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Field article
Following recommendations from the June
2007 workshop, the MOH/GHS adopted the
CMAM approach for the management of SAM
with the establishment of learning sites in two
districts, Ashiedu-Keteke sub-metropolitan
area (Greater Accra region) and Agona District
(Central region) in April 2008. The learning
sites were later expanded to Ga South district in
March 2009. These learning sites provided
accessible practical experience and an opportunity
to refine the strategy for the scaling-up of
CMAM in phases.
Integration and scale up of CMAM
CMAM integration and scale up within Ghana
has been planned in a two-phased approach.
Phase 1 targeted five regions: Upper West,
Upper East, Northern, Central and Greater
Accra. The second phase will target the five
remaining regions of Western, Eastern, Volta,
Ashanti and Brong-Ahafo, which is expected to
start in 2012.
The Phase 1 scale-up of CMAM began in
2010, with a limited number of districts and a
gradual expansion to additional districts in
2011. CMAM scale-up activities have specifically
focused on strengthening the capacities of
the GHS and nutrition partners and developing
competencies for sustainable, quality services
for the management of SAM. An enabling environment
for CMAM was created and
competencies strengthened in partnership with
UNICEF, WHO, USAID, the USAID-funded
Food and Nutrition Technical Assistance Project
II (FANTA-2), national training institutions, and
other partners in health and nutrition.
In Ghana, the operational strategy for
CMAM is managed by the SAM Technical
Committee (SAM TC) at the national level. At
the regional level, support teams working
under the regional health director oversee the
roll-out of CMAM within their regions.
CMAM services and supplies were made
accessible in a sustainable manner, in order that
quality services could be provided to children
with SAM. To ensure quality service provision,
each region initiated CMAM in one or two
districts with a limited number of outpatient
and inpatient sites. These facilities acted as
learning sites for the region, with services then
gradually scaling-up to the rest of the districts
in the region. Decisions to expand CMAM to
new districts were based on the quality of service
delivery at the learning sites, the availability
of qualified technical personnel to provide technical
support and the availability of resources
and supplies to ensure continuous service
delivery in all new districts.
A five-year National Scale up Strategy is
currently being developed. It is expected that
the National Strategy for CMAM will be
discussed and endorsed in a national workshop.
Partnerships
The MOH/GHS is responsible for the overall
coordination of CMAM services, creating an
enabling environment and providing CMAM
services. The MOH/GHS health care providers
manage SAM cases in outpatient and inpatient
care and collaborate with health volunteers to
conduct community outreach activities. Other
GHS human resources at managerial and auxiliary
levels support CMAM services as part of
existing routine health services. MOH/GHS
national, regional and district technical officers
are responsible for building the capacity of the
implementing health care providers.
Table 1: Key events timeline
Date
Activities
June 2007 - Workshop organised to introduce CMAM into Ghana.
December 2007 - Severe Acute Malnutrition Technical Committee (SAM TC) formed to plan and coordinate the
integration of CMAM into the health delivery system.
March 2008 - Sensitisation of regional and district health directorates on CMAM in Central and Greater Accra
regions where learning sites were selected.
April 2008 - Training for health staff in the learning sites on outpatient and inpatient care.
- Training of volunteers in community outreach.
- Initial outpatient care facilities established in the learning sites of Ashiedu Keteke (2) and Agona
Districts (7).
July 2008 - Field testing of the generic community outreach module conducted in Ghana. This is part of the
FANTA, VALID, UNICEF, Concern Worldwide and other partners CMAM training modules
developed in 2008.
March 2009 - CMAM activities scaled up within the learning sites to provide district-wide coverage in Agona
West Municipality and Agona East District.
May 2009 - Field test of the global CMAM costing tool.
July 2009 - Conducted a CMAM training of trainers workshop for regional health staff from Phase 1 regions
(Northern, Upper East, Upper West, Central and Greater Accra).
August 2009 - Conducted the first expanded WHO training of facilitators and clinicians workshop on the
management of SAM in inpatient care. The expanded WHO training included the management
of SAM in the context of CMAM.
January 2010 - Initiated the review and adaptation of the generic CMAM training materials developed by
FANTA, VALID, UNICEF, Concern Worldwide and other partners in 2008 to the Ghana context.
This included recent global developments and best practice in the management of SAM.
- Initiated the review and adaptation of the generic WHO training materials for inpatient
manage ment of SAM in the context of CMAM in Ghana.
May 2010 - Scale up of CMAM started in the Phase 1 regions (Upper West, Upper East, Northern, Greater
Accra and Central).
Feb 2010 - The SAM TC approved the Interim National Guidelines for CMAM and Job Aids.
August 2010 - Review of the integration of CMAM services into the health system.
January 2011 - Consolidated feedback from the regions and districts implementing CMAM on the Ghana
adapted CMAM training materials.
- Consolidated the feedback from clinicians and other trainers on the adapted Ghana inpatient
care training materials.
January 2011 - Conducted regional SAM STs refresher training and annual planning workshop.
January 2011 to
date (Aug 2011) -
Ongoing scale up of CMAM within Phase 1 scale up regions.
The GHS is also responsible for distributing
and storing CMAM supplies through the existing
GHS logistics system. The GHS also
provides routine medication (antibiotics and
malaria prophylaxis) free to children with SAM
in some facilities.
Partners currently supporting the integration
and scale-up of CMAM in Ghana are
USAID, USAID/FANTA-2, UNICEF and WHO.
The partners provide technical assistance that
includes facilitating the development of guidelines,
training materials, monitoring, reporting
and quality improvement tools, and supporting
the review of the learning sites that inform
design of the CMAM services. UNICEF and
USAID also procure CMAM supplies for the
government and provide financial support to
the GHS to conduct trainings and other capacity
building activities.
Implementation of CMAM in Ghana
Enabling environment for CMAM
The MOH/GHS has taken the lead role in the
integration of CMAM into the national health
system. In December 2007, the GHS established
the SAM TC to coordinate and oversee implementation
and integration of CMAM activities
into the service delivery system at all levels in
Ghana. The SAM TC is chaired by the GHS
Nutrition department and is composed of a
range of representatives, including other GHS
Departments, Institutional Care Division (ICD),
Child Health, Policy Planning and Monitoring
and Evaluation (PPME), Korle-Bu Teaching
Hospital (representing the academic institutions),
and partners (UNICEF, WHO, USAID
and FANTA-2).
The SAM Service Unit (SAM SU), which is a
core team of the SAM TC, is housed in the
GHS/Nutrition Department and receives technical
and financial support from USAID,
FANTA-2, UNICEF and WHO. It is responsible
for providing day-to-day technical guidance,
coordination and advocacy for CMAM.
At the regional level, SAM Support Teams
(SAM STs) were established in January 2010.
Their role is to plan and coordinate CMAM
implementation within the region and provide
technical support to the districts and facilities.
The regional SAM STs comprise of GHS staff
specifically the Regional Nutrition Officer,
Regional Public Health Nurse, Regional
Disease Control Officer, Regional Clinical Care
Officer (from the ICD) and an appointed clinician/paediatrician
trained and experienced in
inpatient care. The Regional SAM STs report to
the Regional Health Director.
Integration and scale-up of CMAM is a key
component of nutrition in the HSMTDP
2010–2013. The SAM TC prepares national
annual CMAM work plans and also supports
the regions to prepare region-specific CMAM
scale up plans. These work plans are then integrated
into the overall regional and national
GHS annual work plans in line with the health
sector plan. The nutrition policy under development
will include policy guidance on
implementation and scale up of CMAM in
Ghana.
The MOH/GHS has developed and disseminated
the Interim National Guidelines for
CMAM in Ghana that are widely used within
the implementing regions. CMAM has also
been integrated into the new IMNCI
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