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Field article
The following assessment/evaluations have
been conducted so far:
a) National CMAM coverage survey using
SQUEAC
A survey using the SLEAC 6 and SQUEAC
methodologies was conducted in 2011 7 . This
survey was a major undertaking that took three
months to complete. According to the report,
the point coverage of the programme was classified
at 12.0%, with period coverage reported
at 19.7%. While the results of this survey do
appear low, it must be remembered that
SQUEAC methodology purposively selects
areas where coverage is expected to be lowest,
in order to help identify barriers to access and
uptake.
It should also be noted that CMAM at-scale
is a major and relatively new undertaking.
Whilst higher coverage results are desirable
(and must be aimed for), it might take some
time to achieve them. For EPI programmes, it is
well accepted that coverage of the programme
might be lower in early years, with gradual
increases expected as it matures. It is therefore
reasonable to expect that CMAM coverage
might follow similar trajectories to other major
national initiatives.
b) Evaluation of CMAM Programme
The evaluation was conducted in 2008.
It had the following recommendations:
• Removal of zinc tablets, metronidazole,
paracetamol, aminophylline,
vogalène, anti-vomiting drugs, and
antacid drugs from the pharmacy
(box) used for the treatment of children
with SAM. This is because
use of these medicines can measurably
increase the risk of mortality
in children with SAM.
• Use mid upper arm circumference
(MUAC) for children 6 months and
older only and longer than 65 cm,
to ensure correct measures of age
and length before taking the MUAC
measurement. All treatment sites
should have as a minimum a wooden
dowel (stick) of 65cm to assess children’s
length. Due to challenges in estimating a
child’s age, children older than 6 months
are measured using MUAC in the community
and are reassessed in the facility using
weight and height.
• Ensure correct implementation of the
appetite test using the table provided in the
CMAM protocol (according to the weight
of the child). The appetite test is a crucial
part of assessing whether the child can be
treated at home or whether he/she requires
in-patient care.
c) Nutrition SMART survey
Conducted in 2010, it provided very useful
baseline data for nutritional indicators in Sierra
Leone.
Overall, the challenges to effective M&E
include:
• Inadequate capacity of health staff to take
accurate height measurements
• Poor quality of supply and distribution plans
• Improper recording of caseloads
• Unreliability of HMIS data due to overestimation
of data in some centres and double
counting of some cases
• Late submission of monthly reports and
poor quality data
AS Koroma/MOHS, Sierra Leone
Clinic day
• Inability to accurately complete many
different monitoring forms at PHUs due to
multiple tasks and general work overload
• Limited logistics available for monitoring at
all levels, e.g. transport constraints
Risks of scale-up
If not well managed, the scaling up of CMAM
can result in a number of risks, leading to a
reduction in quality and threatening the
sustainability of the programme. Some of these
risks include:
• Overstretching of health personnel leading
to poor management and insufficient supervision
of the programme.
• Large-scale loss of confidence in the
programme during pipeline breakdowns,
which later necessitates intensification of
community mobilisation.
• Overload of the primary healthcare system,
especially during the introduction of the
Free Health Care Initiative in Sierra Leone,
which has seen increasing numbers of
people seeking health services.
• Financial sustainability can be threatened
when the majority of resources are provided
by donors.
Linkages with other sectors
Integration of CMAM into IYCF and other
programmes
The need to link IYCF to CMAM programmes
has been clearly identified. This can be effectively
managed at the community level,
through involving the CHVs, mother-to-mother
groups and all families with children under five
years of age. In some districts, the IYCF mother
to mother support groups play a dual role of
promoting IYCF, while also following up children
identified as SAM and MAM, to ensure
that screened children attend the relevant
programme for treatment.
Linkages have been created between CMAM
and other health sector programmes, such as:
• Basic emergency obstetric care (BeMOC).
Every BeMOC centre is now an OTP site.
These facilities were included in the last
round of OTP expansion, so that composite
care for both obstetrics and treatment of
malnutrition without complications could
be offered from these service delivery points.
• EPI/Child Health (EPI/CH) has been established
and indicators integrated into the
Child Health card. Growth monitoring is
conducted at these points, weight and height
measurements and age are collected for
weight for height and weight for age determination.
In addition there is oedema
checking for quick referral. MUAC is used
for screening at community level and SAM
children are referred for further assessment.
• SAM children are admitted using both
MUAC and WHZ depending on what
condition prevails. All children with MUAC
less than 11.5 cm without medical complications
are admitted into the OTP. All those
with medical complications are referred to
SCs. Where children have a normal WHZ
but MUAC less than 11.5, such children are
also admitted into the OTP. For the SFP, it is
strictly based on WHZ less than -2.
• Free Health Care Initiative – all children
under five years receive free health care
treatment, including treatment of acute
malnutrition.
• IMNCI strategy. This also caters for malnourished
children, through conducting anthropometric
assessment of all sick under-fives,
using MUAC, WFH and checking for bilateral
pitting oedema. Identified malnourished
children are then referred by staff to SFP,
OTP or SC, according to their classification.
Effective linkages will require a number of
strategies including:
• Mobilisation and training of mother-tomother
support groups in screening and
referral procedures.
• Enhancing food demonstrations in the IYCF
programme and further development of
backyard gardens for the community, to
improve complementary feeding practices.
• Use of simple-to-understand tools such as
graphs/pictorials, which better explain
figures/topics such as detection of malnutrition
and growth monitoring.
• Developing user friendly CMAM guide
lines as an easy reference for overloaded
health workers.
Linkages should also be developed between
nutrition and other related sectors that support
the prevention of malnutrition, including:
Food Security: Advocating to the Ministry of
Agriculture, Forestry and Food Security, small
holder commercialisation programmes to
enhance the production and consumption of
nutritious foods such as beans and sesame
seeds, increase the involvement of women in
farming and increase the provision of farm
inputs to enhance the production of a diversity
of complementary foods.
Education: Promotion of the education of girls
and their retention in schools and prevention of
teenage marriage that can lead to high rates of
low birth weight (LBW) infants. LBW infants
are, by definition, already malnourished at
birth. As the Lancet series (2008) explains,
undernourished children are more likely to
grow into shorter adults, to have lower educational
achievements and, for women, more
likely to subsequently give birth to smaller
infants themselves, thus perpetuating an intergenerational
cycle of undernutrition 8 .
Water, hygiene and sanitation: Promotion of
access to clean potable water to promote
hygiene and food safety at the household level
6
Simplified LQAS Evaluation of Access and Coverage. LQAS:
Lot Quality Assurance Sampling.
7
Using SLEAC as a wide-area survey method. Field
Exchange 42. January 2012. p39.
8
Victoria, C. G et al. For the Maternal and Child
Undernutrition Study Group. Maternal and child undernutrition:
consequences for adult health and human capital.
Lancet 2008. Published online. Jan 17
44