CMAM in India: What happened next?

By Bernadette Feeney and James Lee

Bernadette Feeney is a Technical Advisor with Valid International. She is a nurse and public health nutritionist and provides technical support on implementation of CMAM in both emergency and non emergency contexts.

Pre School Sessions in Anganwadi Centre, Sagar District, Madhya Pradesh

James Lee is a member of Valid International’s management team and is responsible for the organisation’s work in India.

State-level actors in India have been quick to use the momentum established at the Community based Management of Acute Malnutrition (CMAM) Conference in Addis Ababa to take forward the severe acute malnutrition (SAM) agenda. States have considerable autonomy under India’s federal system and have a critical role in service delivery. Consistent with the powerful Indian civil society presence in Addis, next steps have been orchestrated in a three-way discussion between the NRHM¹, the DWCD² (which oversees the ICDS³) and India’s Right to Food movement, with additional participation from UNICEF, donors and technical advisors present at the Addis conference. An obvious starting point for India CMAM planning has been the agreement by all parties that an energy rich nutrient dense therapeutic food formulated to meet the nutritional needs of a child with SAM ]used in State CMAM programmes must not be of foreign manufacture or produced for-profit. With a lead time of at least six months before alternative RUTF local manufacture can begin, investigation of the manufacturing options is proceeding in parallel with planning for CMAM pilot programmes.

Two states, Odisha and Madhya Pradesh (both represented in Addis), are currently in the process of designing pilot programmes intended to furnish evidence on the impact of CMAM in the local context and inform eventual state-wide scaleup. If state (as opposed to national) level implementation strikes some readers as insufficiently ambitious, it is well to remember the size of these states. With an under-6 yr old population of 10 million in Madhya Pradesh and 5 million in Odisha, Madhya Pradesh may have over 700,000 SAM cases at any given moment. Odisha is estimated to have 260,000. The widespread implementation of the CMAM model in either state would thus have the potential to impact significantly on the global burden of SAM. Logistically, however, this is a major undertaking and initial pilots are likely to be implemented at district level or below this, at what is termed ‘block’ level.

Both Madhya Pradesh and Odisha have elected to implement CMAM through the ICDS system of anganwadi centres. These provide children under 6 years with either a hot meal or a dry take home ration according to age, and offers further take home rations to children identified with growth faltering (weight for age). This is a very dense network of service centres, so dense that even in a high prevalence environment like Madhya Pradesh, the number of cases per facility at any one time may be only one or two. Baseline prevalence surveys to be undertaken in pilot ‘blocks’ will help to determine whether pilot activities - along with all the staff training, orientation and community mobilisation to initiate them - will be required in all facilities or only a subset situated in pockets of higher prevalence.

Whilst both MP and Odisha have determined that the anganwadi centre will be the focal point for CMAM delivery, they differ in other important respects, including their approach to RUTF manufacture, and in the issues they expect evaluated through the pilots.

Manufacture of RUTF

In Madhya Pradesh, the State government wishes to explore large-scale industrial production through publicly owned facilities that would provide production capacity sufficient to supply all 50 Madhya Pradesh districts with RUTF (8,000 tonnes per annum). With the help of a food technologist from Valid international, a range of potential suppliers are being assessed and a business case being developed for review and possible investment by the State government. By contrast, the scale of production being investigated in Odisha is far smaller (20 tonnes per annum for two blocks) and is intended to supply the block (sub-district) level with a milk based energy dense nutrient rich therapeutic food. A significant feature of the Odisha plan is that the production facility is to be staffed and managed by the same local women’s self-help groups that already produce take-home rations for local anganwadi centres under contract to the ICDS. A specialist in community-level production provided by Valid International will initially work remotely and later on site with a food technologist nominated by a technical committee that has been set up on CMAM chaired by the DWCD The support will include refurbishing existing facilities to standard, ordering the appropriate materials and equipment, commissioning the facility and training staff.

Pilot objectives

In Madyha Pradesh, where the system of Nutritional Rehabilitation Centres (NRCs) has been greatly strengthened and expanded with UNICEF assistance, the pilot will evaluate the cost effectiveness of adding outpatient care through CMAM to the inpatient care provided under the NRCs. It is expected that SAM treatment coverage will be greatly improved, despite known weaknesses in the anganwadi system (see India article earlier). However, the density of the system required may also impose significant start-up and service provisions costs. It will be important to weigh costs against coverage outcomes and through operational research, investigate how to limit the impact on costs. Before/after coverage surveys carried out in each block as the service expands within the district, are likely to be a major feature of the pilot, along with rigorous documentation of treatment outcomes during the first year of CMAM. In Odisha, the focus of the pilot is somewhat different, in that it will test the efficacy of three different modes:

1. different hot cooked meals at fixed intervals in addition to the hot meals already provided at the anganwadi centre
2. a specially fortified version of the dry takehome ration, prepared by women self help groups, also provided at the anganwadi centre for younger children
3. a milk based energy rich nutrient dense therapeutic food also as a take home ration prepared by women of self help groups also to be provided from the anganwadi centre

Treatment coverage will also be evaluated to determine public health impact, although possibly on a less intensive basis than planned in Madyha Pradesh.

State-level partnerships

Madyha Pradesh and Odisha each have the advantage of being able to draw on support from a DFID-funded technical assistance support team (TAST) with a permanent presence in the state. TAST has provided a valuable point of contact and coordination for external CMAM technical assistance, given that the senior state officials who are driving the CMAM agenda are also extremely busy people.

In Madyha Pradesh, the TAST, together with UNICEF, was instrumental in developing and securing high-level endorsement for a state nutrition strategy that among other things created official policy space for CMAM pilots. Above all, however, it is a good understanding and a shared vision between the senior officials overseeing the NRHM and the DWCD that has been responsible for progress to date. These officials have been clear about what they wish to see, and have created an inclusive environment for state-level CMAM planning that draws in the necessary nutrition expertise both from within India and abroad. Inputs into CMAM preparation and discussion in Madhya Pradesh have been provided at various points by India’s National Institute of Nutrition, UNICEF, the Madyha Pradesh TAST, the Right to Food movement, the Real Medicine Foundation, and Valid International.

In Odisha, a technical working group for CMAM, including representatives from DWCD, NRHM, UNICEF and Odisha TAST, was established following return from the Addis conference. The technical working group has assumed responsibility for reviewing programme design, recipe formulation, determining the facility-level staff to be trained in CMAM, and reviewing both training materials and guidelines.

DFID has provided funding for an experienced Valid International CMAM advisor to spend an extended (2.5 months) period between the two states, working with stakeholders on a variety of technical questions, as well as a local counterpart to be mentored in CMAM in advance of the pilots. The same contract has made possible the site visits and technical appraisal by Valid International’s local production expert and the recruitment of local counterpart food technologists.

The demand side

The energy generated out of the Addis conference comes at a fortuitous time, in that state level advocacy groups that clamoured for years for a more effective response to the problem of SAM deaths are now also being supported to make tentative steps into nutrition education and service provision. These community-level efforts are likely to form an important complement to SAM treatment services, providing the demand-side strengthening that is needed to improve participation in the ICDS (and thus successful CMAM coverage). Particularly in the matter of case-finding and referral using mid upper arm circumference (MUAC), the pilots will require a more active outreach than is typical of the ICDS at present if they are to demonstrate maximum public health impact.

For more information, contact: James Lee, email: jamie@validinternational.org

¹National Rural Health Mission

²Department of Women and Child Development

³Integrated Child Development Services