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Design framework for CMAM programming

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Tamsin Walters

en-net moderator

Forum moderator

13 Dec 2010, 16:27

This question is edited from a discussion initiated by Victoria Sibson directly with the authors of the recent Field Exchange article "Suggested New Design Framework for CMAM Programming". Both Victoria and the authors, Peter Hailey and Daniel Tewoldeberha, are keen to engage more voices in the debate:

I wanted to thank the authors, Peter Hailey & Daniel Tewoldeberha, for the recent article in Field Exchange 39: "Suggested New Design Framework For CMAM Programming". What they describe resonates perfectly with debates I was engaged in a few weeks ago in Niger. We were trying to figure out how to improve the current response, and identify lessons for future nutrition crises, whilst supporting the integrated service. There seems to be a feeling there that you can either mount a full emergency response through surge support OR support an emergency response that uses the already integrated service. People seem fearful that surge will undermine the existing integrated service. It is a shame because what appears to be left out is a great opportunity for capacity building and to me, the quality seems compromised by insufficient surge.

However, I do have a few questions that I'd welcome thoughts from the authors on, as well as from others.

1. How appropriate would you see this model being in Southern Sudan, as an
example of a country with very little MoH capacity to deliver a basic package of health services, let alone integrating the treatment of SAM? There is very little responsive capacity to do CMAM in Southern Sudan in emergencies and capacity building tends not to be very effective because the health system strengthening is not effective and won't be for many years. May be I am too pessimistic, but I wonder if we need to be discerning regarding the countries where we recommend that the integration of SAM should be a priority. The discussions we have had in SC have led us to think that it should only be a priority where burdens of AM are 'very' high but the health system does show some capacity to take it on - the problem is we have not had a chance yet to discuss how we could judge these variables... Your thoughts would be great

2. On your figure 4, the levels of support that might be required - where do you see data collection, analysis and interpretation fitting? From my experience in a few African countries, this is an area that may need a very high level of support even whilst much of the other activities may be a possibility with only light mentoring. I feel without good quality data we are in the dark as to the effectiveness of the service, and yet this can be the hardest thing to get working without a lot of NGO support. Certainly I see this as the single largest challenge in Niger right now.

3. Related to that, the article doesn't seem to address or challenge the CMAM model, in terms of its complexity. In my experience talking to SC employees and various partners, I have heard it criticised as being 'heavy', 'time consuming' and 'burdensome' for development contexts / contexts where we want to support the MoH to take ownership with staff limitations, etc etc. Do you think that the model should be simplified if effective integration can be achieved? And if so any thoughts as to how? Do you think that the data set we collect and monitor could be limited, or would this compromise quality? What would you drop? And, if we simplify, would this simplified model still be valid in an emergency (would the donors buy it?? If not how would be move between the two approaches-??)

4. Do you have any opinion on how we can get better at supporting the integration of CMAM whilst health system strengthening seems to be so slow progress? To my health colleagues it seems a difficult ask to choose SAM as a focus for integration when the whole HSS agenda is about not taking a vertical approach to any one disease. In effect we are seeking to focus attention on SAM and means to treat it, regardless of some of the weaknesses in the health system, even if we do more explicitly work on the capacity building element. I'm struggling to know how to reconcile these approaches so any thoughts would be welcomed.

Also, to save time and share expertise, do you have any good capacity assessment tools that you have used or would recommend, to better judge what the MoH structures can deal with in terms of a caseload rise?

Tamsin Walters

en-net moderator

Forum moderator

13 Dec 2010, 16:39

Below is an initial response from Peter Hailey:

We have been trying to use a capacity based assessment to guide
external resource inputs in Ethiopia. Karamoja, Kenya, Madgascar and a long time ago in Malawi. From a technical point of view there are difficulties and still a lot more work to be done to demonstrate how it might work. However, one of the major bottlenecks is from a conceptual point of view. On the one hand from the resource controlling and priority setting decision makers including in the NGOs and UN and on the other side from the technical "emergency" nutritionists. The decision makers tend to be linear in their view of emergency and development, or to say it in another way, in their view of life saving and capacity building objectives. Since the advent of very large scale CMAM programmes the technicians are torn between priorities that are defined in approaches like SPHERE and on the other hand by the inability to run a programme with this perspective at the scale of the Ethiopian CMAM programme with 7,000 OTPs. To add to all this confusion are the prevalence thresholds. The prevalence thresholds are a simple
tool that has been distorted to such an extent that we no longer even recognise or adequately articulate what they can tell us and what they can't. You know that in most emergencies that single figure often decides the fate of several 100's of millions of USD. We are hoping that the paper can open up the debate on the conceptual approach to allow more space to work on the technical approach.

To your question 3, challenging the CMAM model, in terms of its complexity:
Yes for very large scale CMAM programmes predominantly run by Governments or local authorities, with some outside support, the CMAM model in the guidelines is too complicated. De facto OTPs in countries like Ethiopia are implementing a much simplified guideline. It is the ultimate step in the progression from ACF's guideline that you should have one nurse for every 10 children in a TFC, through CMAM refocusing us on communities and coverage. Can the CMAM programme be robust enough i.e. still save lives and reduce damage from SAM at the scale of a country and with very few technical inputs. It is only these approaches that make it into the lists of essential interventions in papers like those in the Lancet. The focus of programming for those interventions that do make it on the list are health system issues not often technical guideline issues.

Assuming that as nutritionists committed to finding the best way to deal with SAM we imagine an intervention that is robust enough to operate at this scale. We have, i.e. very low tech centres, many children with SAM and a high risk of mortality and a product that can manage that condition. We also have a small window of opportunity whereby countries, donors etc are willing to scale up on a very large scale. I believe that the programme is robust but with some very simple improvements we can improve on number of lives saved for the resources we are investing. Most of the areas for improvement are not technical in the perspective of guidelines. They are things like improved outreach and community based work, improving work on barriers to access, and improved supply chain management. Don't forget that the revolution of CMAM was not the RUTF but the ability to focus on coverage or a "public health approach". In the end we save more lives by reaching more children even if the quality is not as good as we would want it to be. We are better to spend a higher proportion of our resources on ensuring that capacity in these simple areas is improved. I am not advocating for dropping quality work, if only because it has an effect on utilization of services.

In 2005 in Ethiopia the combined CMAM programme was reaching in the low tens of thousands of children, in 2009 the programme reached over 200,000. The quality (SPHERE quality indicators) in terms of defaulters and distribution to non SAM cases has worsened but probably not the mortality rate in the centres. The technical resources (I mean HR in NGOs and UN) and their costs did not increase; the main resource increase has been the RUTF bill. Unfortunately we do not have the data on how many more lives we have saved and how much more efficient we have been but it is impossible that we have not improved. If we had this data we would be able to argue with donors that quality and prevalence is important but simple coverage is better.

As a nutritionist and an NGO coming out of emergencies we tend to concentrate on quality and a temporary approach but CMAM is becoming a programme that should be in place all the time and adapted during an emergency. Essentially an emergency causes an increase in the numbers of SAM children. The phasing up approach based on capacity allows us to describe what it is we would do to change the routine programme to deal with this increase in children until the numbers go down again.

Anonymous 81

Public Health Nutritionist

Normal user

24 Dec 2010, 12:41

First of all i would like to apperciate for Peter Hailey and Daniel Tewoldeberha for their hard work in intiating the dialogue/debate.

My point is regarding the definng of capacity building and caseload. My question is related to the Ethiopia context as your article is mainly based on Ethiopia situation. Now days, the OTP/CMAM implementation is decentralized to the health post level with catchment population roughly about 5000. it is known that the number of MoH staff per health post is maximum two health extension workers. It is known that there is one nutrition officer or nutrition contact person per district. whether or not there is emergency, this structure (two health extension workers) plus contact person at Woreda level is always there. given this situation, what capacity assessment are you looking for?
With regard to definition of caseload, as it more decentralized to HP level, how is going to decide the treshold? for example, in one of the Woreda in North Ethiopia has more than 45 HP and if there is lets say 25 cases per HP there will be 1000 cases. there, are you referring caseload by woreda or by HP?

Anonymous 81

Public Health Nutritionist

Normal user

24 Dec 2010, 13:27

First of all i would like to apperciate for Peter Hailey and Daniel Tewoldeberha for your hard work in intiating the dialogue/debate.

The point i want to raise is regarding assessing and definng of the existing capacity of health system and deciding the treshold for action. My question is related to the Ethiopia context as your article is mainly based on the Ethiopia situation. Now days, the OTP/CMAM implementation is decentralized to the health post level with catchment population of roughly about 5000. It is well known the number of Staff per health post is maximum two health extension workers. this is the governemt policy. Given this situation, what capacity assessment are you looking for? this is already known.
The other point is regard the definition of caseload or treshold of action. The service is decentralized to HP level. even if the prevalence of SAM is about ten percent you can't get the treshold for action/caseload as the population of the catchment for HP is low. so, How is going to decide the treshold?


Mark Myatt

Consultant Epidemiologist, Brixton Health

Frequent user

18 Jan 2011, 13:50

I must admit to being a little confused by the original question. I don't think that CMAM is either expensive or complicated.

CMAM programs have been shown to deliver at well below US$50 per DALY averted in programs with considerable management overheads. This is very cheap (e.g. less than half the cost of DOTS for TB) and means that integration should be possible just about anywhere in the world (WB / UNICEF / WHO / &c. have US$100 - US$150 per DALY averted as the upper limit of cost for inclusion in a basic national health package in the poorest countries).

CMAM is also a simple intervention. SC-US (e.g.) has a 90% coverage program with excellent recovery rates delivered by community-health workers (this came in at about US$26 per DALY averted) with management provided by local MoH and a local NGO.

Getting CTC / CMAM to work well does require skill, effort, and patience. We are usually working in dysfunctional systems that need considerable support.

Cornelia Wakhanu

Normal user

10 Oct 2013, 09:24

On the CMAM framework with the issues of health systems as in South Sudan, mentioned above, I am certain that it can be implemented very well despite challenges here and there.

The word community based explains better for CMAM. The only challenges faced is the resource control otherwise, it has been implemented by other organizations for example Concern worldwide, and Tearfund in Northern Bahel El Ghazal previously. around 2002- 2004 with capacity from Valid international the founder for this strategy in managing the malnutrition.

And on the side of resources, it can also be done. Since i is community based, involve the community leaders in their specific community areas and you will see how these leadership cadre wonderfully do it. Involve the head head of the county and states at different levels during every level of programming for a wide range of accountability responsibilities, do not forget to involve the beneficiaries on engagement participation and feedback mechanism for accountability of everything in the programme.

Most times we think of policy makers and higher officials in systems to do better. Their engagement level differs very much in every context. The health system in Sudan is great on the side of community health workers doing variety of tasks and this places the CMAM even to be better.

I have been in South SUdan and the communities are very much responsive on interventions plus their community leaders. Given the many responsibilities and urgent issues the health system is struggling to address, their backup and authority for a go a head is enough and you deal with the community, payams, with scheduled joint events.activities with counties and state.

Capacity building for the county health need to be among the priorities on health system strengthening. Providing resources when they are not able to use them is not a great work for development. It is like providing a computer and an office to a staff who do not know how to use the computer and mange an office. Capacity building is not the sending of the staff to training alone, but use of equipments, managing an office, managing resources, training on the national and international standards. Not forgetting, training on health issues and like CMAM, what it is and the support needed from the health system and their involvement. I feel most people approach the health system when there is need for recruitment for CMAM and when challenges are faced.

I have the community engagement experience from various NGOs if I may mention them, International Rescue Committee, Save The Children and Merlin. With this, CMAM will work very well in weak health system. Weak systems I feel it is due to many reasons but change in frameworks components can lead to the beneficiaries continuing to get the services.

My experience is that: Challenges are always there, even in places with stronger health systems like in Kenya, there are challenges in implementing the CMAM in some locations. May be at times people have to conceal some challenges by addressing it underground to avoid shame to a strong system.

I came to understand the word 'strong' in any part of the world is not only the higher general system at the national level alone. The system on the ground matters a lot- those supporting the interventions on ground at the beneficiary level. talk of the. state, county, payam, community/village and the community themselves. This is why some states, counties, payams, communities can do better than others but all in all under one national health system.

On the side of human resources for health/nutrition- you will find the framework specifying who to perform what task but based on different counties, this may change with starting from very low level and intensive capacity building on job and workshops. The followed with long term sponsorship for others after higher education to increase he number of higher calibre.

I find CMAM the best intervention for community, the only challenge faced always is the accountability of food items at some few places.

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