International Workshop on Integration of CMAM

The International Workshop on the Integration of Community-Based Management of Acute Malnutrition (CMAM), held between 28th and 30th of April 2008, was the third in a series of workshops on CMAM over the past five years. The workshop was convened by FANTA (Food and Nutrition Technical Assistance) at the request of USAID. Due to the growing demand for implementation and integration of CMAM in many countries, the overall goal of this workshop was to "share experiences and identify the main challenges to integration and scale up of CMAM at country level."

The workshop was successful in providing a clear idea of where and how CMAM is being implemented, as well as in raising a number of issues regarding the scale up of CMAM and its integration with national programmes. Key findings from the workshop were as follows:

Integration of CMAM and the process through which it is achieved is context specific and can occur to various degrees and through different means. Community based management of severe acute malnutrition (SAM) services can be integrated into all or some routine health services, or throughout the health system as part of the health service delivery strategy or essential health care package mandated by the Ministry of Health (MOH). There are also contexts where integration will not be appropriate and services will run in parallel to the MOH. This does not, however, preclude CMAM services from falling under the technical leadership of the MOH.

MOH leadership is always essential for successful integration. Other key elements necessary for successful integration have been identified and elaborated upon through the development of an integration framework. This framework - which summarises key elements for CMAM and encompasses the enabling environment, access to services and supplies, and quality of services and competencies - can be used to assess capacities, available resources and gaps that need to be addressed to facilitate successful integration of CMAM.

Capacities need to be strengthened at most levels of a health system to achieve successful integration and scale up of CMAM within that system. Lack of qualified health care providers creates heavy workloads within existing health systems. Integration of CMAM within these health systems will serve to exacerbate these work loads and strain existing health systems, as the acquisition of new skills and adoption of new procedures will be necessary.

Simplicity is a key factor in integration, sustainability and scale-up. There is a need for simple protocols and monitoring and evaluation (M&E) tools to facilitate implementation, quality assurance and capacity strengthening. Despite the need for further research on the role of Mid Upper Arm Circumference (MUAC) as an indicator for monitoring and discharge, its use as an indicator for admission is a viable way for sustainability of services because of its simplicity and compatibility with easy and early case finding and referral in the community.

Low production and transportation costs for Ready to Use Therapeutic Foods (RUTFs) and Ready to Use Supplementary Foods (RUSFs) are essential for successful integration of CMAM. Achieving low costs will require increasing the economies of scale. This, in turn, is reliant on increasing demand for CMAM and programmes to address Moderate Acute Malnutrition (MAM) through supplementary feeding. Given the need for capacity strengthening to integrate CMAM successfully, a delicate balance must be maintained between matching supply of, and demand for, CMAM services.

There are numerous outstanding questions and gaps in the knowledge regarding scale up and integration. These include broad questions like whether existing Sphere Standards are applicable to large-scale CMAM programming, what models exist for financing scale up and integration, and what are the long-term outcomes of programmes which have been scaled up and integrated within existing systems. More specific questions include explanations for disparities in outcomes between HIV-positive patients in outpatient therapy versus hospitals, and the role of proportional weight gain as a criterion for discharge from programmes.

Open and frequent sharing of information is critical. Sharing information and experiences in real time - between implementers in the field, as well as between implementers and more experienced practitioners or scientific experts - is critically important. There may be a variety of mechanisms for achieving this, including the establishment of an interactive electronic forum where field staff can post experiences and queries, and where those with appropriate experience and expertise can provide support and advice.

A copy of the proceedings of the workshop, prepared by the ENN, is included with this issue of Field Exchange and is also available online at www.ennonline.net or from Tula Michaelides, FANTA, email: tmichaelides@aed.org