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Evaluation database

Evaluation report

2016 Malawi: Evaluation of Community Management of Acute Malnutrition (CMAM) in Malawi

Author: Eric Kouam

Executive summary

With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System (GEROS)". Within this system, an external independent company reviews and rates all evaluation reports. The quality rating scale for evaluation reports is as follows: “Highly Satisfactory”, “Satisfactory”, “Fair” or “Unsatisfactory”. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report, and the executive feedback summary labelled as 'Part 3'.


This report provides the findings of the evaluation of the Community Management of Acute Malnutrition (CMAM) in Malawi.
Acute malnutrition is a leading cause of infant and child mortality in Malawi, where the 2015 SAM burden was estimated at about 79,301 children under-five years of age. Management of malnutrition is 1 of the 6 priorities of the national Growth and Development Strategy 2011-2016 in the country. The National Nutrition Policy and Strategic Plan also includes CMAM as a core component.

The goal of this evaluation was to assess the overall progress and achievements in implementing CMAM within the context of UNICEF 2012-2017 country programme.
The evaluation was commissioned by UNICEF Malawi and was carried out by an independent international consultant. The evaluation was carried out between November 2015 and March 2016.


The overall aim of the evaluation was to assess the degree to which the programme achieved its objectives. The objectives of the evaluation were the following:

  1. To assess the CMAM relevance, efficiency, effectiveness, impact and sustainability, applied to the programme strategic areas.
  2. To assess the extent to which implementation of CMAM has contributed to systems strengthening (i.e. how coordination, governance and management, gender and equity, capacity development, advocacy and policy development, and information/data management has been established).
  3. To document best practices and generate evidence-based lessons and recommendations to strengthen efforts towards quality improvement and coverage of CMAM.


The standard UNEG/OECD-DAC criteria of relevance, effectiveness, efficiency, impact and sustainability were used to generate evidence for the evaluation, which was a process, output and outcome assessment of CMAM that took place from national to district and community levels. Data were obtained from secondary sources, individual interviews, focus group discussions and direct observations during visits to 18 sampled CMAM sites in 14 districts. Both quantitative and qualitative analysis techniques were employed. Outputs and outcome indicators were computed from quantitative secondary data and assessed against the standards/targets outlined in the National Nutrition Strategic Plan and the national CMAM guidelines. The analysis of qualitative data was inductive and thematic. Relevant portions of documents and verbatim (obtained from interviews and FGDs) were grouped under each evaluation question in order to complement quantitative analysis, highlighting contributing factors to the observed achievements. A performance rating of 1 to 4 (1 low; 4 high) was applied to judge each evaluation criterion.  The evaluation report underwent a rigorous review and written feedback from UNICEF and MoH focal points, as well as a validation meeting that took place in Lilongwe on July 11, 2016.

Findings and Conclusions:

The system strengthening target intervention areas were appropriate to the national context as they aimed to achieve full integration of CMAM into the health system.

CMAM guidelines were an important support for trained health workers and volunteers in properly addressing malnutrition in the NRUs, OTPs, SFPs and the community. However, frequent shortages of supplies, high turnover of skilled health care providers, irregular mentoring and delay in activity reporting were recurrent challenges experienced by health workers.

There has been great achievement in geographic coverage, with 100% NRU coverage, 94.8% OTP and 88.6% SFP. However, despite high geographic coverage, less than 50% of the target population have been reached over the 2012-2015 period.  Death rates were also high in some NRUs. The programme performance was within the recommended Sphere standards, except for default rates which were high consecutive to frequent shortage of supplies.

The implementation of CMAM successfully contributed to maintain the GAM prevalence under the emergency threshold. Mass screening lead to a dramatic increase in the number of admitted SAM and MAM cases. Putting more emphasis on community outreach would contribute to reducing the equity gaps by improving access to services in the country. In addition, suppression of service fees, more involvement of religious leaders and traditional healers would offer opportunity for identifying malnourished children. 

Reliance on external funding and lack of national funding commitments are jeopardising the sustainability of CMAM in Malawi. Efficient use of external funds through good coordination of different stakeholders’ CMAM budgets should be initiated for efficiency and sustainability.


  1. Revise the Community Outreach component of the national CMAM guidelines so as to strengthen the linkages between screening, referral, admission and follow up processes.
  2. Strengthen the capacity of health workers, District Health Officers, Health Surveillance Assistants, and volunteers for CMAM.
  3. Develop a community health strategy that strongly links CMAM with other health interventions implemented at community level.
  4. Conduct coverage surveys to appraise the distribution of health facilities that are providing CMAM services versus the actual needs/pockets of acute malnutrition in each district.
  5. Strengthen the national health information system for real time monitoring and timely reporting.
  6. Strengthen the government supply chain and logistics system for timely delivery and storage of supplies in the health facilities.
  7. Conduct operational research on the effectiveness and cost-effectiveness of preventing SAM through counselling during food secure periods.
  8. Strengthen linkages and referral of children discharged from CMAM programme to exiting social protection and livelihoods programmes in the community.
  9. Continue the partnership with donors and development partners in order to ensure long term funding for CMAM, improve access and uptake of CMAM services and prevent acute malnutrition.

Full report in PDF

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