This document summarizes the key findings of a multi-country evaluation of Community Management of Acute Malnutrition (CMAM) programs by UNICEF. The evaluation assessed access to services, quality of service delivery, and use of nutrition information. It found that while CMAM has improved treatment of severe acute malnutrition, greater efforts are needed to integrate services, strengthen community outreach, improve data collection and coverage surveys, and reduce costs to scale up prevention. The evaluation provides recommendations for UNICEF and partners to further support national governments to address both treatment and prevention of malnutrition through strengthened health systems and community resources.

1. 1
K. Belbase and C. E. Kouam
International Conference “What We Know Now: A Decade of Community-Based Treatment of
Severe Acute Malnutrition”
London, 17/18 October 2013
© UNICEF/BANA2013-00414/Jannatul Mawa
Key Findings from a multi-country
Evaluation of CMAM

2. Why this Evaluation?
• Severe acute malnutrition (SAM) affects millions of
children and contributes to close to a million child
deaths a year.
• CMAM is an important and growing area of UNICEF’s
work (implemented in 63 countries by end 2012).
• UNICEF has made significant investments to scale
up treatment of SAM and is a lead actor.
• First multi-country evaluation by UNICEF.

3. Evaluation Process / Methodology
• Conducted by 2 International consultants and 5 national
teams.
• Based on a generalised CMAM theory of change and
evaluation framework.
• Data collection and analysis from various sources, using
mixed methods. An extensive inception phase.
• Some limitations and challenges
• In between country comparisons: varying context/time spans of
implementation
• Insufficient or absence of baseline, outcomes and potential impact data
• CMAM not compared to alternative models for addressing SAM

4. Evaluation Findings and Conclusions
as per the 3 themes of the Conference
(Access; Quality; Nutrition information)

5. 1. Equitable access
Promoting Equity in Access
• Top challenges in improving access: identification of
children who might be missed and developing strategies to
reach them.
• Disjointed planning among government, assistance
partners and communities for CMAM, which hampers the
promotion of equity and coverage.
• Weak awareness of challenges in estimating geographic
and treatment coverage in order to promote effective
strategies to increase access.

6. 1. Equitable access (cont.)
Most Effective tools / Mechanism to improve
Access (2012)

7. 1. Equitable access (cont…)
Major Challenges in Conducting Treatment Coverage
Surveys (2012)
• Treatment coverage surveys are not planned or
funded.
• Reliable data is not available on which to make
the coverage calculation such as
• Estimates of SAM prevalence
• Population numbers (lack of registration of new-borns and
constant in and out migration)
• Technical expertise rarely available.

8. 2. Quality of service delivery
CMAM Effectiveness and Quality of Services
• Capacity development has significantly promoted quality of services;
however there is some redundancy in training among related
interventions.
• Sensitizing the community along with active case finding has critically
improved admissions to services.
• Potential of community outreach is constrained by insufficient needs
assessments, inadequate planning and funding, weak monitoring and
inadequate support for CHWs.
• Outpatient services have been effective in helping admitted children to
recover from SAM.
• Inpatient treatment services was found to be only moderately effective
due to weakness in staffing, psychosocial support, data collection, and
weak coordination around referrals between inpatient and outpatient care.

9. 2. Quality of service delivery (cont...)
How Improvement of Standards and Guidelines Can
Best Be Supported (2012)

10. 3. Nutrition information
• Lack of harmonization in reporting systems among
partners poses challenges for evaluating effectiveness.
• Improvements are needed in data recording and
analysis for community mobilisation and sensitisation,
screening, referral, and follow-up through home visits.
• Joint monitoring is not always undertaken but is effective
when it is. Evaluations and monitoring activities should
be planned and budgeted well in advance and should
cover all CMAM challenges.

11. Additional Conclusions

12. Progress / Issues related to National
Ownership
• Strong nutrition authority and nationally owned overarching
strategy for nutrition → support CMAM’s potential for long-
term impact.
• Global guidance for SAM treatment has contributed to the
development of national treatment protocols.
• Global guidance is needed to inform country level
guidelines in the following areas:
a) Planning and monitoring
b) Community assessment and mobilization
c) Equity and gender
d) Integration of CMAM (national health systems and other interventions)
e) MAM management

13. Main Challenges to Integration of CMAM
into National Health Services (2012)

14. Efficiency - Costs, Supply and Delivery of
RUTF
• Investments in improving the efficiency of the national supply
and delivery chains were found to help open up more areas
to expansion.
• There are challenges in funding and procedures.
• For scaling up and promoting local production of RUTF,
quality assurance and cost remain major problems.

15. Sustainability and Scaling Up
• Scale-up and integration are facilitated by good coordination
among partners; but a cohesive vision for addressing acute
malnutrition does not always exist.
• Globally and nationally, CMAM has not been found to be
sustainable as a stand-alone intervention; integrated health
and nutrition packages that include CMAM were more
successful.
• Evaluations and studies, dissemination of lessons and
retention of the experience accumulated in communities are
still scarce. The CMAM forum is filling some of these gaps.

16. Recommendations

17. Overall Recommendation
17
UNICEF and partners need to urgently scale-up efforts to
address SAM through both treatment and prevention,
ensuring that systems and local resources are
strengthened
(with emphasis on prevention through strengthening community
outreach and integrating CMAM into national health systems and with
other interventions)

18. Recommendations: Access, Ownership and
Integration, Strategy and Policy, Guidelines
1. UNICEF should continue to work with governments, WFP, WHO, IPs,
and other stakeholders to secure a common understanding on the
most effective means of addressing MAM and a joint vision on
acute malnutrition in order to unify approaches.
2. Based on national capacity assessments, support the integration of
CMAM into the health systems and with other national health, nutrition
and community development strategies.
3. Strengthen community outreach by ensuring adequate investment in
CMAM awareness raising activities and their integration with outreach
for other public health interventions.
4. Improve awareness and capacity for conducting treatment coverage
surveys and using the information to analyse trends.

19. Recommendations: Performance and Quality of
Services, efficiency, nutrition information
5. Work with government and partners to strengthen nutrition
information systems for improving CMAM quality.
• Support the decentralization of data collection and analysis at district level
• Reinforce the MoHs’ lead role and joint accountability among the MoH and
partners
6. Strengthen means to reduce costs and promote national
assumption of costs for RUTF and supplementary foods.
7. Support further operational research to find alternative to
RUTF formulas.