10 years of CMAM What did we learn ? What are the remaining challenges ?

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10 years of CMAMWhat did we learn ? What are
the remaining challenges ?

• Dr. André Briend,
• Department for International Health,
• University of Tampere, Tampere, Finland
• andre.briend_at_gmail.com

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10 years ago, the main technical ingredients of
CMAM were already there

• RUTF
• Admission on MUAC
• Community mobilisation
• Some technical fine tuning since (e.g. MUAC for
  discharge).
• BUT,
• We learned it works

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We learned CMAM works and can be integrated into
Governement programmes
NGO run programmes Integrated programmes
Guerrero S, Rogers E, 2013
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Getting a high coverage remains a challenge
NGO run programmes Integrated programmes
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A cultural shift needed to address the coverage
challenge

• In the past, clinical excellence was regarded as
  the most important quality for a programme
• Quality of care still very important
• Fine tuning of treatment still needed
• But clinical excellence without good coverage
  will have limited impact
• Need for a public health approach
• Need for health system strengthening

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Priority action act on factors affecting coverage

• Early and effective case detection in the
  community
• MUAC , frequently (every month)
• Involve frontline workers, mothers
• Avoid RUTF stock-outs good planning needed
• Maintain quality of care

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Key message CMAM is not RUTF dumping

• Staff, supervision, functioning health system
  needed to achieve high coverage and good quality
  of care
• Budget needed, beyond providing supplies
• Political will from Governments needed

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Lack of political commitment

• Only a small proportion of all children with SAM
  get adequate treatment
• SAM still has low profile in the international
  health agenda

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SAM management not listed in the Global 2025
Nutrition targets
2012 World Health Assembly report. Annex on Child
Nutrition lt 2 lines on SAM in a 14 page document
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WHA supreme decision body in WHO

• Run by country delegates who approve resolutions
• 194 delegations
• Country delegates not aware of SAM public health
  importance and possibility of treatment
• Major advocacy failure that SAM treatment did not
  turn up in the 2025 Global Nutrition Targets

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Importance of SAM inadequately perceived by the
International Health Community
Incidence, not prevalence should be used to
assess the burden of an acute condition SAM
related deaths underestimated by a factor of 2 to
8 compared to stunting in the 2013 Lancet papers
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Oedematous malnutrition ignored by the public
health community
Limited prevalence data from NGOs Myatt,
unpublished
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Failure to assess the magnitude of the problem

• NGOs (on donor requests) have estimated for
  decades nutritional situation by WFH prevalence
  surveys.
• Incidence measures needed
• A shift from WFH cross sectional surveys to
  repeated large sample surveys needed or to
  programme data
• Only repeated MUAC measures with oedema
  assessment (as provided by a well run CMAM
  programme) can give an estimate of the problem
  magnitude

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Large scale MUAC surveys are possible and are
highly informative
7000 children measured in 1 month Spatial
distribution
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What did I learn over the last 20 years ?

• We live in a conservative world
• RUTF 5 years 5 years 10 years
• MUAC as admission criteria 20 to 25 years
• MUAC as discharge criteria ??
• SAM burden assessment with incidence not
  prevalence ??
• SAM getting attention from public health
  community ?? Politicians ??