ministry of Health and Sanitation(MOHS) systems and structures are outlined inBox 1. The MOHS has several policies in place,including the National Health Policy, theReproductive Child Health Policy, the Food andNutrition Policy, which provide clear directionsfor the entire health sector. The country is,however, facing challenges in the effective oper-ationalisation of the policies. Most healthfacilities are inadequately staffed, making itdifficult to implement outreach visits. There isalso a low staff/population ratio in SierraLeone. In 2010 there was a total of 2,787

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Community Health Volunteers (CHVs), 906Maternal and Child Health aides, 523 enrollednurses, 244 registered nurses/midwives, 154Community Health Officers, 56 MedicalOfficers, 21 Medical Superintendents and 72District Health Management Team technicalmembers.

Rollout of CMAMThe Community based Management of AcuteMalnutrition (CMAM) programme started as apilot project in 2007 in Sierra Leone. It was trig-gered by continuing high rates of malnutritionin the post war years. The main aim of theprogramme was to maximise coverage andincrease access to services by the highest possi-ble proportion of the malnourished populationacross the country. It was also expected to createa platform for comprehensive communitymobilisation over the long term.

Initially, the programme was piloted in fourdistricts – Bombali, Tonkolili, Kenema andWestern area. In each of the four districts, fiveOutpatient Therapeutic Programme (OTP) siteswere established close to major towns for easeof monitoring (as the programme was new,monitoring was particularly important). Since2007, the programme has been graduallyscaled-up, with the establishment of more OTPsand Stabilisation Centres (SC) for the treatmentof complicated severe acute malnutrition(SAM) cases. Additionally, SupplementaryFeeding Programmes (SFPs) were set-up atcentres to treat those presenting with moderateacute malnutrition (MAM) and provide thecontinuum of care for SAM children.

The initial targets for scale-up were:• To achieve at least one OTP site per

chiefdom by 2010 • To achieve better coverage of remote areas• To cater for the increased caseloads

expected following the adoption in 2010 of the WHO growth standards

From the start, the CMAM programme hasbeen closely linked with other servicesprovided by the health system, such as antena-tal care, IYCF, immunisation and growthmonitoring interventions.

CMAM partners roles and responsibilitiesMinistry of Health and Sanitation (MOHS)The MOHS is responsible for the overall leader-ship of the programme, assuming multipleresponsibilities including policy formulation,strategic planning, setting of standards andregulations, ensuring collaboration between

A Minister and two Deputy Ministers, all appointedby the President, head the MOHS. The Ministry iscomposed of an administrative and a technical wingheaded by the Permanent Secretary and the ChiefMedical Officer, respectively.

The Ministry has eleven directorates, with the Foodand Nutrition Programme located under theReproductive and Child Health ProgrammeDirectorate. Other programmes in this directorateinclude the School and Adolescent Health,Reproductive Health and Child Health/ ExpandedProgramme of Immunisation.

Sierra Leone’s health service delivery system ispluralistic, whereby the government, religiousmissions, local and international non-governmentalorganisations (NGOs) and the private sector are allinvolved in the provision of services.

Public health is delivered from three levels of healthfacilities (from the lowest level to highest): Peripheral Health Units (PHUs) – composed of 1200Maternal and Child Health Posts, Community HealthPosts and Community Health Centres for frontlineprimary health care.Secondary Health Units – composed of 47 hospitalsin the districts, of which 18 are government owned,19 faith-based, 8 private, located in districts and 2non-governmental (NGOs).Tertiary Health Care – composed of eight govern-ment tertiary hospitals, of which three are regionalhospitals and five located in the Western area.

Box 1: MOHS systems and structure

2 2010. The Nutrition Situation in Sierra Leone. Nutrition Survey using SMART Methods, Final Report

3 See footnote 2.4 Government of Sierra Leone. Health Information Bulletin.

Vol 2 No 3. Scaling up Maternal and Child Health through Free Health Care, One year on.

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to the final destinations. WFP supports nationalsurveys (e.g. the Comprehensive Food Securityand Vulnerability Assessment) and providestechnical support to government, such asduring the development of national policiesand protocols for CMAM and guidelines forIYCF.

The World Health Organisation (WHO)provides technical support to government fordevelopment of standards, guidelines andmonitoring systems, such as the implementa-tion of the 2006 growth standards and thedevelopment of new child growth cards. WHOhas also provided support for nutritionalsurveillance by integrating nutrition indicatorsinto the Health Management InformationSystem (HMIS).

NGOs provide support in the following areas: • For OTP and SC services, some interna-

tional NGOs (INGOs) support the manage-ment of malnourished cases in their opera-tional areas, which includes provision of training and capacity building of district staff, supplies for government PHUs and logistics for outreach services. Some INGOs also provide logistic support for RUTF distribution.

• For SFP services, the INGOs transport food supplies from the WFP district warehouses to the PHUs, train PHU staff in managing effective distributions, preparation of the food and accurate reporting.

• For community mobilisation for CMAM, support is provided by INGOs and local NGOs through provision of training for CHVs in how to conduct screening and refer identified malnourished children to the treatment centres.

Strong partnerships have emerged between theMOHS, UN agencies, NGOs and faith basedorganisations (FBOs) involved in CMAMimplementation. Other partners who provideCMAM services are Médecins Sans Frontières(MSF) (NGO), Magbente (FBO) and Panguma(FBO). Technical support to training has beenprovided by Valid International. Three interna-tional NGOs partnering with WFP – Africare,Plan International and World VisionInternational – are now distributing and moni-toring SFP commodities and giving technicalsupport to health facility staff. These partner-ships can be further exploited for implement-ation of preventive nutritional interventions.

AdvocacyThe MOHS and Ministry of Agriculture,Forestry and Food Security with the support ofNGOs and UN REACH partners (UNICEF,WHO, FAO, WFP) conducted a comprehensivesituation analysis of nutrition and food securityin 2011. The conclusions of this analysis wereshared with multi-sector stakeholders in anational nutrition and food security forum andin all regions in the country. Important gapsand opportunities for scaling up nutrition andfood security interventions were identifiedduring this process. The national forum waslaunched by the Minister of Information andCommunication, who deputised for thePresident of Sierra Leone. The participantsincluded senior government ministers, seniorgovernment officials, decision makers from theUN, development partners, NGOs and seniortechnical personnel from the representedorganisations. These fora have given visibilityto the issues of malnutrition and food insecu-

Table 1: Coordination mechanisms under the MOHS

CoordinationMechanism

Convenor Regularity ofmeetings

Details

Health SectorCoordinatingCommittee

Minister Quarterly Highest health policy coordinating body, members includeheads of line ministries, departments and agencies.

Health Sector SteeringGroup

Chief MedicalOfficer

Bi-Weekly This coordinates the work of the technical working group.Members include donors, chairmen of sector workinggroups. INGOs and national NGOs, CSOs, UN Agencies.

Health Sector WorkingGroups

MOHS/Partners Bi-Weekly Senior officers of partner agencies with interest andexpertise relating to the six pillars of the NHSSP.

Nutrition CoordinatingCommittee

NutritionManager

Quarterly Technical participation of organisations active in nutritionsuch as the government ministries, UN and NGOs.

Nutrition TechnicalCommittee

NutritionManager

Monthly Small taskforce comprising of technical agencies in nutrition that supports the Nutrition Programme.

Technical CoordinatingCommittee (TCC) forRCH

Chief MedicalOfficer

Monthly A forum for all technical managers and implementing partners conducting RCH activities countrywide, such asUNFPA, International Rescue Committee (IRC), WHO.

District PartnersCommittee

DistrictMedical Officer

Monthly Coordinates district health implementing partners.

be trained and equipped. Additionally, commu-nity mobilisation must be conducted andlogistic systems organised such that uninter-rupted supplies can be provided to implementthe programme, as discussed below.

Health personnelTo ensure sufficient numbers of skilled healthpersonnel during the roll out of CMAM, twostrategies were applied: the hiring of new staffand capacity building of existing staff. The newstaff included government nutritionists, upfrom six (in four districts) in 2007, to 16 (in ninedistricts) in 2010. The National NutritionProgramme also established two positions withsupport from UNICEF, a CMAM Officer and anIYCF Officer to coordinate, monitor and evalu-ate these separate field activities nationwide. Inaddition to the government employed nutri-tionists, partner NGOs hired a total of 12nutritionists to assist with effective CMAMimplementation in 2010. The total number ofnutritionists in the CMAM programme inSierra Leone currently stands at 14.

Since 2007, considerable effort has beenexpended on training many MOHS staff in themanagement of acute malnutrition for SC, OTPand SFP service provision. The majority oftrainings were sponsored by UNICEF withtechnical support from Valid International,WFP and WHO. Some INGOs have alsoprovided training for health staff in their oper-ational districts e.g. Action Contre la Faim(ACF) in Moyamba for SFP, and MSF in Bo forOTP and SC service provision. The details oftrainings conducted to date are indicated belowin Tables 2 and 3.

Tools developed to support the training of staffinclude: • The first version of the CMAM guidelines

and protocol was developed in 2007 and validated in 2009. A revised version was developed in 2010 following the adoption ofthe WHO growth standards.

• Booklets of handouts were produced and used for the Training of Trainers (ToT) and cascade training of health staff on CMAM in 2010. The booklets contain extracts from the revised protocol.

CMAM facilitiesThe programme has gradually been scaled upfrom the initial five OTPs in four districts of thepilot project in 2007 with the establishment ofmore OTPs, SCs and SFPs in all districts.

rity at national and regional level, which willlead to more support for these programmes atboth levels.

Intense advocacy to the MOHS and seniorhealth officials was undertaken in 2010 for theinclusion of CMAM into the Free Health CareInitiative. The advocacy led by UNICEF and theMOHS Nutrition Programme was successfuland resulted in the inclusion of CMAMsupplies in the essential drug/food list.Anticipated benefits of this are ease of clearingimported supplies through the port, procuredcommodities can be stored in governmentcentral medical stores (treated the same as anyother drug), and government can take on abigger role in the distribution and logisticalmanagement of the supplies.

Another important advocacy event was thelaunching of the first CMAM protocol by theFirst Lady in 2008 during ‘Breastfeeding week’.As CMAM relies on community support for itssuccess, advocacy for community leaders tosupport CMAM is ongoing, often led by NGOs(when present in the area).

CoordinationThe MOHS takes the lead in coordinating allthe health sector partners. The coordinationmechanisms within the health system relevantto the CMAM programme are indicated inTable 1. The MOHS has developed an overarch-ing National Health Sector Strategic Plan(NHSSP) that has six pillars designed to ensureeffective implementation of the national healthpriority areas. These are leadership and gover-nance, service delivery, human resources,health financing, medical products and tech-nologies and health information. UNICEF alsoholds quarterly coordination meetings with theNGO implementing partners to monitor andshare updates on CMAM implementation.

While sufficient coordination mechanismsare in place, they are faced with various chal-lenges such as irregularity of meetings, poorrepresentation and poor time management. Forexample, the Interagency CoordinatingCommittee (ICC) and Technical CoordinatingCommittee (TCC) for Reproductive and ChildHealth (RCH) meetings have not always beenregularly held in the ministry due to timeconstraints.

ImplementationTo implement CMAM at-scale, sufficientnumbers of health personnel and facilities must

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Date Staff trained Content Sponsor

June 2007 National/district health staff,paediatricians, nutritionists

Management of SAM UNICEF with Valid International

2008 PHUs staff Management of SAM UNICEF with Valid International& MOHS

2009 PHUs staff Integration of IYCF to supportCMAM

UNICEF with Valid International

June-August2010

National/district & PHU staff Integrated training on the revisednational protocol for CMAMNew WHO growth standards

UNICEF with Valid International,WHO, WFP, HKI

February-April 2011

One DHMT member/ district On-job training on how toconduct CMAM coverage survey

UNICEF with Valid International

March2011

District Health Sister, NGO & othergovernment staff in each district

On-job coaching and mentoringin OTP skills

UNICEF and Valid International

June – Oct2011

SC staff On-job training on how effectivelyto implement the SC componentof CMAM

UNICEF

Table 2: Chronology of training on CMAM, OTP and SC components

Outpatient Therapeutic Programme (OTP)The OTPs were scaled up from 20 in 2007 to 245in 2011. The decision to open more OTPs wastaken based on availability of trained staff at thePHUs, community needs and financialresources. The scale-up from 2008 to 2011 peryear is shown in Figure 1. The large increase in2010 followed a major training of staff from allexisting PHUs, with financial support from theWHO, UNICEF and WFP. While the scale-up todate has been impressive, it still represents only20% of all PHUs. The scale-up should be grad-ually continued until OTPs are established at allPHUs; a difficult undertaking as some chief-doms are very large and many PHUs aredifficult to access due to very poor infrastruc-ture in some rural areas.

Stabilisation centres (SCs)In 2007, there were only three treatment centresin the whole country, located in the Westernarea, Bombali and Bo. These TherapeuticFeeding Centres (TFCs), admitted all SAM chil-dren for 2 to 3 months until they achieved 80%weight for height. In 2007, following the shift toCMAM programming, the TFCs were trans-formed into SCs, admitting SAM children withcomplications only and discharging them toOTP to complete their treatment once thecomplications had resolved. From 2007, thethree SCs were scaled up to eight by 2009, then14 in 2009 and finally 19 in 2010. Each districtcurrently has at least one SC, with plans to openmore as and when resources allow. WFPprovides food for mothers/caregivers of admit-

Table 3: Chronology of training on CMAM SFP component

Date Staff trained Content Sponsor

2008 Maternal and Child Health (MCH) aidesand district nutritionist in the Western Area

Orientation on SFP WFP

2009 MCH Aides, zonal supervisors, nutritionistand nutrition focal points in Western areaand Moyamba

Orientation on SFP WFP

2010 MCH Aides in Bo, Pujehun and Bonthe Orientation on SFP WFP

May 2010 MCH Aides and Comunity Health Officers(CHOs) in Moyamba District

Comprehensive training in SFP WFP

June-July2010

Civil society staff (‘Health for all’ coalition) Orientation on SFP with basic concepts ofmalnutrition to facilitate monitoring of theprogramme

WFP

2010 District councillors – health committee Orientation to SFP with basic concepts of malnu-trition to facilitate monitoring of the programme

WFP

July 2010 MOHS nutrition focal points and WFP fieldmonitors

Comprehensive training in SFP WFP

June-August2010

Joint cascade training of PHU staff nation-wide

Comprehensive training in SFP, SC, & OTP includ-ing assessment, management and reporting

WFP,UNICEF,WHO

December2010

Training of district Nutritionists Comprehensive training on WFP processes andprocedures

WFP

ted children at some of the SCs. In 2010, thenumber of SCs supported by WFP was 10, upfrom eight in 2008. One of the key challengesfaced by these eight SCs is the lack of food forcaregivers and so they refuse admissions toavoid the high associated cost.

Supplementary Feeding Centres (SFCs)Supplementary feeding for MAM children hasbeen implemented for many years, even beforethe war. In 2007, the supplementary feedingcycle for MAM lasted for three months in SierraLeone. This changed in 2011 to a minimum of60 days to align with the reviewed CMAM proto-col.

In 2008, 385 PHUs were covered by SFCs in12 districts, increasing to 440 in 2009 and 521 in2010. The scale-up was based on the prevalenceof SAM and MAM and availability of NGOpartners. In Sierra Leone, 43% of all PHUs arecurrently providing SFPs, however not all OTPsites are covered (67 OTP sites do not have aSFP). This followed the suspension of SFPs infour districts due to funding constraints. TheNutrition Programme will make a formalrequest to WFP to ensure that all OTPs arecovered by the SFP for the continuum of care toprevent relapse after rehabilitation.

In 2007, community mobilisation was mostlydone by health staff through outreach services,such as the Expanded Programme onImmunisation (EPI). The children werescreened and identified malnourished casesreferred for treatment. Some PHUs had CHVs

300

250

200

150

100

50

01 2 3 4 5

Year

No. of OTPs

Figure 1: Scale-up of OTPs

attached to them (approximately one per PHU)to support the outreach services.

To boost active case finding, from 2007Project Co-operation Agreements (PCAs) weredeveloped and signed between UNICEF andinternational and local NGOs to supportcommunity mobilisation for the implementa-tion of CMAM. By 2011, a total of eight localNGOs and three INGOs were involved acrossall districts, except Koinadugu where theUSAID funded Multi-Year AssistanceProgramme was being implemented byInternational Medical Corps (IMC). A series ofcommunity mobilisation messages were devel-oped by UNICEF.

Additionally, CHVs were trained by theMOHS and NGOs at the district level. TheCHVs hold periodic meetings with the commu-nity and screen children house-to-house on aquarterly basis, referring identified malnour-ished cases to the PHUs. They also makefollow-up visits at home for referred anddischarged children. The number of CHVs hasbeen scaled up progressively over the years,with a total of 3,670 trained between 2007 and2011 (see Figure 2).

All CHVs trained in 2010 and 2011 remainactive. Training is conducted for 3 to 5 days byNGO staff with support from the DistrictHealth Management Team (DHMT). Thenational CMAM protocol for training CHVs inearly case finding and social mobilisation isused. However, as observed during the CMAMcoverage survey in 2011, a large number ofmothers with SAM children reported that theywere not aware of the programme. Thisprovides clear evidence that community mobil-isation in CMAM remains weak. However,since the bulk of the CHVs were trained in 2011,it is hoped that this trend may be reversed aslong as the CHVs remain active.

Supplies and logisticsSince 2007, UNICEF has supplied the therapeu-tic food and routine medicines required for OTPand SC, including F-100, F-75 and RUTF. In2008 and for most of 2009, nutrition supplieswere sent to the regional stores in Freetown,Makeni and Kenema for distribution to thedistrict every two to three months. SinceDecember 2009, supply mechanisms weresimplified by sending them directly to thedistricts, using a new food warehouse in

3000

2500

2000

1500

1000

500

01 2 3 4 5

90420

50442

2668

YearNumber of CHVs trained

Num

ber

Figure 2: Number of CHVs trained

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final destination. The very poor road conditionsin rural areas (especially during the rainyseason) again provide considerable logisticalchallenges.

ResultsSuccesses of CMAMThe efforts towards scaling up CMAM haveresulted in the realisation of results in differentareas of investment. Overall, the number ofSAM children treated has greatly increasedfrom 2,950 in 2007 to 35,000 in 2010. Admissionsin 2012 were higher (105%) than the planningfigures. The cure rates of children with MAMand SAM remain impressive, at 98.7% (MAM)and 97% (SAM) (see Figure 3).

Other successes are: • The integration of CMAM as part of the

basic package of essential health services.• Integration of therapeutic food as part of

the FHC.• Development of national policy and

guidelines for treatment (CMAM guidelinesand IYCF).

• Government leadership of the CMAM programme with the support of UN and partners.

Staff capacity development has been notable. Todate, Sierra Leone has 150 trainers of CMAMwith 1,080 health facility staff trained at alllevels. Similarly, the MOHS has increased thenumber of district nutritionists to nine andcreated two new national positions on CMAMand IYCF, for better coordination and oversight.

ChallengesThe following challenges have been identifiedduring scale-up of CMAM:

Inadequate numbers and skills of health staff: Despite the numerous efforts made to developthe knowledge and skills of MOHS staff onCMAM, the required level for effective servicedelivery has not yet been attained. This affectsthe health facilities, especially where there ishigh staff turnover with staff transfers andreplacements without CMAM knowledgetransfer. The quality of service delivery is alsoaffected by the high burden of work, especiallyafter the introduction of the FHCI as morepeople seek care. It is important therefore thatpre-service CMAM training is included in insti-tutions including those of universities, toensure health staff are graduating with knowl-edge and skills for CMAM to ensuresustainability of quality services.

Inadequate community mobilisation and referralsystem:As reflected upon earlier, most caregivers arenot aware of the programme, thus malnour-ished children are not recognised or identifiedwhich in turn leads to low coverage.

Inadequate management of logisticsand supplies:The stock out experienced is likelyto have a major negative effect onprogrammatic results, especiallydefaulter rates. A major cause ofthis pipeline breakdown was theprivatisation of the port, whichresulted in delays due to new clear-ance procedures and hencedisruption of the whole supplychain in the country. Leakage ofRUTF to non-target populations isalso a major concern. Some moth-

Cured Deaths Defaulters Non RecoveredIndicators

ers sell rations and even use it to prepare familyfood. Mass sensitisation is ongoing in alldistricts to inform communities that RUTF isspecially designed for the treatment ofmalnourished children and that it containsmedicine. An information sheet has beenproduced for community members on thecorrect utilisation of RUTF.

Inadequate service delivery and access:Malnourished children are not receivingadequate attention due to the distance of someOTP facilities (as identified in the SQUEAC5

2011) and lack of comprehensive care in somecentres. This is due to the following:• SFP services are not provided at all OTPs.• The CMAM programme is not understood

as a comprehensive protocol to treat acute malnutrition. SC/OTP and SFP are still considered as two different programmes. For many community members, as well as some health workers, UNICEF-MOHS is understood as having the RUTF programme and WFP the SFP programme.

• Under and over rationing of food. For example, children may be enrolled longer ina programme than is necessary, i.e. more than 12 weeks in an OTP and more than 2 months in SFP after the child is cured. Somechildren are given smaller rations than indi-cated due to stockout.

• Anthropometric equipment is unavailable in some facilities.

• The updated National Protocol for CMAM has not yet been disseminated widely.

Monitoring and evaluation (M&E)At the national level, the MOHS has developedtools, guidelines, checklist for field visits, proto-cols and reporting formats for use by districtimplementers. Monthly reports are submittedto the national or central level by the districtnutritionists. Quarterly reports are written byNGO CMAM partners (where they are active)and shared during the MOHS coordinationmeetings. Joint monitoring visits are alsoconducted with the MOHS, UNICEF and WFPevery quarter. The MOHS also conducts spotvisits. At the community level, the NGOs (intheir working areas) monitor the work of theCHVs.

Currently, data from CMAM sites on thenumber of children who receive therapeuticfood has been integrated into the HMIS, in theDirectorate of Planning and Information withinthe MOHS. However, the system sometimesdouble counts children undergoing treatment,so there is a need to review and train DHMT,nutritionists and health staff to monitor betterthe number of children with SAM and MAM,rather than placing too much reliance onnational surveys. UNICEF has also created adatabase to track CMAM supplies.

At the district level, the nutritionists conductjoint supportive supervision with stakeholdersto PHUs and receive reports on a monthlybasis. During the district coordination meet-ings, the district nutritionist also receivesupdates regarding planned activities fromNGO partners. Staff from the CommunityHealth Centre (CHC) supervises the Maternaland Child Health Post (MCHP), who in turnsupervise the government CHVs.

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Freetown for larger consignments. Stock alloca-tions aim to ensure that there is a minimum oftwo months stock at the PHU level, a fourmonth stock at the DHMT level, a three monthnational buffer stock in Freetown and a onemonth emergency stock at all times, sharedbetween Freetown, Makeni and Kenema stores.

UNICEF hires transporters to move suppliesfrom the Freetown warehouse to the districts.The districts are then responsible for taking thesupplies to the PHUs. UNICEF quite often facesa shortage of supplies, for example from April -June 2008, March – June 2009, Dec 2010 andfrom January – June 2011 due to the long proce-dures involved when clearing goods from theport of entry to the central warehouse. In addi-tion, incidents such as no road-worthy vehiclesor fuel shortages for the DHMT to transporttherapeutic foods from the district headquarterto the PHU or poor road networks (especiallyduring the rainy season) have contributed topipeline breakdown.

UNICEF initially used the PUSH systemwhere food was sent equally to all PHUs.However, to increase the efficiency of foodsupply and minimise stock-outs, UNICEFadopted the PULL system in 2011 whereby foodis issued to a PHU based on the caseload ofmalnourished children. This system is still newand only instituted in August 2011 but will bereviewed.

To further increase the efficiency of thesupply chain, district nutritionists togetherwith other DHMT members have been trainedin storekeeping and monitoring of supplies. Atpresent there is a great deal of work in progress,aiming to integrate the supply chain manage-ment for all medical supplies of the MOHS,including nutrition supplies. Encouragingly,therapeutic foods have very recently beenincluded in the essential drugs list of MOHS.

Supplementary food supplies from WFPinclude CSB, oil and sugar, which are premixedprior to distribution to beneficiaries. The food isall purchased abroad and received at theFreetown port. Some food supplies are stored intwo warehouses in Freetown, with the balanceof food commodities then forwarded to theWFP sub-offices in Tonkolili and Kenemadistricts by commercial transporters and WFPtrucks. WFP trucks, light vehicles and NGOtrucks sometimes assist in getting the food to its

Year Commodity

F-75 F-100 RUTF

2007 1000 kg 6000kg 2,670 cartons (36.8 MT)

2011 8960 kg 8658 kg 35,312 cartons (487.3 MT)

5 Semi Quantitative Evaluation of Access and Coverage

80,000

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60,000

50,000

40,000

30,000

20,000

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98.7%

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ber of children

SAM MAM

Figure 3: Discharge profile for children with MAM and SAM, 2010

Table 5: UNICEF Nutrition Food supplies in 2007 and2011

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The following assessment/evaluations havebeen conducted so far:

a) National CMAM coverage survey using SQUEAC

A survey using the SLEAC6 and SQUEACmethodologies was conducted in 20117. Thissurvey was a major undertaking that took threemonths to complete. According to the report,the point coverage of the programme was clas-sified at 12.0%, with period coverage reportedat 19.7%. While the results of this survey doappear low, it must be remembered thatSQUEAC methodology purposively selectsareas where coverage is expected to be lowest,in order to help identify barriers to access anduptake.

It should also be noted that CMAM at-scaleis a major and relatively new undertaking.Whilst higher coverage results are desirable(and must be aimed for), it might take sometime to achieve them. For EPI programmes, it iswell accepted that coverage of the programmemight be lower in early years, with gradualincreases expected as it matures. It is thereforereasonable to expect that CMAM coveragemight follow similar trajectories to other majornational initiatives.

b) Evaluation of CMAM Programme The evaluation was conducted in 2008.It had the following recommendations: • Removal of zinc tablets, metronida-

zole, paracetamol, aminophylline, vogalène, anti-vomiting drugs, andantacid drugs from the pharmacy (box) used for the treatment of chil-dren with SAM. This is because use of these medicines can measur-ably increase the risk of mortality in children with SAM.

• Use mid upper arm circumference (MUAC) for children 6 months andolder only and longer than 65 cm,to ensure correct measures of age and length before taking the MUACmeasurement. All treatment sites should have as a minimum a woodendowel (stick) of 65cm to assess children’s length. Due to challenges in estimating a child’s age, children older than 6 months are measured using MUAC in the commu-nity and are reassessed in the facility using weight and height.

• Ensure correct implementation of the appetite test using the table provided in the CMAM protocol (according to the weight of the child). The appetite test is a crucial part of assessing whether the child can be treated at home or whether he/she requires in-patient care.

c) Nutrition SMART survey Conducted in 2010, it provided very usefulbaseline data for nutritional indicators in SierraLeone.

Overall, the challenges to effective M&Einclude:• Inadequate capacity of health staff to take

accurate height measurements • Poor quality of supply and distribution plans• Improper recording of caseloads • Unreliability of HMIS data due to overesti-

mation of data in some centres and double counting of some cases

• Late submission of monthly reports and poor quality data

checking for quick referral. MUAC is used for screening at community level and SAM children are referred for further assessment.

• SAM children are admitted using both MUAC and WHZ depending on what condition prevails. All children with MUACless than 11.5 cm without medical complica-tions are admitted into the OTP. All those with medical complications are referred to SCs. Where children have a normal WHZ but MUAC less than 11.5, such children are also admitted into the OTP. For the SFP, it isstrictly based on WHZ less than -2.

• Free Health Care Initiative – all children under five years receive free health care treatment, including treatment of acute malnutrition.

• IMNCI strategy. This also caters for malnour-ished children, through conducting anthropo-metric assessment of all sick under-fives, using MUAC, WFH and checking for bilateralpitting oedema. Identified malnourished children are then referred by staff to SFP, OTP or SC, according to their classification.

Effective linkages will require a number ofstrategies including: • Mobilisation and training of mother-to-

mother support groups in screening and referral procedures.

• Enhancing food demonstrations in the IYCFprogramme and further development of backyard gardens for the community, to improve complementary feeding practices.

• Use of simple-to-understand tools such as graphs/pictorials, which better explain figures/topics such as detection of malnu-trition and growth monitoring.

• Developing user friendly CMAM guide lines as an easy reference for overloaded health workers.

Linkages should also be developed betweennutrition and other related sectors that supportthe prevention of malnutrition, including:

Food Security: Advocating to the Ministry ofAgriculture, Forestry and Food Security, smallholder commercialisation programmes toenhance the production and consumption ofnutritious foods such as beans and sesameseeds, increase the involvement of women infarming and increase the provision of farminputs to enhance the production of a diversityof complementary foods.

Education: Promotion of the education of girlsand their retention in schools and prevention ofteenage marriage that can lead to high rates oflow birth weight (LBW) infants. LBW infantsare, by definition, already malnourished atbirth. As the Lancet series (2008) explains,undernourished children are more likely togrow into shorter adults, to have lower educa-tional achievements and, for women, morelikely to subsequently give birth to smallerinfants themselves, thus perpetuating an inter-generational cycle of undernutrition8.

Water, hygiene and sanitation: Promotion ofaccess to clean potable water to promotehygiene and food safety at the household level

44

• Inability to accurately complete many different monitoring forms at PHUs due to multiple tasks and general work overload

• Limited logistics available for monitoring atall levels, e.g. transport constraints

Risks of scale-upIf not well managed, the scaling up of CMAMcan result in a number of risks, leading to areduction in quality and threatening thesustainability of the programme. Some of theserisks include:• Overstretching of health personnel leading

to poor management and insufficient super-vision of the programme.

• Large-scale loss of confidence in the programme during pipeline breakdowns,which later necessitates intensification of community mobilisation.

• Overload of the primary healthcare system, especially during the introduction of the Free Health Care Initiative in Sierra Leone, which has seen increasing numbers of people seeking health services.

• Financial sustainability can be threatened when the majority of resources are providedby donors.

Linkages with other sectorsIntegration of CMAM into IYCF and otherprogrammesThe need to link IYCF to CMAM programmeshas been clearly identified. This can be effec-tively managed at the community level,through involving the CHVs, mother-to-mothergroups and all families with children under fiveyears of age. In some districts, the IYCF motherto mother support groups play a dual role ofpromoting IYCF, while also following up chil-dren identified as SAM and MAM, to ensurethat screened children attend the relevantprogramme for treatment.

Linkages have been created between CMAMand other health sector programmes, such as:• Basic emergency obstetric care (BeMOC).

Every BeMOC centre is now an OTP site. These facilities were included in the last round of OTP expansion, so that composite care for both obstetrics and treatment of malnutrition without complications could be offered from these service delivery points.

• EPI/Child Health (EPI/CH) has been estab-lished and indicators integrated into the Child Health card. Growth monitoring is conducted at these points, weight and heightmeasurements and age are collected for weight for height and weight for age deter-mination. In addition there is oedema

6 Simplified LQAS Evaluation of Access and Coverage. LQAS:Lot Quality Assurance Sampling.

7 Using SLEAC as a wide-area survey method. Field Exchange 42. January 2012. p39.

8 Victoria, C. G et al. For the Maternal and Child Undernutrition Study Group. Maternal and child undernu-trition: consequences for adult health and human capital. Lancet 2008. Published online. Jan 17

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in order to prevent diarrhoeal diseases that are strongly linked tounder-nutrition.

Social sector: Addressing the social-cultural issues at communitylevel that can have an impact on some of the underlying causes ofmalnutrition e.g. early marriage and lack of exclusive breastfeeding.

Ways forwardThe future for CMAM requires some key actions to move forward:

Advocacy to the government for higher allocation of governmentfunding through the annual budget allocated to the health sector,in order to ensure the effectiveness and sustainability of CMAM.Advocacy is needed also for the inclusion of CMAM training in theundergraduate curriculum of universities.

In terms of planning and coordination, development of a mecha-nism for coordination and communication between health andother sectors, in order to strengthen programming that can preventundernutrition in a more ‘holistic’ manner than is currently beingachieved.

Community mobilisation is critical and requires:• Boost community mobilisation practices by training the imple-

menting NGOs on methods of effective community mobilisationand through the promotion of better IYCF linkages. In areas where there are no NGOs, staff from health facilities in those areas will conduct such mobilisation in their catchment commu-nities.

• Identify additional strategies to mobilise the community • Training and sensitisation of TBA’s on IYCF• Involvement of community and traditional leaders in IYCF

In terms of support of the nutrition programme at district level, toenhance nutrition surveillance and monitoring in particular, thereis an identified need to support transport (vehicles), communica-tion (information, education and communication (IEC) tools) andinformation (documentation).

Lessons learnedStrengthening the capacity of health staff through regular monitor-ing and supportive supervision is crucial to maintain qualitytreatment and care of malnourished children.

Medical doctors need to be trained in CMAM for effectivemanagement of complications in SAM in-patients. A medicaldoctor needs to be attached to the nutrition programme in order toconduct countrywide on-the–job training of staff at the CMAMtreatment site, especially in the stabilisation centres.

Supplies for the programme should be integrated into the exist-ing health system delivery channel of medical products, togetherwith training of health staff on stock management of supplies at theinitial stage of the programme for effective management ofcommodities.

CMAM is a comprehensive programme and its componentsmust be accessible to communities. In particular, it is important toensure that every OTP site has an SFP component attached to it sothat there is an effective continuum of care for patients. There isalso a need to increase the number of stabilisation centres in thedistricts.

Community mobilisation is critical for improving coverage andaccess to services. A strategy must be in place to meet the commu-nity, together with the establishment of the treatment service in thecommunity

For more information, contact: Aminata Shamit Koroma, email: shamitamin@gmail.com, tel: +232 33705866

By Edna Germack Possolo, Yara Lívia Novele Ngoveneand Maaike Arts

Edna Germack Possolo is Chief of the NutritionDepartment of the Ministry of Health, Republic ofMozambique since 2009, where she has worked since2007 as a public health nutritionist. Her responsibilitiesinclude government policy and strategy development,and coordination and management of public health

programmes within the MOH. She is also involved in curriculum devel-opment and training of health workers, nutrition technicians,undergraduate and postgraduate health professionals.

Yara Lívia Novele Ngovene is a Mozambican Nutritionistwho studied in Porto Alegre, Brazil. She has been work-ing in the Mozambican Ministry of Health since 2011and is responsible for the management of the NutritionDepartment’s Nutrition Rehabilitation Programme.

Maaike Arts has a M.Sc in Nutrition from WageningenUniversity and works with UNICEF. Since 2009 she hasbeen working as Nutrition Specialist with UNICEFMozambique, coordinating UNICEF’s support to thecountry’s Nutrition Programme.

This document was drafted with support from FANTA-2/FHI360 (AlisonTumilowicz, Melanie Remane, Dulce Nhassico, Arlindo Machava), Savethe Children (Tina Lloren, Vasconcelos Muatecalene, Isaltina Roque),UNICEF (Sónia Khan, Manuela Cau) and WFP (Nádia Osman, GilbertoMuai).

ACS Agente Comunitário de Saúde (type of Community Health Worker)

APE Agente Polivalente Elementar (type of Community Health Worker)

CCR Consulta de Criança de Risco (‘at-risk child’ consultation)

CHAI Clinton Health Access Initiative

CHW Community Health Worker

CMAM Community Management of Acute Malnutrition

CSB Corn Soy Blend

FANTA Food and Nutrition Technical Assistance

JAM Joint Aid Management

MAM Moderate Acute Malnutrition

MoH Ministry of Health

MUAC Mid Upper Arm Circumference

PEPFAR President’s Emergency Plan for AIDS Relief

PRN Programa de Reabilitação Nutricional (Nutrition Rehabilitation Programme)

RUTF Ready-to-Use Therapeutic Food

SAM Severe Acute Malnutrition

SUN Scaling Up Nutrition

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WFP World Food Programme

WHO World Health Organisation

Acronyms:

Community managementof acute malnutrition inMozambique

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Brief history and backgroundNational nutrition and health situationMozambique has just over 20 million inhabi-tants, of whom approximately 17% are less thanfive years of age. More than half of the popula-tion (55%) lives in poverty1. In 2003, under-fivemortality was 153 per 100,000 live births2. By2008, this had reduced to 1413. During the sameperiod, infant mortality also slightly reducedfrom 101 to 95 per 100,000. The main causes ofchild deaths are malaria (33%), lower respira-tory tract infections and HIV/AIDS (10% each),followed by prematurity (8%) and gastrointesti-nal infections (7%). Acute undernutritionaccounts for 4% of deaths in under-fives4. It hasbeen estimated that undernutrition is acontributing factor to 36% of child deaths5.

In 2008, 16% of newborns had a low birthweight (less than 2.5 kg). The prevalence ofchronic undernutrition has remained stub-bornly high for many years: 48% in 20036 and44% in 2008. However, the prevalence of acuteundernutrition is relatively low: 5% in 2003 and4% in 2008 (2.9% in urban areas and 4.7% inrural areas), with a 1.3% prevalence of severeacute malnutrition (SAM). There has been moreimprovement in child health and nutrition indi-cators in rural than in urban areas. There arealso marked differences between provinces,with the prevalence of chronic undernutrition(height for age < -2 z scores) ranging from 56%in the northern province Cabo Delgado to 25%in the capital city Maputo. Key indicators aresummarised in Table 1. A map of Mozambiquewith the acute malnutrition regional data fromthe Multi Indicator Cluster Survey (MICS) 2008is shown in

The first ever population-based HIV preva-lence survey conducted in 2009 found aprevalence of 11.5% in people between 15 and49 years of age, 13.1% for women and 9.2% formen. In children up to 11 years, the prevalencewas 1.4%, and in children under 12 months itwas 2.3%. The northern region showed a muchlower prevalence (5.6%) than the central andsouthern regions (12.5 and 17.8%, respectively).Prevalence in urban areas was significantlyhigher (15.7%) than in rural areas (9.2%) acrossall regions7.

Vulnerability to emergenciesMozambique is prone to emergencies, includ-ing floods, cyclones and droughts. There arefrequent floods in the Zambezi river basinaffecting the provinces of Tete, Sofala andZambézia. Other rivers in the centre and southof the country, such as the Limpopo and Buzirivers, are also prone to flooding. The highestchance of flooding is from October to March,the southern Africa rainy season, and thecyclone season is usually aroundFebruary/March. In addition, large parts of the

Table 1: Key indicators for Mozambique

Indicator 2003 (DHS) 2008 (MICS)

Poverty 55% (2008– 2009)*

HIV prevalence 11.5% (2009)**

Under five mortality 153 per 100,000 141 per 100,000

Infant mortality 101 per 100,000 95 per 100,000

Chronic undernutrition(stunting, height for age)

48% 44%

Acute undernutrition(weight for height z score)

5% 4%

Underweight (weight for age) 22% 18%

1 Ministry of Planning and Development, 2010.Third National Poverty Assessment, 2008-2009.

2 All 2003 data (unless stated otherwise) are from the Demographic and Health Survey (DHS) 2003 (Ministry of Health/National Statistics Institute, 2004).

3 All 2008 data (unless stated otherwise) are from the Multiple Indicator Cluster Survey(MICS) 2008 (National Statistics Institute, 2009).

4 Ministry of Health, 2009. Mozambique National Child Mortality Study, 2009. The methodology used was verbal autopsies of family members, about child deaths reportedduring the 2007 General Census. A definitionof undernutrition in this report was not given.Source: *See footnote 1. ** See footnote 7.

5 USAID, 2006. Nutrition of young children and mothers in Mozambique.

6 The nutrition data from 2003 (originally based on the NCHS reference population) were re-calculated based on the 2006 WHO growth standards.

7 National Institute of Health, National Statistics Institute and ICF Macro 2010. Inquérito Nacional de Prevalência, Riscos Comportamentais e Informação sobre o HIV e SIDA em Moçambique, 2009 (INSIDA).

8 MoH 2006. Proposta para o programa de reabilitação nutricional (CMAM).

9 UNICEF, 2006 .Draft terms of reference for technical support to introducing community treatment of severe malnutrition in Mozambique.

country, particularly in the south, are prone toperiods of drought, the impact of which ismostly felt between November and January.

The number of people affected by emergen-cies varies considerably. The 2007 floodsaffected about 300,000 people, cyclone Flávioaffected approximately 135,000 people in 2007and a drought in the south in 2009 affected justover 250,000 people. Future climate scenariossuggest that Mozambique’s exposure to naturalhazards will increase as extreme weatherpatterns become more prevalent as a result ofclimate change.

Where nutrition sits in government systemsand structuresThe Ministry of Health (MoH) has a NutritionDepartment under the National Directorate ofPublic Health, which is responsible for policyand protocol development, as well as the plan-ning and oversight of nutrition activities at alllevels. The treatment of acute malnutrition ismainstreamed into regular health services (bothduring and outside of emergency situations).

The responsibilities of the NutritionDepartment are divided into five main areas:1) Nutritional Surveillance, 2) Nutrition Education, 3) Prevention and Control of Undernutrition

and Micronutrient Deficiencies, 4) Nutrition and HIV and Tuberculosis and 5) Nutrition and Non-Communicable Diseases.

At present, the following programmes arebeing managed by the Nutrition Department: 1. Nutrition Rehabilitation Programme

(Programa de Reabilitação Nutricional (PRN))2. Micronutrient Supplementation Programmes,

including de-worming in preschool children3. Nutrition and HIV and Tuberculosis4. Infant and Young Child Feeding (IYCF)5. Food Fortification 6. Health and Nutrition Promotion and School

Nutrition

The government has markedly strengthened itsemergency preparedness and response sincethe beginning of 2000. Multi-sectoral coordina-tion at the national level is the responsibility ofthe National Institute for Disaster Management(INGC), and each community has focal personsassigned to emergency preparedness andresponse.

The Technical Secretariat for Food andNutrition Security (SETSAN) is mandated withthe multi-sectoral coordination of food andnutrition security. Originally, the main focuswas on food security. Since 2011, coordinationof the implementation of the Multi-sectoralAction Plan for the Reduction of chronic under-nutrition (see below) has been added to itsmandate. SETSAN carries out vulnerability

assessments three time per year (aroundFebruary, May and October) to document theextent of acute and chronic food insecurity.

Linkages with the Scaling Up Nutrition (SUN)Global InitiativeThe Council of Ministers approved the Multi-sectoral Action Plan for the Reduction ofChronic Undernutrition in September 2010. TheTechnical Secretariat for Food and NutritionSecurity (SETSAN) coordinates the implemen-tation. The plan includes all components of thepackage of interventions included in theScaling Up Nutrition (SUN) roadmap.However, it does not include the componentsrelated to the treatment of acute malnutrition(the PRN programme is not included) in orderto avoid overloading the plan. The governmentparticipates in inter-governmental meetingsrelating to SUN and Mozambique receivedearly riser status in September 2011.

CMAM/PRN scale-upThe introduction of CMAM in MozambiqueUntil 2004, the standard treatment for SAMamong children in Mozambique was inpatientcare with specially formulated therapeuticmilks (F100 and F75), which were introducedinto the routine health system in 2002, follow-ing a flood emergency. However, coverage ofthe programme was low, children were oftendischarged early or their families took them outof hospital before treatment was complete, risksfor cross infections were high, and mortalityrates in most centres were above the thresh-old outlined in international standards8,9.Recognising these limitations, the MoH inMozambique revised the PRN and introducedthe Community-based Management of AcuteMalnutrition (CMAM) as a key component.Initially the programme focused on HIV posi-tive children, but it was soon broadened tocover all children less than 5 years of age withacute malnutrition, regardless of HIV status.

Figure 1: Map of Mozambique with acute malnutritionregional data (MICS, 2008)

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The term CMAM was not well accepted inMozambique because it suggested that themanagement of malnourished children is onlycarried out in communities. The term ‘outpa-tient treatment’ has therefore been used for thiselement of the PRN. The PRN contains fivecomponents:(1) inpatient treatment for cases of SAM with

poor appetite and/or medical complications(2) outpatient treatment for cases of SAM

without medical complications(3) outpatient treatment for cases of moderate

acute malnutrition (MAM)(4) active case finding and referral at the

community level, and (5) nutrition education at the community and

health centre levels.

The main aim of the PRN is to reduce thenumber of deaths due to SAM. In addition, itaims to reduce the incidence of SAM byimproving early detection, referral and treat-ment of children with MAM.

Linkages with other health and nutritioninterventionsThe MoH actively promotes the integration ofservices. In principle, nutrition is an integratedcomponent of reproductive and maternal andchild health, as well as HIV and AIDS andtuberculosis services. Nutrition is also a compo-nent of health promotion, communityinvolvement and school health activities. Theextent to which integration actually takes placedepends on the level of training and workloadof the staff involved. In 2010, the MoHapproved the broadening of the definition ofchild health services to include children up tothe age of 15 years. Prior to this, childrenbetween 5 and 15 years of age were treatedwithin adult health services (with the exceptionof those living with HIV). The Ministry iscurrently revising the protocols and guidelinesfor all related programmes (in addition toVolume 2 of the PRN), so that they are in linewith this new policy. This shift should helpstrengthen nutrition interventions for childrenin this age group.

Nationwide scale up of the PRNOutpatient treatment for SAM without compli-cations was introduced in Maputo City in 2004as part of treatment services for children withHIV. It was incorporated into general healthservices and expanded to other provinces in2007. The health directorate of one district inNampula Province (Ribaue) initiated a fullpackage of treatment for acute malnutrition as a

pilot in 2007, with support from Save theChildren, Valid International and UNICEF. Thispilot was very successful and was subsequentlyexpanded to other districts in Nampula. By2010, five districts in Nampula Province hadsuccessfully established a pilot learning centrewhere all five components of the PRN wereimplemented. The lessons learned from thepilot were incorporated into the revision of thePRN manual, the Manual de Tratamento eReabilitação Nutricional (Volume 1, coveringchildren aged 0 to 15 years of age). The devel-opment of the manual started in 2005 and wascompleted in August 2010 with the approval ofthe Minister of Health. The new WHO growthstandards (2006) have been incorporated in therevised manual.

Community-based screening, referral andfollow up of SAM cases were introduced in2006/2007 in the Nampula pilot. These havesince been gradually rolled out as part of thePRN. The speed of this roll-out is increasingsince the approval of the PRN manual inAugust 2010 and subsequent training in theimplementation of these components.

The treatment of MAM was included as anintegral part of the programme in the PRNmanual. MAM treatment programmes haveprimarily used Corn Soy Blend (CSB) providedby the World Food Programme (WFP). In 2011,CSB was replaced with ‘CSB Plus’ whichcontains additional micronutrients. Initially, theprotocol for treating MAM covered childrenless than 5 years of age only. This wasexpanded to children aged 0 to 15 years of agein Volume 1 of the revised PRN manual.Volume 2 addresses adults, including a specificfocus on pregnant and lactating women, andthis will be finalised in the near future.

Volume 1 of the PRN manual includes thefollowing procedures for community screeningand referral of malnourished individuals.Community-based Health Workers (CHWs),known as Agente Comunitário de Saúde (ACSs),Agentes Polivalentes Elementares (APEs) andactivists, screen children aged 0 to 15 years ofage for acute malnutrition. This screeninginvolves taking measurements of mid upperarm circumference (MUAC), checking foroedema, and looking for signs of wasting.Screening is also carried out annually duringthe National Health Weeks (NHWs). There aretwo rounds of NHWs, one ofwhich includes screening formalnutrition. The CHWs referthose who meet the criteria tothe nearest Health Centre (HC)where they are then assessedfor acute malnutrition andother health issues andprovided with the relevanttreatment according to theprotocols described below. Inaddition, children in the ‘wellchild check-ups’ who areunderweight or have growthfaltering are referred for screen-ing and can enter theprogramme through this route.

Patients with SAM who havegood appetite and no medicalcomplications are treated on anoutpatient basis with Ready toUse Therapeutic Food (RUTF).

Patients with SAM and additional complicatingfactors are treated with therapeutic milks andRUTF, before transitioning to outpatient treat-ment to complete their recovery. Patients withMAM are treated either with RUTF or CSB Plus,depending on what is available at the HC. Thefollow up is carried out during the ‘at-riskchild’ consultations (Consulta de Criança de Riscoor CCR).

Risks of scale upA number of possible risks are associated withscale-up, including:• The rapid roll-out of the new PRN protocols

might compromise the quality of training and subsequent implementation. Adequate supervision will therefore be crucial.

• Sufficient funding for the training of staff inall health facilities and related reproduction of materials could also become a constraint. The scale up of community screening, both as a routine service and during NHWs, will most likely lead to increased demands for RUTF, CSB Plus and therapeutic milks. However, the funding for these products is not yet fully secured for the coming years. Many of the donors have a limited mandatein terms of target group, age group, geographical coverage or type of interven-tion (procurement, technical support, etc.), which can complicate fundraising.

• The MoH’s recommendation to use RUTF for MAM in places where no CSB Plus is available could lead to shortages, since the number of MAM cases is considerably higher than the number of SAM cases. Furthermore, the introduction of Volume 2 of the PRN Manual includes protocols for the use of therapeutic milks and RUTF for the treatment of SAM in older age groups. These new protocols could also lead to shortages of therapeutic products because at present, the national supply only covers children less than five years of age. The vision is that rollout of Volume 2 will only start after the availability of supplies is ensured.

Nutritional products and local productionof RUTF and CSBWhen outpatient treatment was introduced,UNICEF imported RUTF from Europe. Toensure in-country availability and to increasenational ownership of the product, Nutriset in

MUAC measurement in a child in Gazaprovince during the Child Health Week

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France and UNICEF supported the establish-ment of a RUTF factory as part of the Nutriset‘plumpyfield’ network. The factory was set upin Beira City in the centre of the country,managed by the non-governmental organisa-tion (NGO) Joint Aid Management (JAM).Planning and construction of the factory startedin 2006, with equipment arriving in mid-2008.The factory was certified for local procurementby UNICEF at the end of 2009 and officiallyinaugurated in February 2010.

Sugar and oil are procured locally, as areincreasing amounts of the peanuts. The remain-ing ingredients are imported. The factoryproduced small quantities of RUTF packaged injars until it obtained a sachet line in mid-2011.Sachets are preferred over jars because of theirlonger shelf life, they are easier to prescribe (thecontent of the jars is 220g) and easier to handleby the patients (no spoon is needed).

The Clinton Health Access Initiative (CHAI)procured a proportion of the country’s RUTFneeds for 2011 from the local JAM factory viathe UNITAID Programme. It is expected thatthe sales of locally procured RUTF will increasein the future.

CSB has mostly been imported, with theexception of small quantities procured fromJAM in 2010. In 2011, WFP expanded its workwith JAM to increase the volume of locallyproduced CSB.

Partnerships and fundingThe Ministry of Health and its partnersThe MoH is responsible for the management ofhealth facilities in the country. Non-govern-ment actors are not leading any health facility.The drafting and revision of protocols andguidelines is the responsibility of the MoH.

Clinical and technical partners provide tech-nical support to health services. At present,these include various PEPFAR10 supported part-ners such as CARE, the Elizabeth GlaserPaediatric AIDS Foundation (EGPAF),Vanderbilt University’s Friends for GlobalHealth (FGH), Family Health International(FHI), and the International Centre for AIDSCare and Treatment Programmes of theColumbia University (ICAP), as well as theCHAI, Médecins Sans Frontières (MSF) andSave the Children. Several of these organisa-tions also cover the costs of in-service trainingand supervision for staff of selected districts orprovinces.

Several organisations, including EGPAF,FANTA-2/FHI360, Save the Children, UNICEF,USAID, WFP and WHO, provide technicalsupport at central level. The cost of training andreproduction of training materials and job aidshas been shared by several of the PEPFAR clin-ical partners, FANTA-2/FHI360, UNICEF,USAID and WFP.

FundingIn 2011, the MoH’s annual budget was USD 360million, of which approximately half wasprovided through external funding sources.There is a Common Fund for the Health Sector,to which 16 donors contribute. The NutritionDepartment’s budget for 2011 was approxi-mately USD 260,000, although this amount doesnot include the vertical funds provided byUNICEF, WHO, USAID, WFP and other part-ners who support the implementation ofspecific activities. Funds for the Provincial 10 U.S. President's Emergency Plan for AIDS Relief

Health Directorates come from both centrallevel and donors.

Since 2008, CHAI has procured the vastmajority of RUTF for the country, with UNICEFfilling gaps where needed. Therapeutic milksand other products for the treatment of SAMare in principle procured by MoH, withUNICEF filling gaps where necessary (whichincluded large amounts of therapeutic milks in2009, 2010 and 2011).WFP provides CSB Plusbut the coverage is not nationwide (in 2010, theprogramme covered selected districts in fiveprovinces). The contribution to training andreproduction of materials is described above.

ImplementationGeographical coverageIn principle, the coverage of the PRN isnational, although it will take some time toachieve full roll out across the country. As ofmid-2011, 191 out of about 1,280 health facilitiesin the country (from primary to the fourth levelof health care), provide inpatient treatment forSAM and 229 provide outpatient treatment.However, as yet, not all facilities or districtshave been trained in the updated 2010protocols.

TrainingIn the time between the introduction of outpa-tient treatment for SAM using RUTF and theofficial approval of the new PRN protocols,numerous health workers were trained in draftversions of the protocol that were under devel-opment. Outpatient treatment was initiated forthe rehabilitation phase of SAM treatment andfor the relatively small number of SAM casesthat presented without complications.

Since the end of 2010, three regional (north,central and south) Training-of-Trainer (ToT)workshops for the new protocols have beenconducted, reaching a total of 112 people. Thetraining was rolled-out in a cascade mannerstarting with the three regions, followed byreplication trainings at provincial level andfinally, at facility and community levels. Todate, each province has undertaken at least onetraining session for district staff (reaching 376people). Attempts are always made to includeeither a trained MoH staff member or a memberof a clinical partner organisation to facilitateand/or supervise some of the sessions. Trainingmaterials for Mozambique were developed byadapting WHO-recognised scientific guidelinesand practices to the national context. The mate-rials were updated and improved usingpost-training feedback.

The complete PRN training library includesthree ‘packages’, each consisting of an orienta-tion training package, facilitators´ guides andhand-outs for participants. Complementarytraining materials on HIV and nutrition areprovided at community level.

A strong focus is placed on training of thefull PRN package. The number of days train-ing for each level of participants is as follows:• Facility-based health workers: 5 days. • CHWs: 2 days, plus an additional 2 days

for training on community-based nutrition and HIV for CHWs and home-based care volunteers.

• Community leaders and traditional healers: 1 day covering the basics of the programme.

• Provincial-level health staff: hands-on 3-daytraining covering monitoring, evaluation,

planning and logistics, orientation to tools and databases for the PRN programme.

There are plans to initiate supervision activitieswithin health facilities to observe the quality ofimplementation and to provide refreshersessions where needed. A supervision checklistis currently under development.

Recording and reportingSeveral tools were developed for programmemonitoring, including individual andprogramme level monitoring forms, a databaseto track admissions and outcomes and a data-base to manage the stocks of RUTF, CSB Plusand therapeutic milks. The PRN individual andprogramme level monitoring forms aresummarised in Table 2 with the flow of themonitoring system illustrated in Figure 2 andoutlined in Box 1.

Particular emphasis is being placed on thequality of data recording and reporting, as thishas been identified as a weak aspect of the PRNfor a number of years. A specific data-handlingtraining course was developed alongside thenew protocol training. To date, 34 staff haveparticipated in a dedicated five day monitoringand evaluation (M&E) training that focused onthe PRN database and the related reportingmechanisms. The general PRN training packagealso includes a section on M&E.

Once a person has been screened for acute malnutri-tion, community health workers (CHWs) refer them toa health centre using a standardised referral formthat includes MUAC measurements, presence/absence of oedema, and any other notable signs. Thehealth centre staff conduct further diagnostic tests toascertain if the person has acute malnutrition.

Cases of SAM with complications are referred tothe nearest inpatient facility, where treatment istracked using the ‘multicard’ (multicartão). At the endof each month, the health centre staff report theadmission and discharge statistics using the inpatientmonthly reporting form.

Cases of SAM without complications or MAM casesare admitted into the outpatient programme, andtheir information is recorded in the PRN register book.The beneficiary or the caregiver for the beneficiary isgiven a malnutrition treatment card that containsimportant information regarding the treatment,including a log of the medicine/products given andan indication of when they should return to thehealth centre. The name of the CHW is also includedon the card, and the beneficiary/caregiver is advisedto seek the CHW when they return home. At the endof each month, the health staff complete the outpa-tient monthly reporting form and send it to the districthealth office. These forms are then compiled and sentto the provincial health office.

At the provincial health office, the inpatient andoutpatient monthly reports provide the informationthat is entered into the PRN database (Figure 3). Thedatabases have been designed specifically for thePRN and are intended for use throughout the healthsystem from health facility to central level.

The database spreadsheets automatically link tocharts showing trends over time, supporting straight-forward interpretation and reporting of the results bythe provincial point person for nutrition to thecentral MoH in Maputo. Some of the results that canbe derived from the analysis of data generatedinclude the frequency of referral of new cases ofacute malnutrition according to food availability,season, disease epidemics and various other factors.

Box 1: Flow of data in the programme and fromhealth facility to provincial level

49

Field article

Table 2: Individual and programme level monitoring forms

Monitoring forms Level used

1 Referral form (MUAC, oedema, other signs) usedby CHWs to refer cases to the health centres

Community

2 Inpatient individual health card, called the‘Multicard’ or Multicartão

Inpatient

3 Monthly reporting form (admissions,discharges, mortality rates performance) forinpatient care; from facility to district andprovincial health offices

Inpatient

4 PRN register book for outpatient care; SAMand MAM

Outpatient

5 Malnutrition treatment card (Cartão do DoenteDesnutrido) given to the caretaker to keeptrack of treatment and informing nextappointment date

Outpatient

6 Monthly reporting form (admissions,discharges, performance) for outpatient care;from facility to district and provincial healthoffices

Outpatient

Community

Inpatient Outpatient

Referral completed by CHWs

Referral formcompleted by nurses

Register books for PRN in at-risk child consultationsand pediatric ART, completed by nurses

Multicard (Multicartão) completed bynurses and/or doctors

Monthly report for inpatient treatmentcompiled by nutrition technician and/or

MCH nurse responsible forPRN

Monthly report for outpatient treatmentcompiled by nutrition technician and/or MCH

nurse responsible for PRN

One inpatient report and one outpatient report,aggregating data for all health facilities in theirjurisdiction, completed by the district statistics

technicians

Database disaggregated by district, completedby the provincial nutrition technicians

Database disaggregated by province, completed bythe staff in the nutrition Department of the MOH

Figure 2: Flow of the monitoring system

Health Facility

District Health Office

Provincial Health Office

MOH

Figure 3: A snapshot of the PRN database to track admissions and outcomes

The implementation of the revised M&E system forthe PRN has been halted due to delays in the printingand distribution of instruments required to collecthealth centre-level data. It is expected that finalapproved versions of the instruments will be printedand distributed by the end of 2011, with collection ofdata starting in earnest from January 2012.

Supplies and supply chain managementThe primary supplies for the PRN are therapeuticmilks (F75 and F100), RUTF, CSB Plus, ReSoMal,routine drugs (e.g. antibiotics, vitamin A, dewormingdrugs, malaria prophylaxis, etc) and anthropometricequipment (including MUAC tapes, weighing scalesand height/ length boards).

The MoH receives support from several partners toprocure the products required to treat acute malnutri-tion, including F75, F100, RUTF and ReSoMal. Asmentioned, UNICEF and CHAI have been purchasingimported RUTF for the programme, although thissupport was phased out in 2010.

The WFP supplies CSB Plus to selected healthcentres in the southern and central parts of the coun-try. Initially, this was done via NGOs but it is nowsupplied directly to the provincial health directorates(with financial support from WFP).

Supply chain management capacity at differentlevels is limited. Stock-outs of RUTF, ReSoMal andtherapeutic milks are often reported. In most cases, itis due to inadequate forecasting and communicationbetween the different levels (health facility-district-province-central level). The weak and often latereporting of numbers of children treated is a majorcontributor to the forecasting challenges.

Community involvementThe community components of PRN in Mozambiquewere initiated as part of the pilot in Nampula Provincein 2008 (see earlier). The pilot showed that the strategyof encouraging active community involvement quicklyproduced results. Health centres in the districts wherecommunity activities were being implemented(Memba, Eráti and Ribáué districts) experienced anincrease in the number of referrals. However, require-ments for RUTF resulting from the subsequent increasein caseloads had not been properly forecasted. Whenscreening of acute malnutrition was integrated intoactivities of the monthly health day at provincial level,there were further increases in caseloads.

Following the success of the pilot, the programmewas expanded to other provinces including Sofala,Zambézia and Gaza. Save the Children (the mainprovider of technical assistance to MoH in this area)partnered with other community-based programmes tostrengthen staff capacity. These staff have, in turn,

supported the provincial and district healthservices in the implementation of thecommunity strategies included in PRN.Partner support has included training oftrainers on community mobilisation in thecontext of PRN and home-based nutritioncare for people living with HIV/AIDS inseveral provinces during 2011.

The experience of Nampula Provinceshowed that it is possible to develop a closelink between health professionals andcommunity groups. Monthly meetings wereconducted involving health professionalsand community groups, to discuss relevanthealth issues. Health professionals nowrecognise the importance of active commu-nity involvement for wide dissemination ofhealth messages and of community sensiti-sation to ensure early referrals, when thedisease process is at a less advanced stateand still relatively easy to treat. Many tradi-tional healers now also recognise that thetreatment of malnutrition is complex andrequires referral of the child to the healthcentre for appropriate rehabilitation.

However, it has still proven to be chal-lenging to roll-out the community activities,in part because the focus so far has been athealth facility level. There are a limitednumber of experienced staff who canprovide technical assistance to the MoH’sefforts at community level. This willcontinue to be a problem unless additionalefforts and funding are geared toward thisgap. The delay in printing and distribution

of materials used at the community level,including reference forms, job aids, andMUAC tapes, delayed implementation,even in areas where training and mobilisa-tion were underway.

The MoH recognises the need to priori-tise community components of CMAMwithin the PRN, and is committed to includ-ing community-related activities into plansof action. Support will be sought from vari-ous organisations and donors. Linkages willbe established with the new cadre of CHWs(APEs). In light of the current momentum toestablish large-scale nutrition programmesin Mozambique, it is expected that morecommunities will benefit from efforts toimprove community knowledge and skillsfor the diagnosis, referral and follow up ofcases of acute malnutrition.

CoordinationThe Nutrition Department of the MoH coor-dinates the group of partners supporting thePRN. This group meets weekly whenneeded and less frequently where possible.There is a division of labour between allparticipants, which can be flexible whenrequired, but is based on each organisation’smandate and comparative advantage. Aformal description of this coordinationmechanism is currently being developed.

Results: caseload and outcomesAccording to the data available to the MoH(for many provinces only partial data areavailable), by mid-2011 6,319 children

community level (malnutrition is not neces-sarily perceived as a medical or dietary problem, but rather as a spiritual problem), which prevents communities from seeking professional health care. This should also beaddressed through the strengthening of community mobilisation and involvement in the PRN activities.

The way forwardWhile the PRN can already claim success inexpanding the availability of CMAM, thefollowing steps are required to ensure a contin-ued and successful scale-up of theimplementation of the new protocol:1. Finalise Volume 2 of the manual for the

treatment of acute malnutrition for adults.2. Strengthen the quality of training, includ-

ing the development of additional training tools and video-based training modules.

3. Produce and distribute job aids and materi-als at all levels.

4. Develop a plan to support the implementa-tion of the protocols, once training ofhealth workers is finalised.

5. Establish supportive supervision systems and ensure that they are routinely applied (finalise the tools, implement the supervi-sion).

6. Prioritise community involvement and initiate this in places where it does not exist. This should include building a cadre of specialists who can provide technical assistance on the community components.

7. Strengthen recording, reporting and analysisof the data (promoting the triple A cycle of assessment, analysis and action).

8. Strengthen supply management and logisticsystems.

9. Secure adequate and on-going funds for supplies.

10. Consider the establishment of a technical group focusing on community based work.

11. Investigate the causes of mortality in children with SAM.

12. Design a plan for the introduction of the new protocols in pre-service training of health and nutrition workers of all levels.

For more information, contact: Edna Possolo,Head of the Nutrition Department, Ministry ofHealth. Email: epossolo@misau.gov.mz orednapossolo@gmail.com, Yara Lívia Ngovene,email: yngovene@misau.gov.mz, Maaike Arts,email: marts@unicef.org

are very active in supporting thePRN programme.

Finally, there has been animprovement of awareness on nutri-tional support by many health staffand those in district and provincialhealth offices. This has led to increas-ing numbers of patients receivingnutritional assessments, counsellingand rehabilitation.

ChallengesA number of challenges remain inthe case of Mozambique that willaffect national scale-up:

TrainingQuestions remain as to how to main-tain the quality of training at alllevels using the ToT cascade model. Potentialsolutions put forward include the developmentof a training video, increasing the number ofother training tools and ensuring adequatesupervision where possible.

Implementation/service deliveryClose follow up is also required for effectiveservice delivery. This has not always beenpossible due to capacity constraints. It isexpected that (where active), NGO clinical part-ners can assist the government to follow theprogramme closely, including via clinicalmentoring.

Recording and reportingInsufficient capacity (including knowledge ofsoftware such as Microsoft Excel), commitment,and understanding of the importance of report-ing at all levels create challenges for achieving atimely and accurate reporting system. The dataare rarely analysed or further scrutinised (forexample, for possible causes of high mortalityrates or increasing or decreasing caseloads).This could be due to heavy work-loads of MoHstaff, but the barriers need to be identified inorder to improve the system.

Supply chain managementLack of effective supply chain management,forecasting and procurement create majorchallen- ges to ensuring uninterrupted supplychains. Capacity in this area is weak at alllevels, not only for nutrition supplies but for allsupplies managed by the MoH.

Therapeutic foods are difficult to transportand store because they are heavy and bulky.Weak logistic skills of health staff have led topoor forecasting of the quantity of productsneeded, resulting in frequent stock-outs.

Funding issuesThe short funding cycles of donors and a lack offinancial resource commitment to support thePRN at all levels hinders strategic long-termplanning. RUTF supplies are not yet securedafter mid-2013.

Other challenges include:• The health infrastructure is undermined by

a lack of qualified staff and high turnover ofmedical staff and managers. One approach to address this problem would be to train all health facility and hospital staff in districts where PRN/CMAM operates.

• Issues of community access, e.g. distance from health facilities, preference of the tradi-tional care system and shortage of commu-nity mobilisation efforts.

• Poor understanding of malnutrition at the

50

Field article

under-five were admitted for inpatient treat-ment for SAM, of which 701 (11%) died. Justover 900 children were referred to outpatientcare to continue their treatment and 5,854received only outpatient treatment for SAM.The low percentage of children going directly tooutpatient treatment is probably related to thefact that training in the new treatment protocolswas only scaled up recently.

As reported by the Health InformationSystem, the percentage of facility-based deathsdue to SAM has been slowly reducing.However, in 2010 percentage mortality was stilljust under 10%, with wide regional differences(ranging from 5 to 20%). This could be due tohigh levels of complications and/or inaccurateapplication of the protocols and/or inaccuratereporting. This issue has yet to be studied indetail. Mortality for the past years is shown inTable 3.

In 2010, 31,503 children received a supple-ment for MAM (of which 27,620 received CSBPlus and 3,883 received RUTF).

SuccessesThe introduction and approval of outpatienttreatment of SAM with community involve-ment has been a success in itself. In thebeginning, many paediatricians and othermedical practitioners were sceptical about thepossibility of treating children with SAM asoutpatients, particularly children with oedema.The key decision makers have now beenconvinced by the evidence from the pilotprogrammes and are endorsing the new proto-cols. However it has been stated that all cases ofoedema should still to be treated as inpatients.

The PRN is owned by the MoH and all part-ners have aligned with its protocols andimplementation mechanisms, actively takingpart in the working group meetings.

Other successes include the development ofa set of PRN training and implementation tools(job aids and registration forms and books),theimplementation of a pilot learning centre in fivedistricts in Nampula Province, continuation oftraining and integration in the ‘at-risk child’consultations (CCR), prevention of mother tochild transmission of HIV (PMTCT) services,and triage in many health centres. Additionally,in places where community leaders, practition-ers of traditional medicine and APE/ACSs havebeen trained, there is increasing interest andsupport from the communities.

A further success of the Mozambique experi-ence is the integration of treatment ofmalnutrition for people with and without HIV.The existence of one protocol and one nationalprogramme aimed at treating malnutrition,regardless of HIV status, has resulted in cost-sharing and collaboration among partners anddonors who support the target group of chil-dren less than five years and people living withHIV. For example, PEPFAR-supported partners

Table 3: Facility-based mortality of children under 5due to SAM11

Year 2005 2006 2007 2008 2009 2010

Facilitybaseddeaths inchildrenunder fivedue toSAM

15.2% N/A 11.5% 10.5% 11.8% 9.3%

11 Ministry of Health/Health Partners Group Performance Assessment Framework, March 2011.

Sign for the RUTF factory in Beira City

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Dr Guero H Doudou Maimouna is a Paediatricianand holds a PhD in Public Health. She has over15 years experience in health and nutritionprogramme management in Niger. She currentlyholds the position of National Nutrition Directorof the Ministry of Health, Niger and is a Lecturer

in the Department of Public Health of the Faculty of Medicine ofUniversity Abdou Moumouni.

Dr Guero H Doudou Maïmouna est pédiatre et titulaire d’undoctorat en santé publique. Ayant à son actif plus de 15 ans d’ex-périence en matière de gestion de programmes de santé et denutrition au Niger, elle occupe actuellement le poste deDirectrice nationale de la nutrition au Ministère de la SantéPublique au Niger. En outre, elle est enseignant chercheurvacataire au Département de la Santé publique de la Faculté deMédecine de l’Université Abdou Moumouni.

51

By Dr Guero H Doudou Maimouna, Dr Yami Chegou andProf Ategbo Eric-AlainPar le Dr Guero H Doudou Maimouna, le Dr Yami Chegou etle Prof Ategbo Eric-Alain

CRENAM Rehabilitation Centres for Moderate malnutrition

CRENAS Outpatient Nutritional Rehabilitation Centres

CRENI Intensive Nutritional Rehabilitation Centre (inpatient care for medically complicated cases)

GAM global acute malnutrition

SAM severe acute malnutrition

IMCI Integrated Management of Childhood Illnesses

MAM Moderate acute malnutrition

MDG Millennium Development Goal

MOH Ministry of Health

MUAC Mid Upper Arm Circumference

NGO non-governmental organisations

REACH Ending Child Hunger and Undernutrition partnership

RUTF Ready to Use Therapeutic Food

SISAN International Symposium on Food and Nutrition Security

SUN Scaling Up Nutrition

UNDP United Nations Development Programme

UN United Nations

ATPE Aliments thérapeutiques prêts à l’emploi

CRENAM Centre de récupération nutritionnelle ambulatoire pour la malnutrition modérée

CRENAS Centre de récupération nutritionnelle ambulatoire pour la malnutrition sévère

CRENI Centre de récupération et d’éducation nutritionnelle intensif (soins prodiguésaux patients hospitalisés pour les cas compliqués)

MAG Malnutrition aiguë globale

MAM Malnutrition aiguë modérée

MAS Malnutrition aiguë sévère

MSP Ministère de la Santé Publique

OMD Objectif du millénaire pour le développement

ONG Organisation non-gouvernementale

ONU Organisation des Nations-Unies

PB Périmètre brachial

PCIME Prise en charge intégrée des maladies de l’enfance

PCMA Prise en charge communautaire de la malnutrition aigüe

PNUD Programme des Nations-Unies pour le développement

REACH Partenariat Éliminer la faim et la malnutrition parmi les enfants

SISAN Symposium international sur la sécurité alimentaire et nutritionnelle

SUN Renforcement de la nutrition (Scaling Up Nutrition)

Management of acute malnutrition in Niger:a countrywide programmePrise en charge de la malnutrition aiguë au Niger :Un programme national

Dr Yami Chegou is Director General of PublicHealth at the Ministry of Public Health, Niamey,Niger.

Le Dr Yami Chegou est le représentant dudirecteur général de la Santé Publique auMinistère de la Santé Publique, Niamey, Niger.

Professor Ategbo Eric-Alain is Nutrition Managerat UNICEF, Niamey, Niger.

Le professeur Ategbo Eric-Alain est l’administra-teur Nutrition à l’UNICEF, Niamey, Niger.

The authors acknowledge the contributions of the MOH staff, UNagencies and national and international NGO implementingpartners in Niger.

Les auteurs tiennent à remercier le personnel du Ministère de laSanté Publique, les agences de l’ONU et les partenaires opéra-tionnels non-gouvernementaux nationaux et internationaux auNiger pour leurs contributions.

A child enrolled inthe programmeeating RUTF

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52

BackgroundNational nutrition and health situationNiger is a land-locked Sahelian country with a population of over 15million people, of which approximately 50 per cent are children under 15years of age. Niger ranks 173rd out of 177 countries according to the 2010UNDP1 Human Development Index. Millenium Development Goal(MDG) indicators, such as child mortality and maternal mortality rate, areamong the worst in the world. The maternal mortality rate has stalledover the past ten years and in 2010, was still 554 per 100,000 live births.Moreover, one child out of five still dies before the age of five in Niger.2

Malaria, respiratory infections, and diarrhoea are the main direct causesof under-five mortality. Acute malnutrition is directly or indirectlyresponsible for 50 to 60 per cent of under-five deaths.

For years, Niger has been confronted with chronic food insecurity andhigh levels of maternal and child malnutrition, common to the Sahel region.National nutrition surveys carried out over the past five years all point tothe conclusion that the nutritional status of young children in Nigerremains a matter of great concern. Even in good harvest years, child malnu-trition remains high. Since 2005, the prevalence of acute malnutritionamong children in Niger has always been above the alert level of 10 percent, with a few regions exceeding the emergency level threshold (15 percent) (see Figure 1). The latest national nutrition survey (June 2011) revealeda national average of global acute malnutrition (GAM) of 12.3% with aprevalence of severe acute malnutrition (SAM) of 1.9%. The situation is ofgreat concern among children aged 6–23 months. The prevalence of GAMin this age group is 20.2% according to the latest national nutrition survey.

A high prevalence of chronic malnutrition is also a major problem ofpublic health importance as every other child aged 6 – 59 months isstunted, and there is very little variation over the years (see Figure 2).

In Niger, only 46 per cent of the population has access to safe water.The regions of Zinder, Maradi, Tahoua and Agadez, in particular, facelimited access to drinking water, low sanitation coverage, and poorhygiene practices, especially among the poor. In a context of high foodand nutrition insecurity, the lack of appropriate hygiene, drinking waterand proper sanitation increases the incidence of water-related diseases,including diarrhoea, which is a major underlying cause of malnutrition.The health system in Niger is well structured and quite decentralised.However, it is confronted with a serious issue of staffing.

ContexteSituation en matière de nutrition et de santé au niveau nationalLe Niger est un pays enclavé du Sahel, avec une population de plusde 15 millions de personnes, dont environ 50% sont des enfants demoins de 15 ans. Le Niger se classe au 173e rang sur 177 selon l’Indicede développement humain du PNUD 20101. Les indicateurs del’Objectif du millénaire pour le développement (OMD), tels que lamortalité infanto-juvénile et le taux de mortalité maternelle, sontparmi les plus alarmants au monde. Le taux de mortalité maternellea stagné au cours des dix dernières années et en 2010, il était encorede 554 sur 100,000 naissances vivantes. En outre, un enfant sur cinqmeurt encore avant l’âge de cinq ans au Niger. Le paludisme, lesinfections respiratoires et la diarrhée sont les principales causesdirectes de mortalité des enfants de moins de cinq ans. La malnutri-tion aiguë est directement ou indirectement responsable de 50 à 60%des décès d’enfants âgés de moins de cinq ans.

Pendant des années, le Niger a été confronté à une insécuritéalimentaire chronique et à des niveaux élevés de malnutrition chezles mères et les enfants, commune à la région du Sahel. Des étudesnationales sur la nutrition réalisées au cours des cinq dernièresannées mènent toutes à la conclusion suivante, à savoir que l’étatnutritionnel des jeunes enfants au Niger reste très préoccupant.Même dans les années de bonnes récoltes, la malnutrition chez lesenfants reste élevée. Depuis 2005, la prévalence de la malnutritionaiguë chez les enfants au Niger a toujours été au-dessus du niveaud’alerte de 10%, avec quelques régions dépassant le seuil du niveaud’urgence (15%) (Voir Figure 1). La dernière étude nationale sur lanutrition (juin 2011) a révélé une moyenne nationale de malnutritionaiguë globale (MAG) de 12.3 % avec une prévalence de la malnutri-tion aiguë sévère (MAS) de 1.9 %. La situation est plus préoccupantechez les enfants âgés de 6 à 23 mois. La prévalence de la MAG dansce groupe d’âge est de 20.2 % selon la dernière étude nutritionnellenationale en date de juin 2011.

Une prévalence élevée de la malnutrition chronique représenteégalement un problème majeur de santé publique étant donné qu’unenfant sur deux âgé de 6 à 59 mois accuse un retard de croissance, ettrès peu de variations sont observées au fil des ans (voir Figure 2).

Au Niger, seulement 46% de la population a accès à l’eau potable.Les régions de Zinder, Maradi, Tahoua et Agadez en particulier nejouissent que d’un accès limité à l’eau potable et d’une faible couver-ture en services d’assainissement et font état de mauvaises pratiquesd’hygiène, surtout parmi les pauvres. Dans un contexte d’insécuritéalimentaire et nutritionnelle élevée, l’absence de pratiques d’hygièneappropriées, d’eau potable et de services d’assainissement adéquatsaugmentent l’incidence des maladies d’origine hydrique telles que ladiarrhée, qui est une cause sous-jacente majeure de malnutrition. Lesystème de santé au Niger est bien structuré et très décentralisé.Cependant, il est confronté à un problème de dotation en personnel.

Un pays exposé aux urgencesLe Niger est régulièrement confronté à des périodes d’insécuritéalimentaire résultant de périodes de sécheresse et/ou d’infestationsacridiennes. En 2005, le pays a été confronté à une insécurité alimen-taire majeure qui s’est traduite par une crise nutritionnelle grave. Celas’est produit à un moment où le système de santé du pays n’était pasprêt à gérer des cas de malnutrition aiguë en grand nombre. En 2010,le Niger a été à nouveau confronté à une insécurité alimentaire suiteà une mauvaise saison des pluies en 2009, ce qui a également entraînéune crise nutritionnelle majeure affectant les groupes vulnérables,notamment les jeunes enfants et les femmes enceintes et allaitantes.En février 2010, le Cluster Nutrition avait estimé que 378,000 enfantsâgés de 6 à 59 mois auraient à souffrir de MAS cette année-là. En juin2010, le Cluster Nutrition a réévalué ce chiffre à 384,000. On a estiméà 1.2 millions le nombre d’enfants supplémentaires de la mêmetranche d’âge censés souffrir de malnutrition aiguë modérée (MAM).

En 2010, la pénurie de céréales était d’environ un demi-million detonnes et le déficit de fourrage pour les animaux avait culminé à 16millions de tonnes métriques. En avril 2010, une enquête de sécuritéalimentaire a révélé que 7.1 millions de Nigériens, c’est-à-dire près dela moitié de la population, étaient dans une situation de vulnérabilitéalimentaire, dont 3.3 millions de personnes se trouvant dans une situ-ation de vulnérabilité sévère2. Pour la première fois, cette enquête a

1 United Nations Development Programme2 Multiple Indicator Cluster Survey on Population and Health in Niger (EDSN – MICS), 2006

1 Programme des Nations-Unies pour le développement2 La sécurité alimentaire des ménages nigériens, SAP/INS/FAO/UNICEF/UE/FEWS-NET/

PNUD/PAM, avril 2010

Article de terrainField article

Figure 1: Prevalence of acute malnutrition among children aged 6-59 month in NigerFigure 1 : Prévalence de la malnutrition aiguë chez les enfants âgés de 6 à 59 mois au

Niger

2005 2006 2007 2008 2009 2010 2011

18

16

14

12

10

8

6

4

2

0

Prevalence (%

)Prévalence (%)

GAM: global acute malnutrition. SAM: severe acute malnutritionMAG: malnutrition aiguë globale. MAS: malnutrition aiguë sévère

GAM (Z score W/H <-2)MAG (Z score P/T <-2

SAM (Z score W/H <-3)MAS (Z score P/T <-3

2005 2006 2007 2008 2009 2010 2011

60

50

40

30

20

10

0

Prevalence (%

)Prévalence (%)

Severe chronic malnutrition: (Z score height for age <-2)MS (Z score T/A <-2

Figure 2: Prevalence of severe chronic malnutrition among children aged 6-59month in Niger

Figure 2 : Prévalence de la malnutrition chronique sévère chez les enfants âgés de 6 à59 mois au Niger

53

An emergency-prone countryNiger is regularly confronted with episodes of food insecurity, resultingeither from dry spells and/or from locust infestations. In 2005, the countrywas confronted with major food insecurity that translated into a seriousnutrition crisis. This happened at a time when the health system of the coun-try was not ready to handle large caseloads of acute malnutrition. In 2010,Niger was again confronted with food insecurity following a poor 2009 rainyseason. This also resulted in a major nutrition crisis affecting mostly vulner-able groups, such as young children and pregnant and lactating women. InFebruary 2010, the Nutrition Cluster estimated that 378,000 children aged 6to 59 months would suffer from SAM that year. In June 2010, the NutritionCluster re-evaluated this number to 384,000. An additional 1.2 million chil-dren of the same age group were expected to suffer from moderate acutemalnutrition (MAM).

In 2010, grain shortage was about half a million tons and the animalfodder deficit was as high as 16 million metric tons. In April 2010, a foodsecurity survey revealed that 7.1 million Nigeriens, almost half of the popu-lation, were in a situation of food vulnerability, including 3.3 million whowere in a situation of severe vulnerability3. For the first time, this survey wasalso conducted in urban areas and showed that 26 per cent of urban popula-tions were also affected by severe food insecurity.

The magnitude of the nutrition crisis was revealed by the NationalNutrition Survey of June 2010, which indicated that the prevalence of GAMamong children aged 6–59 months was as high as 16.7 per cent, exceedingthe emergency threshold of 15 per cent4. This included 3.2 per cent of chil-dren affected by SAM. The situation was dire for children aged 6–23 monthswith one in four children affected by GAM. The prevalence of SAM amongthis age group was as high as 7 per cent. Another survey in October 2010confirmed the same picture.

Political willPolitical support for nutrition has improved over time. From a politicallysensitive issue, nutrition became a national concern. The political commit-ment to treat nutrition as a national priority was publicly expressed throughthe organisation of the International Symposium on Food and NutritionSecurity (SISAN) held in Niamey from 28th to 31st March, 2011. The purposeof the Symposium was to address structural causes of food and nutritioninsecurity in order to reduce incidence of all forms of malnutrition amongvulnerable groups. This led to development of a 5 year strategic documentfor nutrition and agreement to a dedicated budget line for nutrition withinthe health budget. Niger joined the SUN and REACH international move-ments and linkages were improved between other public healthprogrammes (vaccination, Integrated Management of Childhood Illnesses(IMCI) and HIV/AIDS).

Where does nutrition fit in government?As a cross cutting issue, nutrition is handled by several sectors includingagriculture, education and health. Emergency Nutrition Response is underthe leadership of the Prime Minister’s Office. Responsibility for the manage-ment of acute malnutrition rests with the Ministry of Health (MOH). Withinthe MOH, there is the Nutrition Directorate in charge of designing nutritionpolicies, plans and strategies, and coordinating and overseeing implementa-tion of nutrition interventions. In each of the eight regions and in each of the42 districts, there is a nutrition focal point, which represents the extendedarms of the Nutrition Directorate. Recently, the newly elected Presidentlaunched an initiative to strengthen food security in the country. This initia-tive was named 3N: Nigeriens Nourish Nigeriens. A High Commission,linked to the President’s Office, is managing the 3N and will probably dealto some extent with nutrition-related issues.

CMAM roll out/scale upThe aim of CMAM provision in Niger is to provide adequate care for all chil-dren affected by acute malnutrition and thus to contribute to the reductionof morbidity and mortality due to acute malnutrition among children inNiger.

Scaling up CMAM in Niger has been gradual, but not according to aparticular plan. Community Management of Acute Malnutrition (CMAM)was partially introduced for the first time as part of the emergency responseto the 2005 food and nutrition crisis. Actions taken were establishment of acore group for coordination, a quick survey of the nutritional situation andidentification of vulnerable areas, development of a national protocol formanagement of acute malnutrition, and support from humanitarian organi-sations in supplies, training and monitoring and evaluation (M&E). Since

également été menée dans les zones urbaines et a montré que 26%des populations urbaines ont également été touchées par uneinsécurité alimentaire sévère.

L’ampleur de la crise nutritionnelle a été révélée par l’Enquêtenationale sur la nutrition de juin 2010 qui indiquait que la préva-lence de la MAG chez les enfants âgés de 6 à 59 mois atteignait 16.7%, dépassant le seuil d’urgence de 15%3. Ces chiffres incluaient 3.2% d’enfants touchés par la MAS. La situation était désastreuse pourles enfants âgés de 6 à 23 mois avec un enfant sur quatre touché parla MAG. La prévalence de la MAS au sein de ce groupe d’âgeatteignait 7%. Une autre enquête menée en octobre 2010 a confirméla même situation.

Volonté politiqueLe soutien politique en matière de nutrition s’est amélioré au fil dutemps. La nutrition est passée du statut de sujet politiquementsensible à celui de préoccupation nationale. L’engagement poli-tique à traiter la nutrition comme une priorité nationale a étéexprimé publiquement à travers l’organisation du Symposiuminternational sur la sécurité alimentaire et nutritionnelle (SISAN)qui s’est tenu à Niamey du 28 au 31 mars 2011. Le but du sympo-sium était de s’attaquer aux causes structurelles de l’insécuritéalimentaire et nutritionnelle afin de réduire l’incidence de toutesles formes de malnutrition chez les groupes vulnérables.L’événement a débouché sur le développement d’un documentstratégique sur 5 ans relatif à la nutrition et sur la signature d’unaccord concernant une ligne budgétaire dédiée à la nutrition ausein du budget de la santé. Le Niger a adhéré aux mouvementsinternationaux SUN et REACH et les liens entre les autresprogrammes de santé publique (vaccination, prise en charge inté-grée des maladies de l’enfance (PCIME) et le VIH/SIDA) ont étérenforcés.

Où se situe la nutrition au sein du gouvernement ?La nutrition, sujet transversal, est gérée par plusieurs secteurs dontl’agriculture, l’éducation et la santé. L’intervention d’urgence enmatière de nutrition relève de la direction du Bureau du Premierministre. La responsabilité de la gestion de la malnutrition aiguërelève du ministère de la Santé Publique (MSP). Au sein duministère de la Santé se trouve la Direction de la nutrition encharge de la conception des politiques, des plans et des stratégiesen matière de nutrition ; elle est également chargée de coordonneret de superviser la mise en œuvre des interventions nutrition-nelles. On trouve dans chacune des 8 régions et dans chacun des42 districts un point focal pour la nutrition qui représente lesantennes élargies de la Direction de la nutrition. Récemment, leprésident nouvellement élu a lancé une initiative visant à renforcerla sécurité alimentaire dans le pays. Cette initiative a été nommée3N : Les Nigériens Nourrissent les Nigériens. Un haut-commis-sariat lié au Bureau du Président assure la gestion de 3N et serasans doute amené à mettre en place un comité multisectorielchargé, dans une certaine mesure, des questions liées à la nutrition.

Déploiement/Extension de la PCMAL’objectif de la disposition PCMA (prise en charge communautairede la malnutrition aigüe) au Niger est de fournir des soinsadéquats à tous les enfants touchés par la malnutrition aiguë et decontribuer ainsi à la réduction de la morbidité et de la mortalitédues à la malnutrition aiguë chez les enfants au Niger.

L’extension à plus grande échelle de la PCMA au Niger a étéprogressive, mais ne s’est pas effectué selon un plan particulier. Laprise en charge communautaire de la malnutrition aiguë (PCMA)a été partiellement introduite pour la première fois dans le cadrede l’intervention d’urgence face à la crise nutritionnelle et alimen-taire de 2005. Les mesures prises ont été la mise en place d’ungroupe de coordination central, une étude rapide de la situationnutritionnelle et l’identification des zones vulnérables, ledéveloppement d’un protocole national pour la prise en charge dela malnutrition aiguë et le soutien de la part des organisationshumanitaires au moyen de fournitures, de formations et d’activitésde suivi et d’évaluation (S&E). Depuis lors, l’approche PCMA a étéinstitutionnalisée et rationalisée. Elle a tout d’abord été mise enœuvre par certaines organisations non-gouvernementales (ONG),tandis que les services gérés par le gouvernement opéraient encoreconformément à l’approche traditionnelle selon laquelle tous les

Field article

3 Multiple Indicator Cluster Survey on Population and Health in Niger (EDSN – MICS), 2006

3 Food Security of Nigerien Households, SAP/INS/FAO/UNICEF/EU/FEWS-NET/PNUD/WFP, April 2010

4 National Nutrition Survey, National Institute of Statistics, June 2010

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cas étaient traités comme des patients hospitalisés. La PCMA a étéadoptée progressivement par d’autres partenaires et reflétée dans leprotocole national pour la prise en charge de la malnutrition aiguë.L’expansion de la PCMA à toutes les parties prenantes est entrée envigueur par l’intermédiaire de la directive d’intégration publiée en2008. Il est ainsi devenu obligatoire pour tous les partenairesimpliqués dans la gestion de la MAS d’intégrer leurs activités ausein du système de santé actuel géré par le gouvernement.

Au niveau opérationnel, la prise en charge de la malnutritionaiguë est entreprise au Niger par le personnel de santé, avec unecapacité d’appoint fournie par des ONG ou les Nations-Unies(ONU) pendant les périodes où le nombre de cas est élevé. Lesagents de santé communautaires ou les ONG procèdent audépistage des cas au niveau communautaire et les cas identifiéssont renvoyés à un centre de santé afin d’être traités conformémentau protocole national. Le dépistage des cas au niveau communau-taire est effectué à l’aide du périmètre brachial (PB) et le diagnosticest confirmé au centre de santé à l’aide du Z-score poids/taille.Pendant les périodes de forte insécurité alimentaire, le PB est util-isé comme critère d’admission indépendant dans le cadre dutraitement de la MAS. Les prestataires de services sont formésfréquemment et supervisés en cours de travail afin d’assurer laqualité du traitement, et ce avec l’appui technique et financier del’UNICEF, du PAM, de l’OMS et des ONG internationales.

Les partenaires fournissent le matériel thérapeutique nécessaire(aliments thérapeutiques prêts à l’emploi (ATPE), laits thérapeu-tiques et médicaments essentiels) et d’autres fournitures, ycompris des moustiquaires imprégnées d’insecticide de longuedurée, des couvertures et du savon. Plus précisément, l’UNICEFfournit toutes les fournitures nécessaires au traitement de la MAS(ATPE, F-75, F-100, médicaments, moustiquaires, couvertures,savon, etc.) et le PAM fournit environ 80% de la nourriture supplé-mentaire requise pour la prise en charge des cas de MAM.

La figure 3 illustre l’organisation des soins. Depuis juillet 2011,pratiquement tous les centres de santé disposent de la capaciténécessaire au traitement de la malnutrition aiguë (voir la couver-ture géographique).

La Direction de la nutrition et son personnel décentralisé auniveau des régions et des districts supervisent la prise en charge dela malnutrition aiguë. Les ressources sont fournies par legouvernement, l’UNICEF, le PAM et des ONG internationales.

Il existe un système pour rapporter le nombre de nouveaux casadmis pour traitement sur une base hebdomadaire de même qu’unsystème de surveillance hebdomadaire des indicateurs deperformance. À l’origine, ces systèmes ont été mis en place et géréspar l’UNICEF en tant que systèmes parallèles, mais sont désormaispleinement intégrés au système national dont la gestion estprogressivement transférée à la Direction de la nutrition.

Plusieurs questions liées à la durabilité, la qualité des services,l’exhaustivité et la rapidité d’obtention des rapports demeurentdes défis à aborder dans un avenir proche.

À ce jour, la prise en charge des cas de malnu-trition aiguë au Niger est entièrement intégréeau système de santé existant et le service estfourni par le personnel du gouvernement avecle soutien des ONG en cas de besoin (capacitéd’appoint).

Couverture géographique de la PCMADans chaque hôpital de district, régional ounational, il existe une unité pour la gestion despatients hospitalisés pour cause de MAS présen-tant des complications médicales. Un total de 50unités de ce type sont disponibles à travers lepays. Les enfants atteints sont traités comme despatients hospitalisés dans ces établissementsconnus au Niger sous le nom de Centres derécupération et d’éducation nutritionnelleintensifs (CRENI). Sur les 850 centres de santéintégrés disponibles, 772 sont en mesure detraiter les cas de MAS sans conditions médi-cales. Ce sont des centres où les enfants sonttraités en soins ambulatoires (CRENAS). Enfin,

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Field article

Healthy childEnfant bien portant

Moderate acute malnutritionMA modérée

Management of AM at Intensivecare unit or Health centre (CRENAM)

PEC de MA au CSI ou CS (CRENAM)

Management of AM – outpatient care

PEC de MA ambulatoire

Management of AM atIntensive care unit (CRENAS) PEC de MA au CSI (CRENAS)

Management of AM – inpatient care (CRENI)

PEC de MA à l’hôpital (CRENI)

SAM without complicationsMA sévère sans complications

SAM with complicationsMA sévère avec complications

Management of AM – intensive carePEC de MA intensif

AM: Acute malnutritionMA: Malnutrition Aiguë PEC: Prise en charge CS : Centre de soin intensifs

Figure 3: Organisational management of acute malnutritionFigure 3 : Gestion organisationnelle de la malnutrition aiguë

then, the CMAM approach has been institutionalised and streamlined. It wasfirst implemented by selected non-governmental organisations (NGOs),while government-run facilities still operated following the traditionalapproach whereby all cases were treated as inpatients. CMAM was adoptedprogressively by more partners and reflected in the national protocol formanagement of acute malnutrition. The expansion of CMAM to all stake-holders became effective with the integration directive issued in 2008. Thismade it compulsory for all partners involved in the management of SAM tointegrate their activities into the existing government-run health system.

At the operational level, management of acute malnutrition is undertakenin Niger by health staff, with surge capacity provided by either NGOs orUnited Nations (UN) agencies during periods when the caseload is high.Community health workers or NGOs undertake screening and case finding atcommunity level and identified cases are referred to a health centre for treat-ment according to the national protocol. Community-level case finding is doneusing Mid Upper Arm Circumference (MUAC) and the diagnosis is confirmedat the health centre using weight-for-height z-score. During periods of highfood insecurity, MUAC is used as an independent criterion of admission fortreatment for SAM. Frequent training of service providers and on-the-jobsupervision are carried out to ensure quality of treatment, with technical andfinancial support from UNICEF, WFP, WHO and international NGOs.

Partners provide the required therapeutic supplies (Ready to UseTherapeutic Food (RUTF), therapeutic milks, and essential medicines) andother supplies, including long-lasting insecticide treated bed nets, blanketsand soap. More specifically, UNICEF provides all supplies required for thetreatment of SAM (RUTF, F-75, F-100, medicines, bed nets, blankets, soap,etc) and WFP provide about 80% of supplementary food required formanagement of cases of MAM.

The organisation of care is shown in Figure 3. As of July 2011, there iscapacity for the treatment of acute malnutrition in virtually all health centres(see geographic coverage).

The Nutrition Directorate and its decentralised personnel in the regionsand at district level supervise the management of acute malnutrition.Resources are provided by government, UNICEF, WFP and internationalNGOs.

There is a system for reporting the number of new cases admitted fortreatment on a weekly basis and a weekly monitoring system of performanceindicators. These systems were initially set up and managed by UNICEF asa parallel system but are now fully integrated into the national system, themanagement of which is being progressively transferred to the NutritionDirectorate.

Several issues related to sustainability, quality of services, completenessand timeliness of reporting remain challenges to be addressed in the nearfuture.

To date, the management of cases of acute malnutrition in Niger is fullyintegrated into the existing health system and the service is provided bygovernment staff, with support from NGOs when need arises (surge capacity).

Geographic coverage of CMAMIn each district, regional or national hospital, there is a unit for inpatientmanagement of SAM with medical complications. A total of 50 such units are

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available throughout the country. Affected children are treated as inpatientsin these facilities, known in Niger as Centre de Rehabilitation NutritionnelleIntensive (CRENI). Of the 850 Integrated Health Centres available, 772 are ina position to treat cases of SAM without medical conditions. These arecentres where children are treated in ambulatory care (CRENAS). Finally theIntegrated Health Centres and some Health Posts offer treatment for MAM.In the country, there are more than 850 sites for the treatment of MAM(CRENAM). See Figure 4.

Main partnersThe management of acute malnutrition in Niger is carried out by multiplepartners, all operating under the leadership of the MOH, through theNutrition Directorate. Approximately 20 NGOs, most of whom are interna-tional, are involved in management of acute malnutrition.

MOH leadership is critical to ensure integration of the management ofacute malnutrition into the existing health system and to avoid a verticalapproach, as often happens in emergency settings. Donors play an importantrole to ensure adequate management of acute malnutrition by providingsufficient resources to procure therapeutic and supplementary foods, drugsand other supplies required for the treatment of acute malnutrition.

NGOs support this programme at the operational level to ensure qualityof care. Their contribution is mainly in terms of surge capacity, capacitybuilding, and quality assurance. Management of acute malnutrition in Nigeris happening at a very large scale. This still, by and large, depends on exter-nal funding. Sustaining the gains is a challenge that still needs to beaddressed.

Community-based approachBeneficiaries could play a greater role in CMAM in Niger. To date, manage-ment of MAM is decentralised to health post level with a significantinvolvement of community members, especially those in charge of managinghealth services in collaboration with the community health worker. In addi-tion to direct management of MAM, community members are involved, viaNGOs, with case identification and referral.

Community members, through community volunteers, are in some casesinvolved with sensitisation on adequate infant and young child feedingpractices along with other key family practices. This is a component of theCMAM programme that still needs some strengthening.

ResultsBefore the 2005 nutrition crisis in Niger, there was only one therapeutic feed-ing centre in the whole of the country. The programme has grown over timeand is now a national programme with more than 820 treatment centres forSAM and a further 1000 centres for the treatment of MAM.

Thanks to the combination of two decisions made by the government toimprove access to health care for the population, more and more childrennow have access to treatment for acute malnutrition. These political decisionswere to waive user fees for healthcare for children under five years and tointegrate management of acute malnutrition into the existing health system.In addition to the increasing political commitment for nutrition in Niger,additional factors contributing to success in CMAM scale up have been thestrong leadership from the Ministry of Public Health for coordination, techni-cal support and assistance from UN and NGO partners, and development oflonger term strategies to address malnutrition.

les centres de santé intégrés et certains postes de santé offrent untraitement de la MAM. On dénombre plus de 850 sites pour letraitement de la MAM (CRENAM) à travers le pays. Voir Figure 4.

Principaux partenairesLa prise en charge de la malnutrition aiguë au Niger est assuréepar de multiples partenaires, évoluant tous sous la direction duMS par l’intermédiaire de la Direction de la nutrition. Environ 20ONG, dont la plupart sont internationales, sont impliquées dans laprise en charge de la malnutrition aiguë.

Le leadership du Ministère de la Santé Publique est essentiel afind’assurer l’intégration de la prise en charge de la malnutritionaiguë au système de santé existant et d’éviter une approche verti-cale, comme cela arrive souvent dans de nombreuses situationsd’urgence. Les bailleurs de fonds jouent un rôle important quand ils’agit d’assurer une prise en charge adéquate de la malnutritionaiguë ; en effet, ils fournissent des ressources suffisantes pour seprocurer des aliments thérapeutiques et supplémentaires, desmédicaments et autres fournitures nécessaires pour le traitement dela malnutrition aiguë.

Les ONG soutiennent ce programme au niveau opérationnelafin d’assurer la qualité des soins. Leur contribution réside princi-palement dans la capacité d’appoint, le renforcement des capacitéset l’assurance de la qualité.

La prise en charge de la malnutrition aiguë au Niger s’effectueà très grande échelle. Dans l’ensemble, elle dépend encore ettoujours des financements extérieurs. Consolider les acquis est undéfi qui reste à relever.

L’approche communautaireLes bénéficiaires pourraient jouer un rôle plus important dans laPCMA au Niger. À ce jour, la prise en charge de la MAM est décen-tralisée au niveau des postes de santé avec une participationimportante des membres de la communauté, en particulier ceux encharge de la gestion des services de santé en collaboration avecl’agent de santé communautaire. En plus de la prise en chargedirecte de la MAM, les membres de la communauté sont impliqués,via les ONG, dans l’identification des cas et dans l’aiguillage.

Grâce à des bénévoles communautaires, les membres de lacommunauté sont impliqués, dans certains cas, dans la sensibilisa-tion au sujet des pratiques d’alimentation adéquates pour lesnourrissons et les jeunes enfants ainsi que d’autres pratiques famil-iales clés. Il s’agit d’une composante du programme PCMA qui aencore besoin d’être renforcée.

RésultatsAvant la crise nutritionnelle de 2005 au Niger, le pays comptaitquelques centres de nutrition thérapeutique non fonctionnels. Leprogramme s’est développé au fil du temps jusqu’à devenir unprogramme national comptant plus de 820 centres de traitementde la MAS et 1 000 autres centres pour le traitement de la MAM.

Grâce à la combinaison de deux décisions prises par legouvernement pour améliorer l’accès aux soins de santé destinés àla population, de plus en plus d’enfants ont maintenant accès autraitement contre la malnutrition aiguë. Ces décisions politiques

Action Contre el Hambre (ACH)AFRICAREBEFENCADEVCARECroix Rouge Française (CRF)EPICENTREFORSANIHelen Keller InternationalHELPInternational Relief and DevelopmentSecours islamiqueMSF-SuisseMSF-BelgiqueMSF-EspagneMSF-FrancePlan NigerSamaritans PurseSave the Children – Royaume-Uni Vision Mondiale

Action Contre el Hambre (ACH)AFRICAREBEFENCADEVCARECroix Rouge Française (CRF)EPICENTREFORSANIHelen Keller InternationalHELPInternational Relief DevelopmentIslamic Relief MSF-SuisseMSF-BelgiumMSF-SpainMSF-FrancePlan NigerSamaritans PurseSave the Children – UKWorld Vision

Box 1: List of NGO partners involved in management of acute malnutrition in NigerEncadré 1 : Liste des ONG partenaires impliquées dans la gestion de la malnutrition

aiguë au Niger

Field article

Figure 4 : Emplacement des CRENI et CRENAS au NigerFigure 4: Locations of CRENI and CRENAS in Niger

Legend LegendeCreniCrenas

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56

ont annulé les frais des soins de santé destinés aux enfants demoins de cinq ans et intégré la prise en charge de la malnutritionaiguë au système de santé existant. En plus de l’engagement poli-tique croissant en matière de nutrition au Niger, les autres facteurscontribuant à la réussite du renforcement de la PCMA ont été lesolide leadership de la part du ministère de la Santé publique en cequi concerne la coordination, le soutien et l’assistance techniquedes Nations Unies et des ONG partenaires ainsi que le développe-ment de stratégies à plus long terme dans le cadre de la lutte contrela malnutrition.

Il existe une forte capacité pour la prise en charge de la malnu-trition aiguë au Niger. En 2009, environ 127,000 enfants âgés de 6à 59 mois ont été traités contre la MAS dans le pays. En 2010,lorsque le Niger a été confronté à une crise nutritionnelle majeure,330,000 enfants âgés de 6 à 59 mois ont été traités contre la MAS et257,000 nouveaux cas de MAM ont été traités. Le 2 octobre 2011,plus de 230 000 cas de MAS et un peu plus de 309,000 cas de MAMavaient été traités au Niger. Pour les cas de SAM, 26,101 (11%) ontété gérés en CRENI et 205,806 (89%) ont été gérés en CRENAS.

La qualité des services est contrôlée au moyen des données surles admissions hebdomadaires par région et par suivi mensuel desindicateurs de performance. Les données sur les admissions pour2010/11 pour la MAS et la MAM sont présentées dans les figures 5,6 et 7.

Les indicateurs de performance du programme sont présentésdans le tableau 1. A partir d’août 2011, le taux de mortalité n’étaitque de 1.5%, tandis que les taux de rétablissement et d’abandonétaient respectivement de 84% et de 5.2%. Ces moyennesnationales ne reflètent pas les variations régionales. Une tendancenette qui ressort des statistiques disponibles est que la qualité dessoins, telle que démontrée par les indicateurs de performance, estbonne dans les endroits où une ONG fournit un soutien technique.Lorsque le personnel du gouvernement représente les seuls etuniques prestataires, la qualité laisse à désirer. Le cas de Niamey,accusant le taux de rétablissement le plus bas, ainsi qu’un taux demortalité et d’abandon élevé, est illustré dans les graphiques desFigures 8, 9 et 10.

DéfisLe Niger est confronté à des défis majeurs en ce qui concerne laPCMA. D’une part, comment assurer et maintenir des soins dequalité dans tous les centres de traitement, indépendamment de laprésence des ONG fournissant un appui technique et d’autre part,comment maintenir une offre suffisante en fournitures thérapeu-tiques. Pour résoudre ces deux questions, il est essentiel que legouvernement renforce le système de santé. Cela nécessitera le

Figure 5: Weekly admissions of cases of severe acute malnutrition, CRENAS/CRENI,2010 and 2011

Figure 5 : Admissions hebdomadaires de cas de malnutrition aiguë sévère, CRENAS etCRENI, 2010 et 2011

Figure 6: Monthly admissions for severe acute malnutrition, CRENAS CRENI,2010-2011

Figure 6 : Admissions mensuelles pour la malnutrition aiguë sévère, CRENASCRENI, 2010-2011

Week Semaine

Weekly admissions of severe acute malnutrition by week, 2011 Admissions de cas de malnutrition aiguë sévère, 2011

Weekly admissions of severe acute malnutrition by week, 2010 Admissions de cas de malnutrition aiguë sévère, 2010

Num

ber of cases

Nombre de cas

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

14000

12000

10000

8000

6000

4000

2000

0

Week Semaine

Num

ber of cases

Nombre de cas

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

14000

12000

10000

8000

6000

4000

2000

0

Month Moisadmissions CRENI 2010

admissions CRENAS 2010

admissions CRENI 2011

admissions CRENAS 2011

Source: Weekly admission figures submitted by UNICEF partners Source : Chiffres d’admission hebdomadaires soumis par les partenaires UNICEF

Num

ber of cases

Nombre de cas

jan fév mar avr mai jui jul aoû sep oct nov déc

40,000

35,000

30,000

25,000

20,000

15,000

10,000

5,000

Weekly admissions of moderate acute malnutrition, 2011 Modéré hebdo, 2011

Figure 7: Admissions hebdomadaires de cas de malnutrition aiguë modérée, CRENAM,2011

Figure 7 : Admissions hebdomadaires de cas de malnutrition aiguë modérée, CRENAM,2011

Type de centreType de centre

Nouvelles admissionsNouvelles admissions

TotalTotal

Total sortiesTotal sorties

Cured (n)Guérison (n)

Cured (%)Guérison (%)

Death (n)Décès (n)

Death (%)Décès (%)

Defaulter (n)Abandon (n)

Abandon (%)Defaulter (%)

Data complete (%)Data complete (%)

CRENI 47,867 49,056 46,663 39,345 84% 589 7.7% 2,471 5.3% 96%

CRENAS 322,840 343,459 283,826 223,993 79% 1,964 0.7% 21,017 7.4% 100%

CRENI/CRENAS 370,707 392,515 330,489 263,338 80% 553 1.7% 23,488 7.1% 100%

Table 1: Summary of programme performance indicators for SAMTableau 1 : Résumé des indicateurs de performance du programme pour la MAS

There is substantial capacity for the management of acute malnutrition inNiger. In 2009, about 127,000 children aged 6–59 months were treated forSAM in the country. In 2010, when Niger was confronted with a major nutri-tion crisis, 330,000 children aged 6–59 months were treated for SAM and257,000 new cases of MAM were treated. As of the 2nd October 2011, morethan 230,000 cases of SAM and just over 309,000 cases of MAM had beentreated in Niger. For SAM cases, 26,101 (11%) were managed in CRENI and205,806 (89%) managed in CRENAS.

The quality of services is monitored using weekly admission data byregion and monthly monitoring of performance indicators. Admission datafor 2010/11 for SAM and MAM are shown in Figures 5, 6 and 7.

The programme performance indicators are shown in Table 1. As ofAugust 2011, the mortality rate was only 1.5% while the recovery anddefaulter rates were 84% and 5.2% respectively. These national averagesmask regional variations. A pattern that clearly emerged from availablestatistics is that where there is an NGO providing technical support, qualityof care, as demonstrated by performance indicators, is good. Where govern-ment staff are the sole providers, quality remains sub-optimal. The case ofNiamey, with the lowest recovery rate, high mortality and defaulter rates, isillustrated in the graphs in Figures 8, 9 and 10.

ChallengesNiger is faced with major challenges as far as CMAM is concerned. First,how to ensure and maintain quality care in all treatment centres, irrespectiveof the presence of NGOs providing technical support and second, how tosustain adequate provision of therapeutic supplies. To address these twoissues, it is essential for the government to strengthen the health system. Thiswill require the recruitment of adequate personnel to staff health facilities. Italso requires setting up and implementing an inclusive quality assurance

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system as well as providing efficient supervision, which will lead to qualityof care. A third challenge is how to scale up MAM programmes across thecountry. Taking charge of malnutrition is an integral part of the axis of nutri-tion in the food and nutritional security policy document of the government.Addressing MAM will require insertion of a dedicated budget line forpurchase of therapeutic inputs and development of social safety nets (with asocial safety net ‘cell’ attached to the Prime Minister’s office).

Niger depends on UNICEF and WFP for procurement of therapeuticsupplies. This is a fragile situation which needs to be changed. The govern-ment could significantly reduce its dependence on UN agencies wheretherapeutic supplies is concerned, by allocating a budget line for procure-ment of therapeutic supplies to the Ministry of Health Budget and includingprocurement of therapeutic supplies in the social safety net package that isexpanding very quickly in the country.

Key lessonsThere are a number of key lessons from the scale up of CMAM in Niger.CMAM success relies on strong government vision and commitment forstrategy, coordination and resource mobilisation. Strong government coordi-nation is vital, especially when many partners are involved. Standardisationof treatment is key to ensure equity in treatment and comparable data.Operational partners prefer to focus on treatment not prevention - there is aneed for more preventative programming.

Ways forwardCMAM is well established in Niger and is being carried out on a very largescale. In addition, quality of care is overall in line with Sphere standards. Itis now urgent to maintain the existing capacity for the management of acutemalnutrition in the country and to improve quality of care where services arestill sub-optimal. In general, the community component of CMAM in Nigeris rather weak and work needs to be done at this level to ensure effectiveinvolvement of communities. Next steps planned include adoption of thenational nutrition plan and development of a national preventative nutritionstrategy based on ‘best practices’.

In terms of scaling up nutrition more broadly and given the scale ofCMAM in Niger, the programme can serve as an entry point for manyinterventions, including other nutrition programmes, especially thosedesigned with the aim of reducing incidence of all forms of malnutrition inthe country.

For more information, contact: Dr Guero H Doudou Maimouna, email: dnutniger@gmail.com or mhalidou2002@yahoo.fr

recrutement de personnel adéquat dans les établissements de santéet également la mise en place et la mise en œuvre d’un systèmed’assurance qualité inclusif et d’une supervision efficace, ce quiconduira à une meilleure qualité des soins. Un troisième déficonsiste à savoir comment renforcer les programmes de MAM àtravers le pays. La prise en charge de la malnutrition fait partieintégrante de l’axe nutritionnel du document relatif à la politiquede sécurité alimentaire et nutritionnelle du gouvernement. La luttecontre la MAM exigera l’intégration d’une ligne budgétaire spéci-fique pour l’achat d’apports thérapeutiques et le développementde dispositifs de protection sociale (avec une "cellule" dédiée à cesderniers rattachée au bureau du Premier ministre).

Le Niger dépend des partenaires techniques comme l’UNICEFet le PAM pour l’achat de fournitures thérapeutiques. Il s’agitd’une situation incertaine qui doit changer. Le gouvernementpourrait réduire considérablement sa dépendance envers lesagences des Nations-Unies en ce qui concerne les fournituresthérapeutiques en attribuant une ligne budgétaire pour l’achat defournitures thérapeutiques au budget du ministère de la Santé, eten incluant l’achat de fournitures thérapeutiques au sein dudispositif de protection sociale qui se développe très rapidementdans le pays.

Principaux enseignementsPlusieurs enseignements clés sont nés du renforcement de laPCMA au Niger. Le succès de la PCMA repose sur une vision fortedu gouvernement et sur un engagement en matière de stratégie, decoordination et de mobilisation des ressources. Une coordinationgouvernementale solide est vitale, surtout quand de nombreuxpartenaires sont impliqués. La standardisation du traitement estun élément clé pour assurer l’égalité dans le traitement et lacomparabilité des données. Les partenaires opérationnelspréfèrent se concentrer sur le traitement plutôt que sur la préven-tion ; ainsi, des programmes plus axés sur la prévention sontnécessaires.

Les voies à suivreLa PCMA est bien établie au Niger et elle est mise en œuvre à trèsgrande échelle. En outre, la qualité des soins est globalementconforme aux normes Sphère. À présent, il est urgent de maintenirla capacité existante en matière de prise en charge de la malnutri-tion aiguë dans le pays et d’améliorer la qualité des soins là où lesservices laissent encore à désirer. D’une façon générale, lacomposante communautaire de la PCMA au Niger est plutôt faibleet des progrès doivent être réalisés à ce niveau afin d’assurer laparticipation effective des communautés. Les prochaines étapesprévues incluent l’adoption du plan national de nutrition et ledéveloppement d’une stratégie nationale préventive en matière denutrition fondée sur des "bonnes pratiques".

En termes de renforcement de la nutrition de façon plusgénérale et compte tenu de l’ampleur de la PCMA au Niger, leprogramme peut servir de point d’entrée pour de nombreusesinterventions, y compris d’autres programmes de nutrition, enparticulier ceux conçus dans le but de réduire l’incidence de toutesles formes de malnutrition dans le pays.

Pour plus d’informations, contacter : Dr Guero H DoudouMaimouna, e-mail : dnutniger@gmail.com oumhalidou2002@yahoo.fr

Field article

Figure 8: Cure rates by region in 2010Figure 8 : Taux de guéris par région en 2010

90%80%70%60%70%60%50%40%30%20%10%0%

80%

1.7%

7.1%

AGADEZ

DIFFA

DOSSO

MARAD

I

NIAMEY

TAHOUA

TILLAB

ERYZINDER

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bined

Combined

Figure 10: Death rates by region in 2010Figure 10 : Taux de décès par région en 2010

Region Région

AGADEZ

DIFFA

DOSSO

MARAD

I

NIAMEY

TAHOUA

TILLAB

ERYZINDER

Figure 9: Defaulter rates by region in 2010Figure 9 : Taux d’abandon par région en 2010

Region Région

16%14%12%10%8%6%4%2%0%

12%

10%

8%

6%

4%

2%

0%

AGADEZ

DIFFA

DOSSO

MARAD

I

NIAMEY

TAHOUA

TILLAB

ERYZINDER

Region Région

Sphere Indicator Norme sphère

Cure rate Taux de Guéris

Sphere Indicator Norme sphère

Defaulter rate Taux d’abandons

Sphere Indicator Norme sphère

Defaulter rate Taux de décès

Article de terrain

EnsembleCom

bined

Ensemble