Community-based management of acute malnutrition (CMAM) in sub-Saharan Africa: Case studies from Ghana, Malawi, and Zambia
Kenneth Maleta and Beatrice Amadi Abstract Background. Recent success with community-based management of acute malnutrition (CMAM) has spurred interest on how to improve coverage while maintaining treatment outcomes. Objective. To document, as case studies, the experience of three African countries, Malawi, Ghana, and Zambia, in scaling up CMAM. Methods. Desk review using published and unpublished data and country programmatic data and key informant interviews. Results. All three countries, with different motivations for startup, have successfully integrated CMAM into their essential health packages for children under 5 years of age, at least in their policy and strategic documents. Strong leadership by the ministries of health has been instrumental, complemented by key stakeholders and donor partners. Implementation is at variable stages, depending on when the program rolled out, with Malawi having achieved the most integration, followed by Ghana and Zambia. Using CMAM, the three countries have significantly extended service coverage and improved treatment outcomes, with cure rates ranging from 73% in Ghana to 90% in Malawi, while maintaining very low death rates: 1.7% in Malawi, 2% in Ghana, and 5% in Zambia. Conclusions. CMAM is a viable option to improve service coverage and outcomes in health systems where inpatient therapeutic care alone cannot suffice.
Kenneth Maleta is affiliated with the University of Malawi College of Medicine, Blantyre; Beatrice Amadi is affiliated with the University of Zambia Medical School. Lusaka. Please direct queries to the corresponding author: Kenneth Maleta, Department of Community Health, University of Malawi College of Medicine, Private Bag 360, Blantyre 3 Malawi; e-mail: [email protected]
Key words: Africa, case study, community-based management, severe acute malnutrition
Introduction Severe acute malnutrition (SAM) in children under 5 years of age remains a major global public health concern. Recent global estimates suggest 52 million under-fives, representing 8% of all under-fives, are moderately to severely wasted. In developing countries, the prevalence is estimated at 8.8% of all children under five. The global estimate of the prevalence of severe wasting is 3.1% (19 million), with higher prevalence in south-central Asia and central Africa, where the prevalence is 5.1% and 5.6%, respectively . In recent years there has been a shift from the traditional facility-based management of acute malnutrition to a combination of facility- and communitybased management following successful research and pilot implementation projects. The dual, integrated approach, which combines inpatient care based on the World Health Organization (WHO)-recommended management protocol  and outpatient therapeutic care complemented by supplementary feeding programs, has been evaluated, demonstrating effectiveness in achieving wide coverage, high recovery rates, low mortality, and low default rates. The key elements of the approach, called community-based management of acute malnutrition (CMAM), are strong community mobilization, outpatient supplementary feeding for patients with moderate acute malnutrition (MAM), outpatient therapeutic care for uncomplicated cases of severe acute malnutrition (SAM), and inpatient care for patients with SAM with medical complications . Outpatient therapeutic care of SAM has been achieved through the use of ready-to-use therapeutic food (RUTF). RUTFs are oil-based pastes with a similar nutrient content (per 100 kcal) to the high-energy milk formula F100, but with a low water content, which does not allow for multiplication of bacteria, a property that
Food and Nutrition Bulletin, vol. 35, no. 2 © 2014 (supplement), The Nevin Scrimshaw International Nutrition Foundation.
Community-based management of acute malnutrition in Africa
makes them amenable to being used safely at home without refrigeration and even in areas where hygiene conditions are not optimal . Based on evidence of the effectiveness of CMAM and with increased availability of RUTF, CMAM was endorsed in 2007 by WHO, the World Food Programme (WFP), the United Nations System Standing Committee on Nutrition, and UNICEF as a new approach for managing SAM and MAM . Since then, many countries in Africa have adopted CMAM as the approach for managing SAM. A recent comprehensive review identified the following as the recipe for successful program rollout: creation of guidelines and policies, availability of an acceptable product that can be steadily supplied, integration of CMAM services into existing health service delivery, implementation of a strong community outreach program, a supply system and logistics management for the food (including local production where feasible), monitoring and evaluation, training, and strong partnerships between local and international agencies . In the present case study, we document progress made in adoption of CMAM in three selected African countries, Malawi, Zambia, and Ghana, as examples of what can be achieved. The three countries were selected because of their high burden of acute malnutrition, with estimated prevalence rates of 5%, 5%, and 9% in Malawi, Zambia, and Ghana, respectively. Additionally, the countries represent different approaches to adoption and rollout of CMAM services, which could provide lessons to countries wanting to adopt CMAM. Specifically, the review sought to document the status of integration of SAM into the public health sector, service organization and coverage, food products in use, monitoring and evaluation, alignment of inpatient treatment of SAM to the WHO guidelines, the measures used to build capacity, and challenges in the management of SAM.
Methods To document the progress made, we reviewed published documents on the inception and rollout of CMAM services in the selected countries and interviewed key informants from ministries of health, stakeholders supporting CMAM rollout, and research groups. The documents reviewed consisted of commissioned reports of CMAM evaluations that were done in 2009 and 2010 by the Food and Nutrition Technical Assistance Project (FANTA) and other evaluators. Additional documented information was sourced from the CMAM Forum, conference presentations, nongovernmental organization (NGO) and national programmatic data and reports, and published review papers on the management of SAM. In Malawi and Zambia, the review also included interviews with key informants from the ministries of health.
Results Integration of management of SAM into the national public health sector
The three countries had different motivations for rolling out CMAM: Malawi was motivated by an emergency situation; Ghana was motivated by a national desire to improve case management and hence had a deliberate rollout plan; whereas in Zambia the drive was from a research project to improve cure rates. Despite the differences in motivation, there are general similarities in the steps that the three countries have taken to roll out CMAM services. The Emergency Nutrition Network defines integration as management of SAM and MAM as integral parts of CMAM. CMAM is one of the basic health services to which a child has access. It is delivered by the same means by which other services are delivered, is embedded as part of a broader set of nutrition activities, such as Infant and Young Child Feeding (IYCF) and micronutrient supplementation, and has a multisectoral approach to tackle the determinants of malnutrition. Based on this definition, all three case study countries have partially integrated CMAM into their primary healthcare at the policy level, whereby children with acute malnutrition receive care through the same pathways and centers they use for access to treatment of other illnesses or infections. Standards and guidelines have been either developed or incorporated into primary healthcare and Integrated Management of Childhood Illness (IMCI) programs, but they differ in the level of integration and stage of implementation. All the countries, however, have included CMAM activities in their national nutrition strategic plans and incorporated them into other child survival programs. In Malawi, CMAM is integrated into the Health Sector Strategic Plan 2011–2016, the National Nutrition Policy and Strategic Plan, Essential Nutrition Actions, IYCF, the Accelerated Child Survival and Development (ACSD) program, and the District Implementation Plans. Similarly for Ghana, CMAM is integrated into the Ghana Health Sector Medium Term Development Plan 2010–2013 and the draft National Nutrition Policy and District Implementation Plans. On the other hand, in Zambia, the integration is less elaborated at the policy level, but CMAM is part of the National Food and Nutrition Strategic Plan for Zambia 2011–2015 and has also been incorporated into District Implementation Plans. In all cases, CMAM activities are included in national health budgets, although the level and scope differ from country to country. In Ghana and Zambia, the program is largely coordinated through the ministries of health, while in Malawi the program is coordinated through a Department of Nutrition and HIV/AIDS, which straddles several ministries, although implementation is mainly through the
Ministry of Health. National advisory, technical, and implementation committees have been set up in Ghana and Malawi in a very structured way to help any districts that plan to roll out CMAM activities. Zambia has similar support, which is nested within the Ministry of Health through the nutrition directorate and draws on cross-sectoral expertise. These structures and committees coordinate policy formulation, scale up activities, provide technical expertise, build capacity, provide monitoring and evaluation, offer learning forums, and help leverage resources for CMAM activities. Program organization
The main treatment used for community-based management of SAM in all three case study countries is a peanut-based RUTF and basic medical care. For inpatient care, all countries were using milk-based F75 and F100. In Ghana and Malawi, F75, F100, and RUTF were part of the essential health package and essential drug list that was procured by the Ministry of Health and distributed throughout the health system using the same mechanisms as those used for distributing other health commodities. In Zambia, until recently RUTF was being procured by UNICEF and the Clinton Health Access Initiative (CHAI), but the Zambian Ministry of Health has since developed a budget line to take over this responsibility. In all three countries, the major national provider for supplementary food programs remains the WFP, which provides corn–soy blend (CSB) as a dry ration. Other NGOs also participate on a smaller scale or in limited geographic locations in each of the three countries. For example, in Zambia the Rainbow Project and World Vision International provide maize meal, CSB, cooking oil, and beans. The commodities for supplementary feeding are almost invariably produced locally in each of the countries. F75 and F100 are imported into the three countries, usually with logistical support from UNICEF. RUTF is produced locally by two companies in Malawi (Valid Nutrition and Project Peanut Butter), which are franchisees of Nutriset S.A.S. (Malaunay, France). The Zambian program receives supplies from both Malawian producers in addition to supplies from Nutriset. In Ghana, there is no local producer and the commodity is imported by UNICEF from Nutriset. All the commodities used are very highly acceptable in the three countries. In all three case study countries, CMAM started in a pilot region or district and in selected health facilities as learning sites. Once the coordinating bodies were satisfied with the performance, additional sites and regions were included incrementally to increase geographic coverage. Malawi, which started earlier than the other two countries, was found to have nearly universal geographic coverage of CMAM programs in all districts and health facilities, with 98% coverage for inpatient
K. Maleta and B. Amadi
care (100 of 102 hospitals) and 82% coverage for outpatient therapeutic care (512 of 624 health centers). Ghana, which completed its first phase of implementation in 2012, had covered half the country, with 5 of the 10 regions implementing CMAM activities in 607 health facilities (567 providing outpatient therapeutic care and 40 inpatient care) and 5461 communities having access to CMAM services. Complete rollout to the rest of the country was planned for the end of 2013. In Zambia, only 5 of 10 provinces were implementing CMAM activities (102 inpatient care sites, 104 outpatient therapeutic care sites, and 73 supplementary feeding sites). In all three countries, supplementary feeding coverage was low, ranging from only 10% in Zambia to 58% in Malawi, according to the national programmatic data. Despite geographic availability of sites providing CMAM activities, there were disparities in the comprehensiveness of services and reach of the programs. Additionally, there is a paucity of data on service or program coverage in all three countries, because coverage surveys have not been comprehensively conducted. In Malawi, CMAM activities have been incorporated into national health management information systems and reported using the same structures. In Zambia and Ghana, although CMAM activities have been incorporated, the monitoring data are handled through a vertical system using a separate database. National programmatic data in Malawi indicate that, despite supplementary feeding program coverage greater than 70% of health centers, coverage of targeted children is below 50%.* Reported national cure rates for outpatient therapeutic care in 2012 were 90%, 80%, and 73% in Malawi, Zambia, and Ghana respectively, while reported death rates were 1.7%, 5%, and 2%, respectively. Default rates remain a challenge in some programs, especially in Ghana, where national data indicate up to a 24% default rate in 2012. Additionally, postdischarge followup in all countries remains weak, considering the low coverage of supplementary feeding program sites. In general, there is a paucity of cost-effectiveness data from the three case study countries. Data from Malawi in 2007 suggest that adding CMAM to existing services cost US$42 per disability-adjusted life-year (DALY) saved , while a similar analysis from 2009 in Zambia suggests that adding CMAM cost US$203 per child and US$53 per DALY saved . Mechanisms to identify children suffering from SAM
Children with acute malnutrition are identified at two levels: in the community and at health facilities. At the community level, this is done by community health workers. In Ghana, the cadres involved include * S. Kathumba, personal communication based on vulnerability assessment data from WFP country office.
Community-based management of acute malnutrition in Africa
community health nurses and community health officers, complemented by community volunteers as well as fetish priests. In Malawi and Zambia, the cadres involved include community health nurses, health surveillance assistants, and community health volunteers. In the community, screening is conducted using midupper-arm circumference (MUAC) and a check for edema. At health facilities, MUAC and assessment of edema may be used, but additionally weight-for-length or weight-for-height or body mass index (BMI)-forage may also be used, depending on the level of health service delivery. These assessments are done during all routine activities and clinical assessments. Additional screening is done at growth-monitoring clinics and during national immunization days and special child health days. In all three countries, further screening occurs through routine clinic visits, maternal and child health clinics, and vertical programs, including tuberculosis and antiretroviral clinics, and any contact with a sick child. The available documented evidence suggests that there is no active case-finding through special community surveys. Alignment of inpatient treatment of SAM with WHO guidelines
All three case study countries have aligned their inpatient treatment to the WHO protocols, with some adaptation. In Malawi, the WHO Child Growth Standards  were adopted in 2008, and revisions of tools and protocols (including IMCI protocols, child health passport, and CMAM guidelines) to accommodate the new case definitions based on the new standards have been completed. Trainings for national trainers to conduct regional and district trainings have started but are yet to be completed. In Ghana and Zambia, a similar process is in place, with draft guidelines and tools developed as of 2012, and training planned. In all three countries, when CMAM was adopted, the ministries of health produced training manuals and guidelines (final in Malawi and interim in Ghana and Zambia) to standardize the level of skills and knowledge of service providers. The training manual was developed to suit the training of all health service providers (clinicians, nurses, and health surveillance assistants) at all levels. The trainings were organized at either the national or the district level, but with emerging changes; orientation of providers to the revised guidelines is yet to take place in most cases. In Malawi and Ghana, such training has included the preservice level for almost all health workers, whereas in Zambia this is yet to happen for some health workers. Stakeholders involved in management of SAM and their roles
In all three countries, implementation is supported
by UNICEF, USAID, WHO, WFP, CHAI, and other NGOs. In general, WFP supports commodities for supplementary feeding in all three countries, while UNICEF provides financial and logistical support. A plethora of international NGOs complements the two with financing, monitoring and evaluation, and occasionally provision of services. Challenges
In all three case study countries, the major challenge is resources. Although there is a demonstrable shift toward ministries of health taking over financing of CMAM, at present there is a significant amount of donor input, which raises questions about sustainability of the programs. In Malawi, the nutrition policy and strategy have been costed and CMAM activities have been included in the costings. Resource allocation, however, remains a challenge, despite strong policy leadership. In Ghana and Zambia, the government is taking over financing of commodities and implementation, but rollout remains incomplete. In all countries, supervision and monitoring remain a challenge because of generally weak health systems. This is especially pronounced in the community component, where outreach to identify those most vulnerable remains weak. In Ghana and Zambia, the lack of local producers of RUTF is another major challenge limiting scaling up of CMAM. Stockouts and logistical challenges are often cited as contributing to the high default rates in outpatient therapeutic care programs. Most of the technical support is external in all three countries, which may affect sustainability after the programs are completely handed over. The dearth of operational research and coverage studies is another major challenge.
Conclusions The three countries reviewed here demonstrate that irrespective of the mode of startup, it is possible to scale up CMAM and improve coverage and treatment outcomes for children with SAM and MAM. With deliberate effort, integration at the policy and strategic level seems to be a key driver to rolling out a CMAM program. The review further documents that considerable technical expertise and experience are readily available for regions and countries wanting to roll out CMAM activities. Key to the process is an incremental approach that allows for fine-tuning the service according to local environments and clear identification of resources for implementation. Although the routes adopted in the three countries may differ, they all seem to be on course to developing a fully integrated CMAM service as part of their primary healthcare.
K. Maleta and B. Amadi
Both authors collected, collated, and reviewed all case study documents. Kenneth Maleta collected information and interviewed informants in Malawi; Beatrice Amadi collected information in Zambia; Kenneth Maleta wrote the first draft; Beatrice Amadi reviewed and approved the contents of the paper.
The authors thank all the key informants for providing information. Special thanks go to Dr. Seth Adu-Afarwuah for collating the Ghana data and Dr. John Phuka and Mr. Sylvester Kathumba for their contribution to the Malawi data.
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