Federal DemocraticRepublic of EthiopiaMinistry of Health

EmergencyNutritionNetwork

CMAM/SUN Conference14th - 17th November 2011

Addis Ababa, EthiopiaScaling up Community Management of Acute

Malnutrition and Scaling up Nutrition (SUN)

Global experiences of CMAM scale-upA synthesis of lessons

Carmel Dolan, Jeremy Shoham & Andres Mejia Acosta (ENN)

Aim

Identify common enabling factorsand challenges

Contribute to genericguidance/lessons for scale up

Ways forward

Synthesis Report:

A work in progress…..

Informed by conference deliberations

Finalise and disseminate postconference

Some broad conclusions/lessons (1)

Getting CMAM onto the Agenda

Emergencies

Pilots

Determination of the scale of SAM

Agenda setting and keeping it there

Dialogue with experts and support from agencies

National champions for CMAM can come fromdifferent levels

Demand driven from districts seeing results

Technical groups/forums/exposure visits, learningsites

Inclusive process of developing guidelines

Some broad conclusions/lessons (2)Policies

Policy setting facilitated by group with buy in from nutritionpartners – advocating with one voice

Reflecting CMAM in health policy essential… but not sufficient

Planning

Scale up plans

Reliance on short term funding

Lack of good costing data

Some broad conclusions/lessons (5)Health system decentralisation andprogramme linkages

Balancing the degree of decentralisation (to achieve coverage)and capacity (to implement quality CMAM)

Integration within health/nutrition programmes-many entrypoints and

Between sectors

Inclusion of SFPs

Some broad conclusions/lessons (3)Developing Capacity-Health Structures& Communities

Additional human resources particularly at district and/or regionallevel.

Capacity development a challenge with short term funding

NGOs shift focus to capacity development -more reliable funding

Community component often not prioritised at beginning

OTP Dafur

Some broad conclusions/lessons (4)Developing Capacity (training)

Expert trainers (practically skilled on CMAM) conducting trainingwith follow-up mentoring has proved most effective

Train everyone (avoids turnover issues)

Training/mentoring for management of CMAM has provedparticularly important (planning, supply chain, monitoring andreporting, supervision) at district/regional level

Pre service training identified as a need everywhere but nothappening

Some broad conclusions/lessons (7)Speed and Modality

Balance speed for scale-up with programme quality

Balance geographical coverage with ‘true’ coverage

Phased approach, expanding based on demonstrated quality ofservice, and availability of resources has proved successful

Gradual building of coverage by adding measures to assess andact upon poor coverage

To much too soon can be triggered by short term funding anddetrimental to quality

Some broad conclusions/lessons (6)Supervision and MonitoringInsufficient supervision capacity & incomplete and late reporting

Joint supervision, third party monitoring

Simplification of monitoring formats

Potential to include some (not all) CMAM indicatorsin HMIS

Rapid SMS

Sphere indicators appear mostly reached in case studies

Coverage may need context specific timeframe

Coverage monitoring is essential

Some broad conclusions/lessons (7)

CMAM Financing

Majority of CMAM funding has come from emergency budgets

Short term funding reliance has limited scale-up.

Chronic emergency countries have managed to achieve scale-upwith short term funds

New opportunities from donors for longer term funding

Scaling Up Nutrition movement may offer main mechanism forintegrating CMAM into longer term arrangements

Some broad conclusions/lessons (7)CMAM Financing –key questions

Stop Start CMAM programming?

Global fund for CMAM?

How widespread new funding initiatives?

Can bilateral budgets support be used for CMAM?

Some broad conclusions/lessons (8)Supply – RUTF

Storage and constant supply issues

Pipeline breaks common

Registering RUTF as essential commodity

Forecasting problematic if based on estimates

Ways of improving reliability of pipeline

Some broad conclusions/lessons (9)Local Production of RUTF-what are the benefits?

Out of 9 case study countries, 5 are workingtowards local production

Reduced transit time, cost reductions (transport),support of local industry and farmers

Limited by number of factors, e.g. patent,ingredient costs, ingredient quality (peanuts),quality control requirements

Partnerships with producers, NGOs and farmers,working capital (investors), private sector

A Nutrition Governance Approach to CMAM

• Central Government Coordination• National development agendas• Strong executive leadership for coordination

• The effective decentralisation of CMAM• CMAM implementation at all government levels• Alternative decentralisation paths• The role of local elites

• The financing of CMAM• From emergency funding into long term funding• From donor dependency to government ownership

Central Government Coordination

• Embedding CMAM into National Development Agendas

• The Executive can play a critical role to generate greaterpolitical commitment around CMAM

• Strong executive leadership for coordination

• The Executive can play a significant role to improve thesustainability and quality of CMAM programming

The effective decentralisation of CMAM

• CMAM implementation at all government levels• Pre-existing decentralisation of governments contributed toeffective implementation

•Alternative decentralisation paths• Training, capacity development, and data sharing arealternative drivers to facilitate decentralisation

• The role of local elites• Increased local ownership can contribute to effective CMAMimplementation and scale up

The financing of CMAM

• Shifting from emergency funding into long term funding• Developing cost estimates to achieve long term CMAM goals• Promote greater political commitment through budgetsupport or nutrition sector earmarks

• From donor dependency to government ownership• In some cases, governments can reduce costs of RUTFthrough public-private partnerships, working with farmers,etc.• To improve the collection, reliability and transparency ofcosts and expected coverage data around CMAM

Acknowledgements

Tanya Khara, (ENN Consultant)Andres Mejia Acosta (IDS/ENN Consultant)Jeremy Shoham and Carmel Dolan (ENN)Emily Mates and Marie McGrath (ENN)Maria Isabel Berbegal (IDS)

Emerging questions ……….