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Evaluation database

Evaluation report

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

Author: UNICEF Evaluation Office

Executive summary

“With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System". Within this system, an external independent company reviews and rates all evaluation reports. Please ensure that you check the quality of this evaluation report, whether it is “Outstanding, Best Practice”, “Highly Satisfactory”, “Mostly Satisfactory” or “Unsatisfactory” before using it. You will find the link to the quality rating below, labeled as ‘Part 2’ of the report.”


The Government of Pakistan (GoP) and the Department of Health (DoH) initiated the Community Management of Acute Malnutrition (CMAM) programme in Khyber Pakhtunkhwa (KP) in 2008. CMAM
was scaled up following the flood disaster of July 2010 to address malnutrition and promote optimal child feeding practices. It was implemented in collaboration with UNICEF, WHO and WFP, and through
implementing partners (IPs) and covered northern, central and southern districts of KP. Other child nutrition programmes include Infant and Young Child Feeding (IYCF) and prevention and control of
micronutrient deficiencies. CMAM is also implemented in Sindh and Punjab provinces. Wasting, a measure of acute malnutrition, has increased over the last decade in Pakistan; it was
estimated at 11.8% in 2001, 13.1% in 2006, and 16.8% in 2011.


UNICEF undertook this evaluation to assess CMAM programme performance and gather lessons to inform scaling-up of CMAM. The CMAM evaluation in Pakistan is part of a global evaluation commissioned by UNICEF, which covers five country case studies and a synthesis report. The four CMAM components in Pakistan are: 1) Community outreach (screening, referral, follow-up, and community mobilization); 2) Outpatient treatment (OTPs) for severe acute malnutrition (SAM) without complications and home-based administration of ready to use therapeutic food (RUTF); 3) Inpatient treatment in stabilization centres (SCs); and, (4) Management of moderate acute malnutrition (MAM) through a supplementary feeding programme (SFP).


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. Quantitative data on beneficiaries were analysed to determine whether
programme targets had been met. Qualitative data also supported the analysis. Programme data was analysed for sample districts from December 2010 to November 2011.

Findings and Conclusions:

Relevance and Appropriateness
The evaluation has determined that CMAM is a relevant and effective approach in KP for addressing SAM and that effectiveness, efficiency and sustainability of the programme can be improved through the recommendations below. The implementation of CMAM in KP has been of good quality, resulting in a high rate of cure for children admitted with SAM. While the approach is evolving toward stronger integration into the national health system, CMAM’s potential is reduced by lack of government priority for nutrition and absence of a comprehensive national nutrition policy. Progress has been made in developing a Provincial Integrated Nutrition Strategy, which would be aligned to the Pakistan Integrated Nutrition Strategy (PINS) in KP. The PINS provides a strategic framework but does not have any funding attached to it.
Global Guidance and National Needs. Stronger adherence to global guidance is required for community assessment, results based planning and monitoring. There is currently no effective framework to guide integration of CMAM with the national health system. The national CMAM guidelines focus on treatment protocols and require expansion to discuss cultural adaptation, gender and equity, IYCF, and programme performance monitoring and to clarify screening, admissions and referral procedures.
UNICEF’s Technical and Organizational Support. UNICEF effectively provided surge capacity to expand CMAM, promoting success in meeting most Sphere standards for children admitted with SAM, UNICEF’s support resulted in establishment of a Nutrition Information System (NIS) and strengthening of the nutrition cluster nationally and provincially. However, for scaling up, UNICEF needs greater headquarters and regional support and more staff members with nutrition expertise to promote nutrition policy and provide consistent guidance to the GoP and IPs. [...]

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The recommendations are closely tied to the findings and conclusions above. The GoP should take the lead in all except Recommendation 3, where UNICEF takes the lead.
Policy, Strategy, Guidelines
1. Advocate for and support joint planning for development of a national nutrition and provincial strategy which outlines the strategic priorities, assigns nutrition authority and coordination mechanisms, sets out capacity needs, and makes budget commitments for nutrition interventions.1 A focus on multisectoral and integrated longer term approaches is seriously required.
2. Strengthen and update national CMAM guidelines to include detailed protocols for referrals and admissions to SCs, more on IYCF, intersectoral coordination, and guidance on addressing cultural, gender and equity issues and monitoring programme performance.
3. Provide technical support to the CO to design CMAM expansion. Strengthen monitoring and advocacy at the national and provincial levels by ensuring dedicated staff with nutrition expertise for managing CMAM.
Planning and Monitoring
4. Strengthen the NIS oversight to ensure reliable and consistent collection of gender disaggregated programme data and training of staff who are responsible for data recording.
Programme Implementation and Quality Assurance
5. Conduct coverage surveys in KP and track coverage as part of programme performance analysis.
6. Given the scale of MAM in Pakistan, seek alternative approaches to ready to use supplementary products, through researching local recipes, and strengthen IYCF through increasing numbers of COWs and Lady Health Workers.
Capacity Development
7. Conduct a training needs assessment for each CMAM site and provide appropriate levels of training according to staff experience and knowledge. Evaluate training periodically.

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Lessons Learned:

1) The CMAM model works effectively to treat and manage acute malnutrition but it cannot be “applied” without significant fine tuning. Assessments should identify the groups most at risk (such as children of women who are not allowed to leave their homes) as well as knowledge, attitudes and practices that challenge the application of the model (such as use of private health care providers, lack of nutrition knowledge, etc.) and recommend actions which are then designed in the planning stages.
2) One of the first considerations in planning CMAM is the cultural attitude towards caretakers’ and children’s participation. These may be constraints to access to women and children and should be detailed through the assessment process. In patriarchal societies, access to women and children by health workers may be limited by tradition and men’s attitudes. In Pakistan, immediate involvement of men in the community in planning CMAM is important to sensitize them and necessary for successful screening, coverage and involvement of mothers and children in the programme.
3) Training needs assessment to meet individual requirements for quality job performance and more indepth training for those who may be less experienced is important to ensure high quality and consistent services across CMAM sites. Refresher training courses are critical to test skills and bring staff up to date.
4) The non-existence of referral mechanisms between SC and OTP makes it difficult to trace children that are discharged from SCs. Protocols must be updated to address this gap in CMAM implementation.
5) All external agencies should promote sustainability when implementing CMAM and avoid the ownership of the programme to be kept largely among the external actors. Strong coordination for planning, integration, ownership, and capacity transfer is essential among the government, UN, donors and IPs.


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