July 2012 Issue 43 ISSN 1743-5080 (print) Special focus on government experiences of CMAM scale up Contents From the Editor Aim and structure of this special issue This Field Exchange special issue on ‘Lessons for the scale up of Community-based Management Field Articles of Acute Malnutrition (CMAM)’ mainly aims to provide some insights on scaling up CMAM from a government perspective. A large part of this edition is therefore taken up with the proceedings of 15 CMAM rollout in Ethiopia: the ‘way in’ to scale up an international conference on government experiences of CMAM scale up held in Addis Ababa, nutrition 14-17 November, 2011. A collaborative initiative between the Government of Ethiopia and the ENN, participation was heavily biased towards senior government representatives from 22 African 21 Effectiveness of public health systems to support and Asian countries. There were however, some representatives from United Nations (UN) agen- national roll-out strategies in Ghana cies, non-governmental organisations (NGOs), academia, bilateral donors, foundations and individual experts. Nine government-led country case studies (Ethiopia, Pakistan, Niger, Somalia, 27 Integrated Management of Acute Malnutrition Kenya, Ghana, Sierra Leone, Malawi, and Mozambique) were presented at the conference. These (IMAM) scale up: Lessons from Somalia operations take the form of nine field articles at the core of this issue, with a tenth article on experiences from India that includes a postscript of developments post conference. The Addis conference contribu- 39 Capacity development of the national health tions are complemented by two more field articles from Nigeria and Zimbabwe and a selection of system for CMAM scale up in Sierra Leone research, evaluation and news that all speak to the CMAM scale up theme. 45 Community management of acute malnutrition in Mozambique Rabia, seven months, with 51 Management of acute malnutrition in Niger: a her mother at an OTP countrywide programme/Prise en charge de la malnutrition aiguë au Niger: Un programme national 67 Scaling up CMAM in the wake of 2010 floods in Northern Lucia Zoro, Nigeria, 2011 Pakistan 74 Creating an enabling policy environment for effective CMAM implementation in Malawi 78 Integrated management of acute malnutrition in Kenya including urban settings 85 Managing severe acute malnutrition in India: prospects and challenges 88 Postscript CMAM in India: What happened next? 90 From Pilot to Scale-Up: The CMAM Experience in Nigeria 95 Frontline experiences of Community Infant and Young Child Feeding in Zimbabwe 97 Postscript cIYCF in Zimbabwe Éditorial Research 36 Linear programming to design low cost, local RUTF 9 UNICEF Global reporting update: SAM treatment in UNICEF supported countries News 58 Framework for integration of management of SAM into national health systems Objectif et structure de cette édition spéciale Cette édition spéciale de Field Exchange consacrée aux « Leçons pour le déploiement de la 62 Integration of the management of severe acute prise en charge communautaire de la malnutrition aiguë (PCMA) » vise principalement à malnutrition in health systems: ACF Guidance fournir des éclairages sur le déploiement de la PCMA d’un point de vue gouvernemental. Une grande partie de ce numéro porte en conséquence sur le déroulement de la conférence 63 En-net update, March-May 2012 internationale sur les expériences gouvernementales en matière de déploiement de la PCMA qui s’est tenue à Addis-Abeba du 14 au 17 novembre 2011. La conférence était issue d’une MAMI-2 research prioritization – call for collaborators 63 collaboration entre le Gouvernement de l’Ethiopie et l’ENN et la majorité des acteurs 64 Conference on Government experiences of CMAM présents étaient des représentants gouvernementaux de haut rang venus de 22 pays scale-up: meeting report africains et asiatiques. Étaient également présents des représentants des Nations Unies (ONU) et d’agences non-gouvernementales (ONG), des personnalités des milieux universi- 64 Nutrition Exchange 2012 (formerly Field Exchange taires, des bailleurs de fonds bilatéraux, des fondations et des experts individuels. Neuf Digest) now available études de cas sur des pays et menées par des gouvernements (l’Éthiopie, le Pakistan, le Niger, la Somalie, le Kenya, le Ghana, la Sierra Leone, le Malawi et le Mozambique) ont été présen- 65 CMAM Forum Update tées lors de la conférence. Ces études de cas par pays sont présentées sous la forme de neuf articles de terrain qui sont au cœur de ce numéro, un dixième article relatant les expériences 65 FANTA-2 reviews of national experiences of CMAM obtenues en Inde, y compris une note sur les développements survenus après la conférence. Dans ce numéro, les contributions issues de la conférence d’Addis sont accompagnées de A standard for standards in humanitarian response 65 deux articles provenant du Nigéria et du Zimbabwe, ainsi que d’un choix de recherches, 65 What do you think of Field Exchange? d’évaluations et de nouvelles qui traitent toutes du déploiement de la PCMA. L’objectif global de la conférence d’Addis Abeba était d’identifier des exemples de Update on Minimum Reporting Package (MRP) 66 déploiement fructueux d’initiatives de PCMA ainsi que des défis communs dans le domaine. trainings in London and Nairobi Deux mises en garde importantes doivent être mentionnées ici. Tout d’abord, le fait que des pratiques de déploiement PCMA réussies aient été relevées ne signifie pas nécessairement Evaluation que ce qui a été fait dans un contexte ou à un moment donné dans le passé représente le 83 Management of acute malnutrition programme meilleur procédé à appliquer dans un autre contexte ou à un autre moment. Deuxièmement, review and evaluation le but n’était pas de prescrire des moyens tout faits pour organiser le déploiement de la PCMA, notamment en termes de structure et de gestion du programme. Le but était plutôt Professional Profile d’attirer l’attention sur quelques caractéristiques qui doivent être abordées et les mécan- ismes locaux et mondiaux qui pourraient être renforcés afin de guider et de soutenir le 98 Dr Nadera Hayat Burhani déploiement de manière plus efficace. 1 The overall aim of the Addis Ababa conference was to the number of children under five years treated as part of inclusion of SFPs within CMAM programming2 and identify examples of CMAM scale up success and CMAM programming. The figure is very close to 2 million. current CMAM working definitions from FANTA2 and the common challenges. Two important caveats should be The speed and scope of scaling up CMAM is quite breath- CMAM Forum specifically include MAM children within stated here. Firstly, whilst successful practices in scaling taking and unprecedented in terms of the scaling up of their scope. Indeed at ENN we may well be guilty of this up CMAM were noted, it should not be assumed that other nutrition interventions. However, and without increasing ‘blind spot’ when it comes to MAM, opting to what has been done in one context or at one time in the wishing to be overly cautious or even to sound negative, focus most of our attentions on SAM management in past represents the best action for another context or there are major challenges that need to be tackled in CMAM in the Addis conference. Part of our rationale for time. Secondly, the aim was not to prescribe set ways to order to take this promising approach to a level whereby this at the Addis conference was the lack of a clear frame- organise CMAM scale-up, particularly in terms of how the the majority of children that develop severe acute malnu- work for treatment and prevention of MAM and absence programme is structured and managed. Rather, the aim trition (SAM) will have access to appropriate care of leadership around the inclusion of MAM treatment in was to point towards some features that need to be administered through government run health systems in the context of CMAM; we did not want any ensuing addressed and the local and global mechanisms that the long term. Actions to help plan integration into debate to overshadow the lesson capture at the heart of could be strengthened in order to guide and support national health systems are reflected in two news pieces: the conference. MAM management certainly featured in scale-up more effectively. a framework on integration of SAM management being some of the nine case study countries but not consistently piloted by UNICEF EASRO, and a guidance written by so, and there were many related questions emerging (with To help distil lessons for CMAM scale up, a synthesis Action Contre la Faim on the same topic. few answers). Furthermore, where MAM does feature in of lessons learned from government CMAM scale up was programming, the emphasis seems to be on food/ 1 produced by the ENN . This extended editorial It is sobering to consider that the figure of 2 million specialised product interventions with little programming summaries the synthesis findings and identifies the key SAM cases treated probably represents less than 10% of around non-food MAM interventions. So one of ENNs learning points and ways forward that emerged from the the global SAM case load. This partly reflects the fact that (many) lessons from the conference experience is we need case studies and conference proceedings. These are countries such as India with the most significant case- to talk about MAM. To this end, we encourage you to presented under ten emerging themes, illustrated with loads are only at the beginning of scale up. It also submit experiences, research and challenges to Field country-specific examples that are detailed in the field undoubtedly reflects the fact that scaling up is difficult Exchange on this topic, and especially welcome those that articles included in this edition. The Addis Ababa confer- on many levels.