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2012 Nepal: Evaluation of Community Management of Acute Malnutrition Community (CMAM): Nepal Case Study



Author: UNICEF

Executive summary

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Background:

The Government of Nepal (GoN), Ministry of Health and Population (MoHP), and UNICEF have been piloting the Community-based Management of Acute Malnutrition (CMAM) program since 2008; it currently operates in five districts. The Nepal CMAM programme aims to improve access to treatment for acute malnutrition among children 6-59 months of age, to promote integration of the CMAM programme in regular health services, and to create effective treatment capacity of the health system. In 2012, the programme will be expanded to the Integrated Management of Acute Malnutrition including infants under six months of age (IMAMI) in six new districts. Other ongoing nutrition programmes include Infant and Young Child Feeding (IYCF), micronutrient supplementation to children and women, food fortification, and food distribution in food insecure areas.

Wasting, a measure of acute malnutrition has remained stagnant over the last decade in Nepal; it was estimated at 11% in 2001, 13% in 2006, and 11% in 2011. Currently Severe Acute Malnutrition (SAM) affects 2.6% of children under five years of age. The MoHP and UNICEF undertook this evaluation to assess CMAM programme performance and gather lessons to inform scaling-up of CMAM. The CMAM evaluation in Nepal is part of a global evaluation commissioned by UNICEF, which covers five country case studies and a synthesis report.  The criteria of relevance and appropriateness, effectiveness and coverage, efficiency, and sustainability were applied to CMAM components and cross cutting issues. To accommodate time and budgetary limits, data were obtained from secondary sources, health system databases, visits to sample CMAM sites and interviews with stakeholders.

Purpose/Objective:

The evaluation will assist in advocating for resources for strengthening existing programmes and expanding community based treatment to the most affected areas of the country. The MoHP in 2012 has decided to scale up Integrated Management of Acute Malnutrition including infants under six months of age (IMAMI), starting with 6 additional districts of Nepal in 2012 with the support of UNICEF (in five districts) and ACF and UNICEF (in one district). At the same time, UNICEF will support MoHP to maintain and further strengthen the existing five pilot districts incorporating the specific evaluation recommendations. The Nepal country case study will also be part of the global consolidated CMAM evaluation report, which is expected to enhance the global CMAM knowledge and evidence base for sharing with other countries, as well as serve as input for advocacy and policy decisions on its future directions.

Methodology:

To accommodate time and budgetary limits, data were obtained from secondary sources, health system databases, visits to sample CMAM sites and interviews with stakeholders. Quantitative data on beneficiaries were analysed to determine whether programme targets had been met. Qualitative data also supported the analysis. Varying levels of programme maturity (from nine to 25 months) were factored in by creating reference periods for each district.

Findings and Conclusions:

Differences by pilot district such as accessibility of health facilities, management approaches, and durations of the projects (between nine to 25 months) all had an effect on programme outcomes. Despite these differences the overall programme target has been reached and the factors contributing to greater percentages of children receiving treatment (surpassing baseline estimates of children with SAM) include community-based mass screenings and referrals, increases in number of OTPs and SCs as part of routine health services, improvements in availability of supplies including medicines, home-based administration of RUTF, and community outreach to promote awareness of malnutrition and treatment activities.

CMAM can be sustained through integration in the regular health services with existing human resources and facilities as evidenced by the high quality of services available in OTPs and SCs in government designated health posts provided by health services staff. As CMAM service delivery has gradually strengthened and the SAM caseload at OTPs has been reduced, the district health staff has taken over the duties of the CMAM nutritionists and monitors, whose positions were phased out. Still, it is necessary to strengthen the integration with other existing child survival programmes, such as IMCI, ECD, INP, and CBCNP, for more efficient use of staff time and data collection systems and to reduce overlaps and duplications.

The evaluation analyses and findings have shown that the Sphere minimum standards on effective treatment for children admitted with SAM were achieved and surpassed in the pilot districts.

Recommendations:

Unify the “National Medical Protocol for CMAM” and the “Treatment Guidelines for Outpatient Treatment for CMAM”.
Develop guidelines on integration of CMAM/IMAMI into the national health system.
Study options for improving MAM management. Develop guidelines and protocols for setting programme objectives and performance indicators.
Review the effectiveness of coordination in support of nutrition policies and programmes.
Link CMAM (and IMAMI) through joint assessments and programme planning with government and assistance organizations working with infections control, water and sanitation, Early Childhood Development, Social Protection, and food security programmes.
Incorporate gender and equity in all CMAM surveys, assessments, programme planning documents, data collection, and evaluative reports.
Define a community outreach package supported by sufficient resources and guidelines for DHO implementation. Link community outreach tightly with MAM management to increase impact of counseling and community support with alternative options to treat MAM
Strengthen performance monitoring and trend analysis for screening of the under-five population.
Design improvements in quality of services where needed in OTPs and SCs.
Strengthen the capacity of the MoHP staff to expand CMAM and launch IMAMI.
Strengthen the logistics management centrally by placing staff directly responsible for CMAM in the DoHS and supply management at the DoHs
Increase the number of SCs and OTPs or facilities offering SAM treatment such as in sub-health posts.
Strengthen coordination among monitors and health workers across districts and national borders.
Ensure GoN commitment for increasing its share of funding and donors’ commitment for funding and technical support to the scale up of IMAMI to six new districts and continuation of the existing CMAM programme in five districts.
Support local production of RUTF for longer-term sustainability and cost-efficiency.



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