Community Management of Acute Malnutrition (CMAM)

(an overview)

Anirudra Sharma Nutrition Specialist

UNICEF

National Nutrition Advocacy Meeting

15 July 2012

•Overview of Community based Management National Scale Up Plan

UNICEF

2012 - 2017

Status of wasting (by eco-regions)

Source: NDHS 2011

JHAPAMORANGSAPTARI SUNSARI•Rajbiraj

•Biratnagar•Chandragadi

FAR-WESTERN REGION

DOLPA

MUGU

JUMLA

KAILALI

BARDIYA

HUMLA

DOTI

SURKHET

NAWALPARASI KAPILBASTURUPANDEHI

DANG

BANKE

ACHHAM KALIKOT

SIRAHA

DARCHULA

BAJHANGBAITADI

DADEL-DHURA

KANCHAN-PUR

BAJURA

PARSA

BARA RAUTA-

DHANUSAMAHO-TARI

SARLAHI

DHADING

MAKAWANPURCHITWAN

KASKI

TANAHU

PALPA

SYANGJA

PARBAT

ARGHAKHACHI

GULMI

UDAYAPUR

SINDHULI

ILAM

BHOJ-PUR

PACHETHAR

DHANKUTA

TAPLEJUNG

RAMECHHAP

OKHAL-DHUNGA

TERHA-THUM

KHOTANG

Patan

B

KTMSOLUK-HUMBU

DOLAKHA

SANKHUWA-SABA

NUWAKOTSINDHU-PALCHOK

KAVRE

RASUWALAMJUNG

GORKHA

PYUTHAN

ROLPASALYAN

MYAGDI

DAILEKHJAJARKOT

RUKUM

MUSTANG

MANANG

•Simikot•Darchula

•Baitadi

•Dadeldhura

•Mahendranagar

•Dhangadi

•Dipayal

•Chainpur •Martadi

•Magalsen

•Gularia

•Birendranagar

•Dailekh

•Manma

•Jumla

•Gamgadi

•Jajarkot

•Dunai

•Jumlikhalanda

•Salyan

•Nepalgunj

•Ghorahi

•Liwang

•Jomosom

•Beni

•Baglung

BAGLUNG

•Kusma

•Pyuthan

•Taulihawa

•Sandhikharka

•Tamghas

•Sidharthanagar

•Tansen

•Syangja

•Pokhara

•Chame

•Besisahar

•Damauli

•Parasi•Bharatpur

•Gorkha

•Dhadingbesi

•Dhunche

•Bidur

•Hetauda

•Birgunj•Kalaiya

•Gaur

HAT

•Dhulikhel

•Chautara

•Charikot

•Ramechhap

•Sindhulimadi

•Malangwa

Jaleshwor •Janakpur•Siraha •Ineruwa

•Gaighat

•Diktel

•Salleri

•Okhaldhunga•Bhojpur

•Khandbari •Taplejung

•Phidim•Ilam

•Dhankuta

•Terhathum

EASTERN REGION

CENTRAL REGION

WESTERN REGION

MID-WESTERN REGION

CMAM Pilot

Legend

CMAM Pilot Districts

Situation of Emergencies in 2007/08 in Nepal

• Droughts in hills and mountains • Floods in terai regions• Severe food insecurity in many hills and mountain districts• A traditional seasonal out-migration • Disease epidemics – diarrhoea/cholera • Global Acute malnutrition was in critical threshold - 13%

nationwide and <15% in many districts • Impact of the ten-year lasting armed conflict with high

migration, displacement – disruption of basic social services, dysfunctional authorities, absenteeism of human resources

• Poor socio economic status • Concentrated epidemic of HIV and AIDS• Increased 3F (financial, food and fuel) crisis

As per the Baseline Survey, the Status of Under Five Wasting in Five Pilot Districts was…………….

Districts Mugu Kanchanpur Bardiya Achham Jajarkot

Years May/Jun2008

May/Jun 2008

May/Jun, 2008

Sept, 2008

Dec, 2008

GAM 26.6 % 17 % 16.2 % 18.0 % 10.5 %

SAM 7.1 % 3.3 % 2.8 % 3.6 % 2.4 %

Severity of Nutrition Crisis ( WHO Benchmarks)Severity Prevalence of Global

Acute malnutrition (GAM)

Action required Status of Nepal

Acceptable

< 5 % No any district fall in this box

Poor 5 – 9 % No need for population interventions Attention to malnourished individuals through

regular community services[

Approx. 30 districts fall in this status Even in the poor nutrition situation, attention

should be given to the acutely malnourished children

Critical 10 – 14 % or 5-9% with aggravating factors*

No general rations, but Supplementary feeding targeted to individuals

identified as malnourished in vulnerable groups Therapeutic feeding for severely acutely

malnourished individuals

Most of the districts (more than 40) fall in critical threshold

Nepal has 11% GAM and 2.6% SAM. Therefore, national wide, acute malnutrition crosses the critical threshold

Serious > = 15 % or 10-14% with aggravating factors*

General rations (unless situation is limited to vulnerable groups); plus

Supplementary feeding for all members of vulnerable groups.

Therapeutic feeding for severely acutely malnourished individuals

Few districts especially mid and far western hills and mountainous, few districts of central and western Terai and central hills falls in the serious situation

* The aggravating factors include: general food ration below the mean energy requirement, epidemic of measles of whooping cough (pertussis), high incidence of respiratory or diarrheal diseases, epidemic of HIV and AIDS, prevalence of malaria, natural disasters such as floods, earthquakes, droughts, heavy snow/hail falling, climate change and destroying humankinds or foods or livelihood, High prevalence of pre-existing malnutrition, e.g., stunting, Tsunami etc.; complex humanitarian situation such as arm conflict, Household food insecurity, Crude mortality rate greater than 1/10,000/day; Under-five crude mortality rate greater than 2/10,000/day etc;

Emergency Threshold

Source: WHO, Management of Malnutrition in Major Emergencies, 2000

Steps towards CMAM PilotDec 2007: Conducted feasibility studyOctober 2007: Organized orientation workshop for potential partnersMarch 2008: Organized child health sub-committee meeting on protocol

& implementation framework; and finalized national guideline and treatment protocol

June 2008: MoHP approved emergency nutrition policy, including CMAM piloting; and conducted CMAM baseline survey

January 2009: Organized national pilot planning meeting, organized Master TOT; and Started implementation in three districts

Sept. 2010: Implemented in next two districts2010/2011: CMAM is Recommended for national scale up from SUN

initiative, health sector nutrition evidence review and formative evaluation

2012: DHS/MoHP decided for national scaling up CMAM in new 6 districts; and pipeline in 9 additional districts

Goal of CMAM

Create increased access to treatment for (severe) acute malnutrition by bringing appropriate nutrition services (including awareness raising, outreach and counseling for prevention) nearer to the community

The Objective of CMAM pilot in Nepal

To evaluate the feasibility of the CMAM approach in different districts and different agro-ecological zones in Nepal. Following the monitoring and evaluation of the programme, recommendations will be made to the MoHP as regards treatment of acute malnutrition and the potential scale-up of the CMAM approach to most of the districts in the country.

9

• Identification of key individuals in community for activities

•Community case finding

• Promote understanding of programme and who is eligible

• Dialogue on barriers to uptake

•Case referral

•Case follow up

•Counselling

•Defaulter follow up

Principles and Components of CMAM

Principles: •Maximum access and coverage•Timeliness•Appropriate medical and nutrition care •Care for as long as needed

Components:

10

Classification for Acute Malnutrition(new classification by WHO)

*Complications: severe oedema, marasmic-kwashiorkor, anorexia, intractable vomiting, convulsions, lethargic, lower respiratory track infection, high fever, severe dehydration, severe anaemia, hypoglycaemia, hypothermia

CMAM Stakeholders in Nepal

National Lead: Child Health Division of DoHS/MoHP

Implementing Agencies: •District Public/Health Offices including local health system/structures•Local NGOs•Local Governance Institutions (DDC and VDCs)

Support agency: •UNICEF•EU•DFID•ACF

CMAM Performance in Five Districts(as of December 2011)

Why CMAM National Scale Up is Needed• Stagnant Status of Acute Malnutrition since last decade• Approx. 385,000 under five children are GAM (91,000 SAM) at a point of

time and it could be 2 times or more case load throughout a year i.e. 770,000 Moderately Acute Malnourished 182,000 Severely Acute Malnourished per year-more than WHO defined crisis threshold

• WHO estimates have shown that mortality among children with severe acute malnutrition (SAM) is 5 to 20 times higher compared to well-nourished children

• Aggravating factors and immediate determinants such as infections, insufficient food intake, different types of disasters for GAM are widely prevalent

• Approx. 2/3rd of total districts (50 districts) cross the crisis threshold throughout the country

• CMAM is recommended for national scale up by health sector nutrition evidence review and therefore, it is endorsed in MSNP for national scale up to address the issues of SAM

CMAM Scaling Up Modality

4. Programmes to address MAM (capacity building and Counselling of family and communities on IYCF and

care, health, ECD, and WASH)

2. Out-patient treatment programme (OTPs)

3. In-patient

treatment

programme

(SCs/NRH)

1. Community outreach/social

mobilization/Screening

5. Strengthen and improve

WASH facilities in OTPs/ SCs

Hygiene promotion

Multisectoral Involvement of Stakeholders at Local Level

Districts for Scale-up in 2012Region Districts GAM rate based

on ecological zone

Remarks

Mid-western development region

Jumla 13.2% Muntain district

Western Development region

Kapilvastu 15.2% Terai district

Central development regions

Dhanusha, Sarlahi 10.4% Terai districts

Eastern development region

Saptari and Okhaldhunga

10.3% in Terai and 10.5% in the hills

One Terai and one hill districts

JHAPAMORANGSAPTARI SUNSARI•Rajbiraj

•Biratnagar•Chandragadi

FAR-WESTERN REGION

DOLPA

MUGU

JUMLA

KAILALI

BARDIYA

HUMLA

DOTI

SURKHET

NAWALPARASI KAPILBASTURUPANDEHI

DANG

BANKE

ACHHAM KALIKOT

SIRAHA

DARCHULA

BAJHANGBAITADI

DADEL-DHURA

KANCHAN-PUR

BAJURA

PARSA

BARA RAUTA-

DHANUSAMAHO-TARI

SARLAHI

DHADING

MAKAWANPURCHITWAN

KASKI

TANAHU

PALPA

SYANGJA

PARBAT

ARGHAKHACHI

GULMI

UDAYAPUR

SINDHULI

ILAM

BHOJ-PUR

PACHETHAR

DHANKUTA

TAPLEJUNG

RAMECHHAP

OKHAL-DHUNGA

TERHA-THUM

KHOTANG

Patan

B

KTMSOLUK-HUMBU

DOLAKHA

SANKHUWA-SABA

NUWAKOTSINDHU-PALCHOK

KAVRE

RASUWALAMJUNG

GORKHA

PYUTHAN

ROLPASALYAN

MYAGDI

DAILEKHJAJARKOT

RUKUM

MUSTANG

MANANG

•Simikot•Darchula

•Baitadi

•Dadeldhura

•Mahendranagar

•Dhangadi

•Dipayal

•Chainpur •Martadi

•Magalsen

•Gularia

•Birendranagar

•Dailekh

•Manma

•Jumla

•Gamgadi

•Jajarkot

•Dunai

•Jumlikhalanda

•Salyan

•Nepalgunj

•Ghorahi

•Liwang

•Jomosom

•Beni

•Baglung

BAGLUNG

•Kusma

•Pyuthan

•Taulihawa

•Sandhikharka

•Tamghas

•Sidharthanagar

•Tansen

•Syangja

•Pokhara

•Chame

•Besisahar

•Damauli

•Parasi•Bharatpur

•Gorkha

•Dhadingbesi

•Dhunche

•Bidur

•Hetauda

•Birgunj•Kalaiya

•Gaur

HAT

•Dhulikhel

•Chautara

•Charikot

•Ramechhap

•Sindhulimadi

•Malangwa

Jaleshwor •Janakpur•Siraha •Ineruwa

•Gaighat

•Diktel

•Salleri

•Okhaldhunga•Bhojpur

•Khandbari •Taplejung

•Phidim•Ilam

•Dhankuta

•Terhathum

EASTERN REGION

CENTRAL REGION

WESTERN REGION

MID-WESTERN REGION

CMAM pilot districts

Legend

CMAM in Nepal

New CMAM districts, 2012

Districts in the pipeline for CMAM implementation, 2012/13

CMAM Scaleup Plan (proposed)(Considering >10% GAM Threshold)

Year Districts to be maintained

Districts to be scaled up

Total districts

Remarks

2012 5 6 11

2013 11 5 16

2014 16 5 21

2015 21 10 31

2016 31 10 41

2017 41 9 50

Challenges• Considering CMAM intervention as development agenda • RUTF procurement and supply and local production • Addressing the issues of MAM – assessment of economic

feasibility, sustainability and acceptance of the food based nutrition approach as compared to alternative approaches (strengthened IYCF counseling, ECCD, WASH) and voucher scheme or cash transfer

• The aggravating factors for wasting such as - monsoon floods, diarrhea epidemic and current social strata and vulnerabilities

• Resources for national scale up – the major challenges – Resources?? Donors support??

Way Forward • Incorporated in GoN regular AWPB for CMAM scale-up and

advocacy with EDPs for sustained financing • Establish and strengthen adequate coordination among service

providers • Build sufficient capacity of national duty bearers/only few

organizations are working in emergency nutrition sectors• Strengthening community outreach • HR management and development• Regular capacity building of health workers and volunteers• Quality monitoring and supervision

• Programme integration

Thank You