Creating an enabling policy environment for effective CMAM implementation in Malawi

By Mr Sylvester Kathumba

Mr Sylvester Kathumba is Principal Nutritionist with the Ministry of Health, Malawi. This article was authored by Mr Sylvester Kathumba with policy and support from Catherine Mkangama, Director of Nutrition, HIV and AIDS Office of the President and Cabinet and CMAM Advisory Services.

The author would like to acknowledge the Department of Nutrition, HIV and AIDS-OPC, CMAM Advisory Services (CAS), Clinton Health Access Initiative (CHAI), UNICEFMalawi, VALID International, CIDA Malawi and Irish Aid Malawi.

Background

Community mobilisation

The Community based Management of Acute Malnutrition (CMAM) approach aims to increase the coverage and accessibility of treatment for acute malnutrition. It provides treatment for malnourished individuals through decentralised care from health centres, treating the majority of severely malnourished cases as outpatients through the provision of Ready to Use Therapeutic Food (RUTF) and basic medical care.

The CMAM approach is built on the principle of community involvement and aims to increase the ability of people to prevent, recognise and manage malnutrition within their communities. CMAM complements existing health services and can potentially create new opportunities and points of contact for follow-on health and nutrition activities, such as HIV testing, family planning and nutrition counselling.

The CMAM programme in Malawi serves children less than 12 years of age through the following components:

• Community outreach to raise community awareness, identify cases and follow up malnourished children.
• Severely malnourished children who have appetite and no complications are treated in their homes using RUTF, with weekly check-ups in the Outpatient Therapeutic Programme (OTP).
• Severely malnourished children with medical complications are treated as inpatients through Nutrition Rehabilitation Units (NRU) until their condition improves and they can complete their recovery in the OTP.
• Children with moderate acute malnutrition (MAM) are given dry take-home rations through the Targeted Supplementary Feeding Programme (TSFP).

The CMAM Programme in Malawi also provides services to moderately malnourished pregnant and lactating women through the TSFP.

CMAM evolution in Malawi

CMAM in Malawi has evolved through a lengthy process that started from the food crisis that developed during 2001. A number of nongovernmental organisations (NGOs) came to assist with this disaster. Two of these organisations were Valid International and Concern Worldwide who supported the Ministry of Health (MoH) in the emergency, conducting an operational research programme to test the safety and efficacy of the new CMAM approach in Dowa District during 2002. Due to the early success of the Dowa programme, the MOH added another district to the operational research in 2003.

Through the decentralisation of treatment, the CMAM approach in Dowa was able to address some of the difficulties of service access that the population were facing. These included:

• Inaccessible services for most of the children that required care.
• Recurrent seasonal rises in severe acute malnutrition (SAM), from <0.5% to >3%.
• Increased case loads that the health system was struggling to cope with, compounded by HIV/AIDS.
• Congestion in health facilities due to long in-patient stays, HIV related complications and chronic food shortages.

In 2004, the Ministry organised the first national CMAM dissemination workshop for District Health Officers (DHOs), NGOs and partners. There was a great interest among the DHOs, who demanded that the programme should also be started in their districts. In response to this, the Ministry added three more districts in 2005. Gradual scale up to cover all 28 districts of Malawi has continued since then (see Table 1 for a timeline and milestones of CMAM scale up). This clearly demonstrates the power of evidence-based research, creating demand from service providers through robust programming and dissemination of results.

In 2006, the CMAM approach was adopted by the MoH as a strategy for managing acute malnutrition among children in the country. To achieve this, a number of processes took place, including:

• Formation of the CMAM steering Committee, which provided the policy support body to guide the scale up process of CMAM across the country.
• The CMAM Advisory Service (CAS) was set up to provide support to the MoH with technical assistance for the scale up process and to ensure the standardisation of operations.
• Interim guidelines were developed to harmonise implementation modalities of the programme.

Figure 1 presents the timeline Malawi has taken to scale up CMAM programming.

The primary aim of the scale-up of CMAM was to expedite and accelerate sustainability of the programme, by incorporating it into the routine health activities of Primary Health Care (PHC) services. In this way, children with acute malnutrition who are at increased risk of morbidity and mortality can receive the care they need through the same pathways that they routinely access treatment of other illnesses or infections.

Vision for CMAM in Malawi

CMAM is not implemented as a vertical, standalone programme. Instead it is included as one of the many services that are routinely provided at health facilities. This implies that health policies and guidelines must fully incorporate all CMAM components into their preventive and curative protocols and monitoring and evaluation systems.

The overall aim of the scale-up of CMAM in Malawi was to ensure the programme was designed to be fully integrated within existing institutions and structures and therefore sustainable. Some characteristics important for an integrated CMAM include:

• CMAM services are fully managed, implemented and supervised by the DHO and MoH staff.
• Regular health services at both health facility and community level routinely identify, refer and treat malnourished children.
• CMAM activities are funded through District Implementation Plans (DIP) as part of the district health budget.
• RUTF and other CMAM supplies are ordered, stored and distributed through the essential supplies distribution system.
• CMAM data are collected and reported using the same reporting structure and schedule as other health centre data.
• Key indicators on CMAM are reported through the Health Management Information System (HMIS).
• Pre-service training curricula of health professionals include management of acute malnutrition.
• Effective linkages with other child survival and HIV programmes are in place.

Policy environment

During the 1990s, nutrition remained largely on the ‘back burner’ in Malawi, buried amongst the multitude of health issues that the country faced. The food crisis of 2001/2 took policy makers somewhat by surprise, as Malawi had been considered ‘food secure’ for a number of years, even exporting many agricultural products such as beans and maize. This food crisis focused attention on the neglected problems of malnutrition within the country.

The increased attention provided the environment for a slow but steady transformation. During 2001/2, nutrition in Malawi benefited from combined forces: a conducive policy environment, a reasonably well developed NRU system within MoH structures, some nutrition ‘champions’ within the MoH, and a new revolutionary treatment for SAM cases, using RUTF. Malawi was one of the first countries to test and then adopt the CMAM approach. Evidence of the successful treatment of thousands of severely malnourished children through CMAM gradually helped to convince decisionmakers that the country had the capacity and needed to tackle the issues of widespread malnutrition.

During 2005, a major change was implemented - coordination of nutrition moved to the Office of the President and the Cabinet (OPC). This move ensured that nutrition could become a cross-cutting issue, an essential step if the root causes of malnutrition were to be effectively addressed.

The OPC is responsible for policy direction and for mobilising resources, while the MoH has the responsibility for implementation of these policies, such as the National Nutrition Policy and Strategic Plan, which was developed within the wider EHP (Essential Health Package).

A Nutrition Committee is chaired by the OPC and meets twice a year. Additionally, there are multiple technical working groups established under this committee, such as those looking at Infant and Young Child Feeding (IYCF) issues, Targeted Nutrition Programmes, CMAM Stakeholders Committee, etc.

This move to the OPC enabled the MoH to focus its attention on implementation of programmes, while helping to strengthen the policy environment for nutrition. An example of this is the clearly defined role of nutrition in the Malawi Growth and Development Strategy (MGDS). The MDGS is an overarching operational medium-term strategy for Malawi designed to attain the nation’s Vision 2020. The MGDS has six pillars. The 6th Pillar is ‘Prevention and Management of Nutrition Disorders, HIV and AIDS’. This pillar has three focal areas namely:

1. HIV and AIDS: the goal is to prevent further spread of HIV and AIDS and mitigate its impact on the socioeconomic and psychological status of the general public.
2. Nutrition: the goal is to ensure nutritional well being of all Malawians.
3. Interaction between HIV/AIDS and nutrition: the goal is to improve the nutritional status and support services for people living with HIV/AIDS (PLHIV) for improved quality and duration of life.

Furthermore, nutrition has a separate line item within the budgets of the DIPs. Challenges remain when trying to translate policies into action, mostly due to the number of urgent health priorities that the country is trying to deal with and the limited resources for this. However, Malawi is currently on target to meet Millennium Development Goal (MDG) 4, which if successful will be a major achievement.

Due to strong leadership within government, nutrition is now being packaged as a cross-cutting issue in the same way as accounting. So while there is a general Ministry of Finance, there are also accountants located in each of the ministries to assist with the finance of each Ministry. For example, the Ministry of Transport has its own accountants. The same idea is being applied to nutrition. It is planned that each of the ministries will have a nutrition section based within it, which can ensure that that nutrition issues remain firmly on the agenda of each Ministry.

Another example of a successful advocacy tool utilised in Malawi has been the production of a ‘MP’s kit’ in 2008. The MP’s tool kit was developed to help parliamentarians guide actions. It included explanations of the magnitude of malnutrition problems, the consequences, why nutrition matters for national and economic development, their role as MPs, and what they could do to promote nutrition. This advocacy has been very effective, with MPs recently resisting the budget cuts that were suggested for nutrition.

Local production of RUTF

In most countries, all RUTF is centrally procured by UNICEF. However it is encouraging that MoH in Malawi recently started procurement of RUTF from its own budget to supplement the supplies procured by UNICEF and the Clinton Health Access Initiative (CHAI).

Due to the high cost of imported RUTF and the long process of transportation from France, two organisations have setup local production facilities that currently provide all the RUTF needs for Malawi. In Blantyre, Project Peanut Butter (PPB) was established during 2005. This production facility started from a small facility in a local hospital, developing into a large enterprise that has a current production capacity of 120 metric tons per month. In Lilongwe, Valid Nutrition (VN) also started from humble beginnings in a small factory, which has grown to become a major production facility capable of producing 160 metric tons per month.

There are a number of challenges associated with local production of RUTF, particularly with the importation of certain raw materials (powdered milk and the mineral vitamin complex). Problems also arise with aflatoxin contamination of the groundnuts (peanuts) used for the RUTF. Sufficient testing equipment is only available in Europe, which can mean long delays between production and test results.

Valid Nutrition are also committed to developing new formulations of RUTF using recipes intended to bring the cost of production down, whilst maintaining the curative integrity of the product. Formulations specifically for nutritional rehabilitation of persons with HIV have also been developed and tested in Malawi.

Progress on scaling up and integrating CMAM

National scale-up

Establishment of the CAS (previously known as the CTC Advisory Service) in 2006 helped considerably with the rapid country-wide scale-up of CMAM. The CAS is currently staffed by members of Concern Worldwide, with its role to provide technical support for the MOH to scale-up CMAM activities. There is particular emphasis on the standardisation of implementation activities, assistance with development of strategic plans, training and operational plans, mentoring and monitoring and evaluation (M&E) of MoH-led CMAM services.

All 28 districts of Malawi are implementing CMAM as of May 2010. However, the percentage of health facilities offering CMAM varies across districts, with some districts providing CMAM services in all hospitals and health centres, while others operate only a few CMAM sites. One of the main reasons for the disparities in site coverage is the necessary gradual nature of the scale up process. The Ministry wants quality service delivery such that it cannot authorise rapid scale up when the performance of an existing site is poor. Meanwhile, other districts benefited from NGO support and supervision, capacity building and provision of supplies.

In total, 70% of all health facilities in Malawi currently offer CMAM services for severely malnourished children. This is a major achievement.

The admissions to OTPs increased dramatically from 2004 mainly due to the scale up process. After the adoption of CMAM programmes by the MoH senior management team in 2006, there was a rapid scale up process. This meant that a lot of malnourished children had far greater access to decentralised services. However the increase in the number of NRU admissions is mostly due to reorganisation of data management. Previously the NRU and SFP data were being captured by WFP but from 2006, data management was moved to the CAS. Unfortunately, during the process some data were lost.

From 2004, the programme performance rates have generally been above the Sphere standards. The recovery rates have always been above the Sphere cure rate of >75% and the default rate <11% since 2005. The death rate has been <3% since 2004, apart from 2009 and 2010. This is impressive for a programme largely supported by the MoH.

There are a number of possible explanations for the increase in mortality rates in 2009 and 2010. These include poor clinical participation in CMAM, sub-optimal case finding activities leading to late presentation of cases, and nonadherence to CMAM protocols. This could also be due to a higher proportion of the caseload presenting with serious underlying illnesses such as HIV/AIDS or TB.

MAM treatment and prevention

During the first four years, CMAM had focused on SAM, while MAM was treated as a separate programme managed by WFP. However in 2009, MAM was integrated into the CMAM programme. The SFP programme treats moderately malnourished children from 6 months to the age of twelve years, and pregnant and lactating mothers. The beneficiaries are usually given take home dry rations of Corn Soy Blend (CSB), which is a premix of 4kg CSB, 500ml vegetable cooking oil and 500g of sugar.

MAM cases are identified in the community through the same mechanisms as identification of SAM. Community volunteers use mid upper arm circumference (MUAC) bands and refer those identified as malnourished (by yellow colour or 11.0-11.9cm) to the site.

The three components (SFP, NRU and OTP) have strengthened the continuum of care. Children can be directly admitted to any of the three components. However children can also be referred from one component to the other depending on treatment progress.

The MoH has made efforts to increase nutritional awareness amongst the community, particularly in relation to IYCF practices. Counselling on IYCF has been included in the CMAM guidelines to assist service providers to counsel the caregivers effectively on appropriate feeding practices. The guidelines have included preventive actions and optimal IYCF behaviours are widely promoted within the community in order to reduce malnutrition.

HIV linkages

MUAC assessment in the community

Malawi is highly affected by the HIV/AIDS epidemic, with a national prevalence rate of 12%.¹ The synergistic effects of HIV and poor nutrition are well understood, both as a direct cause (HIV causing malnutrition) and due to the enhanced nutritional needs of persons taking anti-retroviral therapy (ART). Within the NRUs, there is a very high HIV prevalence of 28%, which can rise to 50% in higher level referral facilities.

During the early days of programming at OTP, there were concerns that if the issue of HIV infection were raised, that there was a danger that you would ‘lose’ the child, with the parents/caregivers not willing to return to the health facility, i.e. if HIV issues were openly discussed and testing offered. These fears have, however, proven to be unfounded. All children are offered HIV testing on their first visit to the OTP, with parents/caregivers required to ‘opt out’ if they are not willing for the child to be tested. Current testing uptake rates are very high at around 90% (programme reports). Furthermore, parents are very keen to find out the results. It has been reported by many health workers that on the second visit, the mother has brought the father in for testing after discussion at home about the benefits of determining HIV status. Having already gained the trust of the community, through effective and appropriate programming, CMAM is thus proving to be an excellent entry point for HIV testing and counselling, and referral to appropriate treatment services, as required. Prevention of mother to child transmission (PMTCT) services have also been scaled-up to 491 out of 544 health facilities in the country (90%). The PMTCT clinics are also case detection points for CMAM services.

Much of the change in attitudes by both health providers and caregivers towards HIV can be attributed to the immense efforts made by Malawi to tackle stigmatisation issues. For example, a number of ‘HIV testing weeks’ have been implemented since 2008. During these weeks, intensive encouragement of testing using advertisements on TV and radio, nationwide mobilisation strategies, etc. are made. Much discussion surrounds ‘breaking the silence’, encouraging individuals and couples to come forward and check their status. Intensive counselling is offered for individuals and couples.

Key achievements

All 28 districts now implement CMAM (72% of all health facilities). In the scale up of CMAM in Malawi, there have been a number of key achievements to date. A key achievement was the integration of CMAM into the national nutrition policy and into national strategies for Integrated Management of Childhood Illnesses (IMCI), Essential Nutrition Actions (ENA), Accelerated Child Survival & Development (ACSD), and Infant and Young Child Feeding (IYCF). Coupled with the development of national guidelines for CMAM, a harmonised CMAM approach has been made possible throughout the country (national protocols, reports, training materials, etc). Significant developments around training include development of a national training manual and establishing a national CMAM training team (39 national trainers drawn from District Health Offices and supporting partners). Encouragement to train, reporting and supervision are included in DIPs in districts implementing CMAM. Terms of reference (ToRs) for CMAM, focal points and CMAM programme monitoring tools have been developed to guide the implementation and enable supervision of programmes. Furthermore, a national monitoring and evaluation system has been developed to compile, store and enable analyses of data on the management of acute malnutrition.

There have also been significant achievements around financing. The majority of districts fund CMAM costs out of district budgets. This includes initial and refresher CMAM trainings, supervision and district based coordination meetings. MoH and partners are procuring RUTF for the districts and the expansion and certification of local production of RUTF has been a success. Other health services have been strengthened through provision of an ‘entry point’ for services, such as HIV testing and support, and preventive nutrition programmes. The CMAM Learning Forum is a key initiative that brings together people throughout Malawi to share experiences and best practices.

Enabling factors

Government leadership and commitment has been a key enabling factor to scale up. National and district-level coordinating bodies are present and active. There is strong partnership involving donors and NGOs. Technical support and capacity building is available through the CAS. RUTF supplies are available from local producers. Results are well-documented and best practices are shared (CMAM Learning Forums, national reviews, involvement of district staff). There is an improved nutrition management information system at all levels and promotion of research, documentation and dissemination of best practices.

Challenges

Currently, a large amount of technical, financial, and logistical support for CMAM is provided by NGOs and international donors. This means that the service faces challenges around longer-term sustainability. Malawi is a country where health services are under-resourced and dependent on external funding sources for much of basic service provision. However, it is hoped and anticipated that external support for CMAM will be increasingly phased out over the coming years, as the MoH is more able to assume full management and funding of CMAM activities.

Specific challenges to the full integration of CMAM at national level include:

• Sustained longer-term funding of CMAM resources and supplies needs to be secured. A total of US$45,697,975 is required for 2011-2015 that comprises US$2,625,000 for training, US$337,975 for community mobilisation and US$42,735,000 for supplies, equipment and service delivery.
• Continued technical support to the CMAM scale-up in Malawi is necessary to ensure high-quality, effective CMAM.
• There are human resource constraints, for example, high turnover of staff within health facilities, necessitating frequent retraining and shortages of trained clinical staff and other health workers. There are difficulties in effective monitoring and evaluation of CMAM activities, such as late or incomplete reporting and poor data quality from some facilities.
• There are difficulties sustaining community outreach work, for example, some volunteers are inactive because of lack of incentive or expectation for financial incentives and there is inadequate supervision and documentation of outreach activities.

Conclusions and way forward

In order to strengthen CMAM programmes in terms of coverage, access and quality of service, the Government of Malawi will continue to advocate for CMAM, engage partners, strengthen domestic resource allocation through DIPs and budgets and mobilise resources from non traditional donors. It will continue to invest in strengthening institutional and human capacity and strengthen district and community systems (Community Nutrition and HIV Workers).

Although CMAM in Malawi started in an emergency context, the programme has evolved and integrated into routine primary health care services implemented by MoH staff. The MOH in Malawi has a strong role in providing CMAM services. The commitment is evident from the great strides that Malawi has taken to support the scale up process. This has involved development of CMAM and nutrition strategies, policies and guidelines, financing CMAM, linking CMAM to other child health activities and interventions (notably HIV/AIDS) , delivering on pre-service and in-service training, and realising national production and management of supplies of RUTF.

It is the view of the MoH in Malawi that effective and efficient implementation of a national CMAM programme will definitely contribute to the reduction of child morbidity and mortality and consequently improve the wellbeing of Malawian society.

For more information, contact: Mr Sylvester Kathumba,
email: kathumbasylvester@gmail.com, sylvesterkathumba@yahoo.co.uk

¹Malawi Demographic and Health Survey (MDHS), 2010