Report on innovations in CMAM

By Anne Marie Kueter, Claudine Prudhon, Emily Keane and Megan Gayford

The implementation of community-based management of acute malnutrition (CMAM) as the standard model of care for children with acute malnutrition has significantly increased cost-effectiveness of treatment and the potential for larger coverage, largely due to a shift from inpatient to outpatient management. However, in places where CMAM services are available, coverage is still not optimal. Distance and high opportunity costs in seeking treatment have consistently been reported as the top barriers to access (Puet et al, 2013). It has been reported that less than 20% of children with moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) are receiving treatment (CORTASAM, 2018).

In recent years new methods have been developed, tested and implemented to simplify or improve the classic CMAM model to increase coverage and cost-effectiveness, facilitate implementation in a humanitarian emergency and facilitate implementation by a health system. A Save the Children (SC) report (updated July 2018) on these innovations in CMAM provides an overview of newly developed methods and approaches, including evidence of their effectiveness, country experiences, available guidance and an overview of on-going initiatives. The report covers the following innovative approaches:

Expanded admission criteria: Provides temporary options for combining treatment of SAM and MAM children. This approach is sometimes implemented in emergency settings in the absence of either an outpatient therapeutic programme (OTP) or targeted supplementary feeding programme (TSFP). The World Food Programme (WFP) and UNICEF authored Moderate Acute Malnutrition: A Decision Tool For Emergencies¹, which covers the expanded admission criteria.

Integrated treatment protocols for SAM and MAM: This is similar to the expanded admission criteria, but rather than being developed in response to crisis, is the result of a weighing up of the costs/benefits of integration. Different versions of this approach have been implemented in Niger and Sierra Leone and this method is currently being researched through various studies, including the Combined Protocol for Acute Malnutrition Study (ComPAS) – a cluster-randomised controlled trial in South Sudan and Kenya using a simplified mid-upper arm circumference (MUAC)-based dosage chart for the treatment of both SAM and MAM (Bailey et al, 2018). The Mango Study² run by Action Against Hunger (AAH) in Burkina Faso and a MUAC-only study run by ALIMA in Burkina Faso are both researching similar methods.

Using MUAC only as admission criteria and mothers using MUAC to screen their children: Available evidence for the use of MUAC-only programming is covered in the report as well as available evidence and guidance³ developed by ALIMA on the training of mothers to measure MUAC. A recent recommendation of CORTASAM for No Wasted Lives supporting these approaches states that: “MUAC should be used as the primary tool for the detection and discharge of acute malnutrition in children 6-59 months of age in the community.” (CORTASAM, No Wasted Lives, 2018).

Integration of treatment of acute malnutrition into integrated community case management (ICCM): This method has been researched by AAH through the C-Project in Mali and Pakistan (details included in full report) and SC has conducted operations research in Kenya in collaboration with AAH. In line with this approach, International Relief Committee (IRC) has developed a simplified protocol and tools for low-literacy health workers to treat SAM, based on several years of field testing in South Sudan.

Community-based management of at-risk mothers and infants under six months (C-MAMI): In 2009 the MAMI project published a report on the management of acutely malnourished infants under six months of age. Since then SC has partnered with a number of agencies to improve knowledge and evidence on the management of acute malnutrition in infants. Research is still ongoing in Bangladesh, where the C-MAMI tool developed by ENN, LSHTM, SC and collaborators in 2015 is being tested in both development context as well as in emergencies during the current Rohingya response (see field article in the MAMI special section of this issue). Version 2 of the C-MAMI tool has recently been launched (see news item in MAMI special section).

CMAM mHealth: World Vision, together with implementing partners International Medical Corps (IMC) and SC, have developed a CMAM mHealth app that guides health workers through CMAM protocols and provides accurate and timely data to improve programme quality and efficiency (Keane et al, 2018; Frank et al, 2017). The application was piloted in Chad, Kenya, Mali, Niger and Afghanistan between 2014 and 2016. There are no specific on-going activities, but there is intent in principle to continue collaboration between SC and World Vision if further funding can be identified.

CMAM surge approach: One of the main goals of this approach is to build the resilience of health systems over time by making them better able to cope with periodic peaks in demand for services for acute malnutrition without undermining the capacity and accountability of government health actors. Concern Worldwide was the first to start a pilot project (in Kenya from 2012 till 2014) and has developed an operational guide as well as a facilitators’  guide⁴.  Save the Children is currently supporting implementation of this approach in Mali.

An updated version of the review has been completed in July and can be downloaded here.

For more information, please contact Claudine Prudhon.

Endnotes

¹https://reliefweb.int/report/world/moderate-acute-malnutrition-decision-tool-emergencies

²www.actioncontrelafaim.org/en/mango-project/

³www.alima-ngo.org/empowering-mothers-prevent-malnutrition

⁴www.concern.net/resources/cmam-surge-approach

References

Bailey et al, Combined Protocol for Acute Malnutrition Study (ComPAS) in rural South Sudan and urban Kenya: study protocol for a randomized controlled trial. Trials, April 2018

CORTASAM 2018. Research Agenda for Acute Malnutrition. A Statement from the Council of Research & Technical Advice on Acute Malnutrition (CORTASAM), No Wasted Lives, 2018.

Frank T, Keane E, Roschnik N, Emary C, O’Leary M and Snyder L (2017). Developing a mobile health app to manage acute malnutrition: a five-country experience. Field Exchange 54, February 2017. p7. www.ennonline.net/fex/54/mobilehealthapp

Keane E, Roschnik N, Chui J, Osman IA and Osman HM (2018). Evaluation of mobile application to support the treatment of acutely malnourished children in Wajir county, Kenya. Field Exchange 57, March 2018. p61. www.ennonline.net/fex/57/mobileappsmalnutkenya

Puett C, Hauenstein Swan S & Guerrero S. (2013). Access for All, Volume 2: What factors influence access to community based treatment of severe acute malnutrition? (Coverage Monitoring Network, London, November 2013)