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EVALUATION OF COMMUNITY MANAGEMENT OF ACUTE MALNUTRITION (CMAM) UNICEF Evaluation Management Response Template Evaluation title: Evaluation of Community Management of Acute Malnutrition (CMAM) – Global Synthesis Report

Year: 2013

Office and person in charge for management response: Werner Schultink

Overall response to the evaluation: The overall direction of the evaluation was defined in consultation with PD Nutrition, specifically through input into the TOR. There are several strengths to the evaluation, in particular that it draws from a range of data sources (survey, case study, desk review) and covers the range of country contexts. While many of the conclusions confirm existing knowledge in the nutrition field, the consolidation provided by the evaluation provides valuable insight into the current status of CMAM implementation, views of staff, and specific details on case study countries. There were also some limitations to the evaluation, including the length of time to complete the evaluation (a period of 2 years) during which time CMAM practice continued to evolve. The desk review was drawing primarily on CMAM evaluations in case study countries, which may not reflect the wealth of information already available in existing CMAM evaluations and risks overlooking innovative examples of how to move CMAM practice forward. In some instances the teams were not optimally prepared with background information, affecting their general understanding of country contexts and issues which in turns affected the efficiency of the evaluation and accuracy of the findings and recommendations. The recommendations do not differentiate between typologies of country contexts in terms of maturity of programme, scale or burden, or strategic direction of the nutrition programme. Overall, the recommendations provide a valuable moment to take stock and reflect on concrete ways to improve and mainstream UNICEF’s direct and partnership roles in CMAM in terms of policy level engagement, capacity building, and supply chain issues. HQ Nutrition will identify typologies of support required at CO level (action under recommendation 6), prioritize regional level issues through events such as 2 RO workshops on CMAM and nutrition information, as well as continue support to lesson learning internally through various activities outlined in the response, as well as externally through CMAM Forum. The majority of activities outlined in the response involve RO consultation which will also serve to sharpen response focus on regional level and country specific issues related to CMAM along the broad areas outlined in the evaluation.

Planned use of evaluation: The evaluation will be shared externally (email circulation, posting on the Evaluation external website, and presentation at an interagency technical meeting on community based SAM treatment in London in November 2013) as well as internally (with ICON as well as targeted dissemination through ROs to COs). The material from the evaluation will be cited and incorporated where relevant in UNICEF nutrition policy papers and technical briefs that are developed in future. The actions covered in the management response will form the basis for the 2014 workplan development for HQ and RO Nutrition.

Evaluation Recommendation or Issue 1: Continue to work with governments, WFP, WHO, IPs, and other stakeholders to secure a common

understanding on the most effective means of addressing MAM in order to unify approaches, to strengthen community-based preventive

measures, and to prevent SAM and relapses into SAM.

Management Response: (Agree, Partially Agree, Disagree): Agree

If recommendation is rejected or partially accepted, report reasons:

2

Actions planned Responsible

Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled

Actions taken Supporting

documents

In order to better understand the

relationship between SAM treatment

and MAM treatment, UNICEF and

WFP will engage in a strategic review

of the outcomes from the recent SAM

and MAM mappings in order to

identify and address key issues related

to these two components of CMAM.

NiE/SAM

with inputs

from RO

Q2 2014 Underway Initial discussions with WFP and

agreement on review, though scope and

timing TBD.

UNICEF will continue to play a

technical role in the MAM Task Force

under the Global Nutrition Cluster

(GNC) in order to ensure that guidance

on decision making for MAM

treatment and prevention in

emergencies promotes appropriate

linkages between programming to

prevent and treat acute malnutrition.

NIE/SAM Q4 2013

(for revision

of GNC

guidance

document)

and

continued

TF

participation

through

2014

Completed Review of field testing of version 1 of

the MAM decision making tool

undertaken and revision of the guidance

finalized by MAM Task Force.

As part of coordinated workplanning

for 2014 between UNICEF and WFP,

UNICEF will define its strategic role

in collaboration with WFP to prevent

acute malnutrition and will actively

participate in WFP’s efforts to

consolidate the evidence base and

approach for treatment of MAM and

prevention of acute malnutrition

through existing technical platforms.

NIE/SAM and

WFP HQ,

with inputs

from RO

Q1 2014 Underway Initial agreement on coordinated

workplanning secured from WFP.

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Evaluation Recommendation or Issue 2: Establish a guideline or framework for integration of CMAM into the health system and with other

interventions that is useful at national level when based on capacity assessments and national health, nutrition and community development

strategies.

Management Response: (Agree, Partially Agree, Disagree) Agree



Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

UNICEF and WHO will continue to

co-lead the Task Force on Integration

of the Management of SAM into

Health Systems. The Task Force aims

to facilitate analysis of existing

integration approaches, develop

technical guidance and tools, develop

communication materials for engaging

with stakeholders, and support

capacity for implementation of the

guidance and tools. While the Task

Force will develop collective

materials, its role is also to facilitate

interagency sharing and learning in

order to promote best practice,

including documentation of criteria for

integration and sustaining integrated

services.

NIE/SAM

with the range

of partners in

the integration

Task Force,

with inputs

from UNICEF

Health

Section

Q3 2014 Underway The TOR for the Task Force has been

revised based on partner feedback in

2013. A Task Force telcon in Q4 2013

reviewed the TOR and defined key

activities and deliverables for 2014.

TOR for the

integration

Task Force,

minutes from

the Dec 2013

telcon.

Nutrition and Health will work in

close collaboration to ensure that

Nutrition is part of community based

service packages. Inputs from Health

will be essential as integration of

nutrition into health services will be

limited by function of the health

system. UNICEF Health and Nutrition

NIE/SAM and

UNICEF

Health

Section

Ongoing

through Q4

2014

Underway Tool kit developed with Health and HIV

section that specifically includes SAM:

“Guide on country level adaptation for

coverage determinant indicators for

health, nutrition and HIV interventions

delivered through the health system.”

Ongoing work with UNICEF Health to

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will continue to work with RO to

support the mainstreaming of the

MORES approach at CO level as a

means to identify bottlenecks and

solutions in order to increase effective

coverage of SAM at different service

delivery platforms (community, health

facility and outreach).

continue building UNICEF capacity in

MoRES application, including technical

support to COs upon request.

In order to complement government

capacity in supply chain management

(recommendation 9) a strategy will be

developed to assess feasibility of

integrating CMAM commodities into

existing national supply systems (e.g.

essential medicines).

SD &

NIE/SAM

Q3 2014 Not started Assessment conducted in Ethiopia based

on CO request. Report shared with RO.

Assessment planned for Burundi and

Pakistan (USAID Funding) based on SD

workplan priorities.

Supply Chain

Assessment

Methodology

Evaluation Recommendation or Issue 3: Facilitate coordination and technical support at regional/national level to expand or develop

national CMAM guidelines as CMAM is integrated with other interventions such as IYCF.




Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

Structured technical support will

continue to be provided to CO in 2014

based on coordinated planning with

RO, prioritizing countries that are

developing or revising CMAM

guidelines.

NIE/SAM and

RO

Ongoing Underway

The IYCF in Emergencies toolkit will

be revised and where relevant,

linkages to other nutrition

interventions such as CMAM will be

strengthened.

NIE/SAM and

IYCF with

input and

support of RO

Q2 2014 Underway TOR developed and funding secured for

the consultant to facilitate the revision.

TOR

In order to determine needs for NIE/SAM and Q 2 2014 Not started

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revision or additional guidance in

relation to IYCF and CMAM, a

stocktaking will be undertaken on

dissemination, adaptation and use of

current IYCF in CMAM guidance.

IYCF with

input and

support of RO

Evaluation Recommendation or Issue 4: Strengthen community outreach by ensuring adequate investment in CMAM awareness-raising

activities and their integration with outreach for other public health interventions.




Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

Recommendation 2 addresses

integration of CMAM into health

structures, while this recommendation

focuses on the community

mobilization aspect. Linked to

integration work outlined under

recommendation 2 (MoRES/DHSS

and other efforts to support integration

and scaling-up) the outreach

component of CMAM will be

examined from the supply and demand

sides. If the need for specific guidance

is identified in recommendation 2,

guidance will be developed for

community outreach based on best

practice, literature review, and partner

consultation.

NIE/SAM,

C4D, with

input and

support from

the RO and

CO in

partnership

with

ACF/CMN

Q4 2014 Underway Data collection underway

Structured technical support will be

given to CO who are

revising/expanding community

outreach activities, in coordination

with RO.

NIE/SAM in

collaboration

with RO

Ongoing

through Q4

2014

Underway

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Evaluation Recommendation or Issue 5: Decentralize nutrition information systems to strengthen data collection and analysis at district

level supporting and reinforcing the MoHs’ lead role and joint accountability among the MoH and partners for improving quality.




Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

Technical support will be provided to

RO and COs to map and assess

existing information systems

(including reporting on supply

availability) and identify opportunities

for institutionalization of nutrition

information systems at CO level

(linked to MoRES implementation and

Health System Strengthening).

NIE/SAM

with RO and

SD support

Ongoing

through Q4

2014

Underway Pakistan and Vietnam assessments and

provision of technical support.

Nutrition information system mapping

and bottleneck tool drafted.

Mission

reports.

The development of software and

systems for the use of Rapid SMS in

routine nutrition information systems

and surveys at national and

subnational levels will be documented

and lessons learned disseminated.

NIE/SAM,

ROs and

ACF/CMN

Q4 2014 Underway Presentation of current work at a series

of conferences. To date, this includes a

global audience in Oct 2013 in London,

and WCARO and ESARO regional

audience in Q1 2014.

Ongoing support for Rapid SMS in

selected countries on request, with a

specific focus on countries supported by

Food For Peace as this is a funded

activity under the grant proposal.

Evaluation Recommendation or Issue 6: Define a standardized monitoring system to assess the quality of the CMAM services to inform the

MoH, UN partners, IPs and other stakeholders where more capacity is needed.

Management Response: (Agree, Partially Agree, Disagree) Partially agree

If recommendation is rejected or partially accepted, report reasons: There is no one monitoring system that will fit every country context.

Countries will always need to adapt global standards to the specific context. The HQ role will be in sharing available experience, provision of

technical support, and further development of tools and resources that can be adapted at country level to fit country level realities and systems.

In addition, standards monitoring is addressed through the MoRES approach. MoRES will support L3 monitoring to improve programme

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outcomes and quality. Capacity may be one component that can be unpacked further if identified as a critical bottleneck, under the MoRES

framework.


Office/Person

Expected

completion

date

Implementatio

n stage: Not Started

Underway

Completed

Cancelled


documents

At global level, information on

nutrition programming at CO level

will continue to be collected annually

through the Nutrition Dashboard

(NutriDash) in order to aid in

prioritization of support to ROs and

COs in CMAM. NutriDash will

continue to collect SAM programme

information, but is expanded this year

to cover aspects of IYCF and

micronutrient programming, as well as

supply forecasting. Results will be

made available through a web-based

platform, and databases will be

developed to facilitate strategic

oversight of programmes by HQ and

RO.

PD Nutrition

with ROs and

SD

Q1 2014 (for

preliminary

report)

Underway

The NutriDash questionnaire has been

expanded and updated based on

consultation with HQ, RO and selected

CO. The actual web-based data

collection tool was launched in

December 2013, with supply data due in

January 2014 and other programme

modules due in February 2014.

Linked to recommendation 2,

technical support will continue to be

provided to COs in applying the

MoRES approach to improve

monitoring and evaluation of SAM

programming.

NIE/SAM in

collaboration

with RO

Ongoing

through Q4

2014

Underway Technical support provided to Nigeria

CO upon request from the CO under the

high-burden country cluster.

Trip reports

Linked to recommendation 2, a

methodology for countries to assess

their supply chain capacity will be

developed, and technical support will

be provided to country-lead capacity

SD with input

and support of

NIE/SAM and

RO

Q3 2014 Not started

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development of national distribution

systems to deal with nutrition supplies.

Evaluation Recommendation or Issue 7: Strengthen planning for CMAM through conducting community assessments, and greater use of

joint integrated results-based planning exercises and mapping information to help prioritize areas for scaling up.




Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

The UNICEF Programme Guidance

Document: “Management of Severe

Acute Malnutrition in children:

Working towards results at scale” will

be finalized and disseminated.

NIE/SAM

with input and

support of RO

and SD

Q1 2014

disseminatio

n followed

by technical

support

Underway Draft being finalized after extensive

consultation. Caseload estimation annex

already circulated to support 2014

supply planning.

A “How-to-Guide for Risk Informed

Programing for Health, Nutrition and

HIV” will be developed to enhance the

capacity of UNICEF country offices,

programmes, and partners in risk prone

or fragile settings to: (1) use risk

information to develop flexible

programmes, (2) to strengthen systems

to adapt/adjust programmes based on

risk, and (3) make the guidance and tools

available to prepare and respond to

shocks. Considerations for SAM

programming, in addition to other

nutrition interventions, will be addressed

in the guidance and tools.

NIE/SAM,

HATIS,

Health, HIV,

with input and

support of RO

Q4 2014 Underway Concept note for guidance developed,

funding secured, lead consultant

recruited and additional consultants in

the process of being recruited.

Concept note,

TORs for

consultants

Evaluation Recommendation or Issue 8: Improve awareness and capacity for conducting treatment coverage surveys and using the

information to analyze trends.

Management Response: (Agree, Partially Agree, Disagree) Partially agree

If recommendation is rejected or partially accepted, report reasons: As detailed in the State of Global SAM Management Coverage

document, a range of methodological issues need to be addressed in relation to coverage surveys before we can advocate that these are

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undertaken in all contexts.


Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

The technical paper “The State of

Global SAM Management Coverage”

developed by UNICEF/ACF/CMN in

2013 consolidated for the first time

review of the availability, accessibility

and coverage of SAM management

worldwide. The findings will be

disseminated widely in various fora to

stimulate partnership around

addressing technical gaps. A 2014

paper will be developed.

NIE/SAM,

ACF, CMN,

with input and

support of RO

Q4 2013 for

2013 report,

and Q2

2014 for

2014 report

Completed/

Underway

2013 report developed, HQ and RO

inputs secured and addressed, and

document shared internally and

externally. Initial discussions on scope

of 2014 report undertaken.

Final

document

Advocacy will be undertaken with

partners to secure practical action to

address critical methodology issues in

relation to coverage assessment, in

order to consolidate UNICEF’s

approach to coverage surveys. Some

of this work will be accomplished

through the current PCA partnership

with ACF-UK.

NIE/SAM,

ACF with

input and

support of RO

Q4 2014 Underway Active PCA in place PCA

Two regional-level workshops will be

designed and delivered by HQ in

collaboration with RO with a focus on

integration of CMAM into government

systems and supply management, and

strengthening nutrition information

systems and coverage assessment.

Priority areas for action identified will

guide further follow up by HQ.

NIE/SAM,

ACF, CMN,

with input and

support of RO

Q1 2014 Underway Events in planning stages, e.g. agenda

and materials developed and invitation

sent.

Concept note

and agenda

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Evaluation Recommendation or Issue 9: Strengthen means to reduce costs and promote national assumption of costs for ready to use

therapeutic and supplementary foods.


If recommendation is rejected or partially accepted, report reasons: The evaluation highlights the potential for local production to address

some of the cost issues, however it must be noted that local production is not the one and only way to reduce costs. There are a range of

efficiencies – negotiated costs, reduced wastage through better forecasting- that can be explored.


Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

SD will continue efforts to expand the

RUTF market, to promote market

competitiveness, and to investigate

means to reduce RUTF prices.

Knowledge shortfalls in relation to the

RUTF market and RUTF prices, which

have been noted to be limiting factors,

will be addressed through enhanced

communication.

SD with

support of

NIE/SAM and

RO

Q4 2014 Underway

SD and NIE/SAM will continue to

work with RO and CO to identify

appropriate strategies for next steps in

local production. This work will

include documentation of experience

in local production, actual costs,

limitations and potential mitigation

factors, as well as conditions for

sustainability. These experiences will

be documented and disseminated in

the form of an advocacy brief/policy

stance paper.

SD with

support of

NIE/SAM and

RO

Q4 2014 Underway

A supply chain guideline for RUTF

and other supplies relevant to SAM

treatment will be developed. This

guideline will build off of the existing

SD with

NIE/SAM and

partners

Q4 2014 Not started

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supply chain guideline developed by

WFP and partners with input from

UNICEF (released November 2013).

That foundational guideline addresses

supply forecasting, food safety and

food quality issues, and logistics of

supplies for treatment of MAM and

prevention of acute malnutrition.

Evaluation Recommendation or Issue 10: Conduct further operational research to find alternative RUTF formulas to promote feasibility of

local production that meets international standards.

Management Response: (Agree, Partially Agree, Disagree) Partially Agree

If recommendation is rejected or partially accepted, report reasons: The information on which this recommendation is based seems to be

limited.

There is a need to clarify between operational research (which confirms practicalities of using particular product in programmatic

environment) versus clinical research (that is needed to identify whether a formula will achieve intended treatment outcomes). Significant

reduction of RUTF price can be achieved only by replacing the most costly ingredient (i.e. milk powder) with a less costly alternative which

would require clinical trials. Currently Valid Nutrition is undertaking work in this area. Once results are available, published and endorsed, the

feasibility of manufacturing (e.g. local production) can be initiated.

Replacing other ingredients in RUTF (e.g. peanuts) will not lead to price reduction but will make product more palatable/acceptable in

countries where peanuts are not part of common diet. This option may also be explored; however the research must be undertaken outside

programmatic environment. It is unlikely such research will be funded and managed by manufacturers; hence CIFF is funding development of

database of potential RUTF ingredients. UNICEF can then use the outcomes of this research as the basis of further strategic discussions in

relation to its approach to leading/managing such research.

Finally, UNICEF needs to clarify its role in relation to operational and clinical research in relation to nutrition.


Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

12

SD will lead development of an

agency level approach to engaging in

development of alternative RUTF

recipes and guidelines for their

introduction into the programmatic

environment.

SD with

NIE/SAM

Q4 2014 Underway

SD will lead UNICEF’s engagement

in the process of alternative recipe

development by supporting initiatives

from manufacturers and leveraging

initiatives such as the CIFF-funded

project of consolidating potential

ingredient database.

SD with

NIE/SAM

Q4 2014 Underway

SD will support the development of

guidance for countries to follow when

embarking on alternative recipe

development.

SD and

NIE/SAM

Q4 2014 Not started

Evaluation Recommendation or Issue 11: Strengthen policies and partnerships that sustainably support scale up.




Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

In order to build off of best practice in

the field and refine UNICEF’s

engagement in nutrition governance in

relation to CMAM programming,

structured lesson learning on policy

level engagement, integration of SAM

management into government systems,

and scale up of programing will be

undertaken. Findings will be

disseminated widely and will be used

NIE/SAM

with input and

support of RO

Q3 2014 Underway Scope of the lesson learning drafted

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to update available guidance.

Technical support will continue to be

provided to CO to strengthen

engagement in SUN countries and

advocate for adoption of SUN (or

SUN-like mechanisms) through

technical briefs, consolidation of

evidence, and guidance.

UNICEF senior management will

continue to play a key advocacy role

in promoting partnerships,

coordination platforms and donor

support (in particular linking

humanitarian and development

funding streams).

UNICEF senior management will

continue to support advocacy with

government officials as requested for

uptake of SUN.

PD Nutrition

and senior

management

with input and

support of

ROs

Ongoing

through Q4

2014

Underway

UNICEF senior management advocacy

with high-level delegation from Sudan

to adopt SUN.

A mapping of requirements for

registration of CMAM commodities

and putting them into the market will

be undertaken.

SD with

NIE/SAM

support

Q4 2014 Not started Review of registration requirements

already undertaken in Ethiopia and

Tanzania.

Evaluation Recommendation or Issue 12: Plan and implement exercises which strengthen a joint vision among UNICEF, WFP, WHO, IPs

and the MoH on acute malnutrition.




Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

UNICEF will continue to provide

support and technical guidance to RO

NIE/SAM

with input and

Q4 2014 Underway

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and CO in relation to joint

workplanning and partnership

opportunities with relevant agencies

around acute malnutrition

programming.

support from

RO

UNICEF will advocate for revision of

the 2007 joint statement on CMAM in

order reaffirm respective roles and

collaboration in relation to CMAM

across the continuum of care.

NIE/SAM and

senior

management

Q4 2014 Underway Linked to proposed joint workplanning

with UN sister agencies and work under

recommendations 1 and 2.

UNICEF and UNHCR will develop

technical guidance to guide

development of country level LOUs

between the two agencies in relation to

activities addressing treatment of acute

malnutrition.

NIE/SAM and

senior

management

Q1 2014 Underway UNHCR technical guidance drafted and

pending finalization

UNICEF and WFP will proactively

identify and promote best practice in

relation to SAM and MAM treatment

(e.g. planning, screening and referral,

etc).

NIE/SAM

with input and

support of RO

and WFP

Q4 2014 Underway Linked to joint workplanning with WFP

under recommendation 1

Evaluation Recommendation or Issue 13: Based on training needs assessments, job descriptions and appropriate supervision, scale up on the

job training (OJT), training of trainers (TOTs), pre-service training (PST) and refresher training ensuring coverage of districts.




Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

UNICEF will define its engagement in

relation to pre-service training as a

complement to on the job training,

TOTs and refresher training. Existing

initiatives will be mapped and

potential partnerships identified for

NIE/SAM Q4 2014 Not started

15

development and delivery of technical

support in these areas. Relevant

bottlenecks (such as human resource

management in relation to mitigating

capacity loss due to staff turnover, and

updating certification criteria of

specific cadres in terms of

institutionalization of capacity inputs)

will be identified and addressed.

Evaluation Recommendation or Issue 14: Strengthen prevention of SAM through ensuring that management of acute malnutrition is part of

a minimum package of nutrition interventions in all priority countries.




Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

Technical support will continue to be

provided to COs to design nutrition

programmes to promote delivery of

high impact nutrition interventions in

both SUN and non-SUN countries.

Additional focused support will be

provided to high-burden countries.

PD Nutrition

with input

from ROs

Q4 2014 Underway

Other relevant actions are already

detailed in relation to integration

(recommendation 2), scale up

(recommendation 11) and monitoring

of scale up (recommendation 6).

Underway

16

Evaluation Recommendation or Issue 15: Strengthen knowledge and lesson dissemination and sharing of successful approaches to

integration and scaling up.




Office/Person

Expected

completion

date

Implementation

stage: Not Started

Underway

Completed

Cancelled


documents

UNICEF will continue its partnership

and engagement in the CMAM Forum

in terms of sharing of technical

documents, lessons learned, and inputs

into technical briefs on integration and

SAM programming.

NIE/SAM and

CMAM

Forum with

inputs from

RO

Ongoing

through Q4

2014

Underway Financial and technical support

provided through current PCA.

Two UNICEF e-newsletters will be

developed and disseminated to share

field experience and best practice.

NIE/SAM

with inputs

and support of

RO and CO

Q2 and Q4

2014

Not started

A short technical brief on “state of

play” for community-based treatment

of SAM will be developed and

disseminated.

NIE/SAM

with support

of RO and

Evaluation

Office

Q3 2014 Underway Initial scope outlined.

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