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Evaluation report

2012 Ethiopia: Evaluation of Community Management of Acute Malnutrition (CMAM): Ehiopia Country Case Study



Author: Independent consultants: Sheila Reed, and Camille Eric Kouam. Breakthrough International Consulting PLC: Abebe Alebachew, Habtamu Fekadu, and Meselech Roro.

Executive summary

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Background:

The Government of Ethiopia (GOE) through the Federal Ministry of Health (FMOH) has promoted community management of acute malnutrition (CMAM) since 2003 and the program has been rapidly scaled up countrywide since 2008. The CMAM program has evolved into being among the top priorities of the FMOH as stipulated in the Health Sector Development Program (HSDP) IV. It is implemented in collaboration with UNICEF, WHO and WFP and implementing partners (IPs). Other child nutrition programs include Infant and Young Child Feeding (IYCF) and prevention and control of micronutrient deficiencies.

Severe acute malnutrition (SAM) is a major childhood health challenge in Ethiopia, especially during emergencies. Wasting, a measure of acute malnutrition, was estimated at 10.5% in 2000 and 10.0% in 2011. The FMOH and UNICEF undertook this evaluation to assess program performance and to document key successes, good practices, gaps and constraints in scaling up CMAM in Ethiopia. The evaluation will contribute to a global synthesis report. Three CMAM components were evaluated: 1) Community outreach; 2) Outpatient treatment (OTP) for SAM cases without medical complications; and 3) Inpatient treatment in therapeutic feeding units (TFU). The evaluation of the fourth component, management of moderate acute malnutrition (MAM), is planned by FMOH as a separate exercise, however, linkages among the components are discussed. 

Purpose/Objective:

The CMAM evaluation aims to strengthen on-going and future CMAM programmes by generating and disseminating evidence on CMAM experiences. The findings from the evaluation will also be used to promote good practices in collaboration with UNICEF Head Quarters.

Methodology:

The criteria of relevance, effectiveness, efficiency, and sustainability and scaling up, were applied to CMAM components and to cross cutting issues. Data were obtained from secondary sources, health system databases, observations during visits to sample CMAM sites and interviews with stakeholders. Quantitative data were analysed to determine whether program targets were met and qualitative data supported the analysis. Data collection took place at the federal level and in five regions, 15 woredas and 45 health facilities.

Findings and Conclusions:

The CMAM approach has been effective in treating admitted SAM cases in Ethiopia; the decentralization, scale-up and integration of CMAM were facilitated by strong collaboration among government and  implementing and development partners. The process of moving from a largely emergency response mode to a longer term programmatic mindset is ongoing and lacks continuous funding support. The CMAM approach is relevant to community needs and demands, however, continuing evolution is warranted to adapt to new community structures, and to better serve pastoralist populations.

The decentralization of CMAM significantly improved access and coverage; the number of SAM cases treated annually has increased since 2002 from 18,000 to 230,000—more than 12 fold. Geographic coverage of OTPs has improved dramatically, overall health facility coverage is 59% and coverage for hot spot (most vulnerable to emergencies) priorities 1 and 2 woredas is more than 80%. CMAM has been less effectively decentralized in the pastoralist regions (Somali and Afar) due to weaknesses in the pastoralist Health Extension Program (HEP) which is under government review.

The cost per treated SAM case, excluding routine drugs, is estimated to be US $110. If fixed health service costs are removed, the cost per child is around $73. The cost associated with the RUTF comprises about 50% of the cost per child and 33% goes to clinical services. If Ethiopia changes from the current SAM admission cut off point of <11 cm MUAC to the 2006 global standard of <11.5 cm (weight for height <3 SD of WHO standards) to reach more children, the cost per child will decrease but cost per woreda will increase significantly by as much as 100%.

The efficiency of usage of RUTF has improved partly through community education to curtail inappropriate sharing, but a stronger system of accountability and monitoring may be needed. Procurement of RUTF poses a considerable constraint for scaling-up. 

Recommendations:

1. Enhance government ownership and commitment to scaling up for a permanent integrated CMAM.
2. Integrate CMAM with the woreda-based plan including CMAM indicators in the annual targets, annual review meetings and supportive supervision.
3. Strengthen the capacity of the FMOH and Disaster Risk Management and Food Security Sector (DRMFSS) to manage the Emergency Nutrition Coordination Unit’s data with minimal technical support.
4. Use opportunities for screening through the monthly Growth Monitoring Program contact point of Community Based Nutrition. (GOE)
5. Scale up CMAM to other geographic sites and non-hot spot woredas to reach all children who need the service. 
6. Extend training opportunities to all who directly deal with CMAM including health workers and as well as district managers.
7. Strengthen the use of performance and quality data at the district and facility level to allow them to make their own analyses and to promote decision making.
8. Develop a transitional plan to strengthen the national logistics system to handle the CMAM supplies through Pharmaceutical Fund and Supply Agency. (GOE,UNICEF)
9. Consider the inclusion of therapeutic feeding items (through the Food, Medicine, Health Care Administration and Control Authority - FMHACA) in Ethiopia’s essential drug/commodity list to facilitate the oversight of the production and importation. (GOE,UNICEF)
10. Explore options on how to finance the cost of routine drugs that are necessary for CMAM.
11. Further explore the benefits and costs of changing from the current SAM admission cut off point of < 11 cm MUAC to the 2006 global standard. (All Partners)
12. Advocate for CMAM funding and make sure it is given priority in SUN, REACH and other child survival programs. (GOE,UNICEF,Donors)
13. Encourage and support the private sector to produce RUTF locally by providing tax exemption privileges, bank loans, and land for investment and through public-private partnership funds. (GOE,Donors)

Lessons Learned:

1.  Where the supply and logistics system for CMAM is operated in parallel to the national health system logistics, sustainability outcomes require that an investment is made to strengthen the national system, including harmonization of any importation requirements for RUTF, and integrate CMAM supply and logistics as soon as possible.

2.  The planning and budgeting  for CMAM should be reflective of and integrated into the planning systems in the country, including at the planning level closest to the community, to promote efficiency and sustainability; having separate planning processes at federal and local levels does not strengthen the local processes which are strategic to promoting funding, coverage and effectiveness.

3. To support Monitoring and Evaluation (M&E) activities (recording, reporting, support supervision), two major issues need to be addressed: weak monitoring of the program itself and integration of M&E with the health management system.

4. When there is functioning CMAM program, emergencies can be contained through development intervention; however, the paradox needs to be addressed that funding development interventions through emergency humanitarian resources will not be sustainable.



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