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Field Article
The CMAM Programme in Malawi also
provides services to moderately malnourished
pregnant and lactating women through the
TSFP.
CMAM evolution in Malawi
CMAM in Malawi has evolved through a
lengthy process that started from the food crisis
that developed during 2001. A number of nongovernmental
organisations (NGOs) came to
assist with this disaster. Two of these organisations
were Valid International and Concern
Worldwide who supported the Ministry of
Health (MoH) in the emergency, conducting an
operational research programme to test the
safety and efficacy of the new CMAM approach
in Dowa District during 2002. Due to the early
success of the Dowa programme, the MOH
added another district to the operational
research in 2003.
Through the decentralisation of treatment,
the CMAM approach in Dowa was able to
address some of the difficulties of service access
that the population were facing. These
included:
• Inaccessible services for most of the children
that required care.
• Recurrent seasonal rises in severe acute
malnutrition (SAM), from 3%.
• Increased case loads that the health system
was struggling to cope with, compounded
by HIV/AIDS.
• Congestion in health facilities due to long
in-patient stays, HIV related complications
and chronic food shortages.
In 2004, the Ministry organised the first
national CMAM dissemination workshop for
District Health Officers (DHOs), NGOs and
partners. There was a great interest among the
DHOs, who demanded that the programme
should also be started in their districts. In
response to this, the Ministry added three more
districts in 2005. Gradual scale up to cover all 28
districts of Malawi has continued since then
(see Table 1 for a timeline and milestones of
CMAM scale up). This clearly demonstrates the
power of evidence-based research, creating
demand from service providers through robust
programming and dissemination of results.
In 2006, the CMAM approach was adopted
by the MoH as a strategy for managing acute
malnutrition among children in the country. To
achieve this, a number of processes took place,
including:
• Formation of the CMAM steering
Committee, which provided the policy
support body to guide the scale up process
of CMAM across the country.
• The CMAM Advisory Service (CAS) was set
up to provide support to the MoH with
technical assistance for the scale up process
and to ensure the standardisation of
operations.
• Interim guidelines were developed to
harmonise implementation modalities of
the programme.
Figure 1 presents the timeline Malawi has taken
to scale up CMAM programming.
The primary aim of the scale-up of CMAM
was to expedite and accelerate sustainability of
the programme, by incorporating it into the
routine health activities of Primary Health Care
(PHC) services. In this way, children with acute
malnutrition who are at increased risk of
morbidity and mortality can receive the care
they need through the same pathways that they
routinely access treatment of other illnesses or
infections.
Vision for CMAM in Malawi
CMAM is not implemented as a vertical, standalone
programme. Instead it is included as one
of the many services that are routinely provided
at health facilities. This implies that health policies
and guidelines must fully incorporate all
CMAM components into their preventive and
curative protocols and monitoring and evaluation
systems.
The overall aim of the scale-up of CMAM in
Malawi was to ensure the programme was
designed to be fully integrated within existing
institutions and structures and therefore
sustainable. Some characteristics important for
an integrated CMAM include:
• CMAM services are fully managed, implemented
and supervised by the DHO and
MoH staff.
• Regular health services at both health facility
and community level routinely identify,
refer and treat malnourished children.
• CMAM activities are funded through
District Implementation Plans (DIP) as part
of the district health budget.
• RUTF and other CMAM supplies are
ordered, stored and distributed through the
essential supplies distribution system.
• CMAM data are collected and reported
using the same reporting structure and
schedule as other health centre data.
Table 1: History of CMAM in Malawi Figure 1: Timeline of CMAM roll-out in Malawi
Year Milestones
2001 Hunger crisis
2002 CMAM in emergency and operational research in 1 district
2003 Scale up to one more district for further operational pilot Local small scale RUTF
production
2004 CMAM national dissemination workshop
More interest generated among DHOs, partners and NGOs
2005 Another food crisis
Three additional districts to pilot CMAM
Second dissemination and consensus meeting
2006 CMAM adopted as a national strategy
• Formation of the CMAM Advisory Service
• Interim guidelines
• Intensive advocacy for buy-in within MOH management, DHOs, NGOs and partners
• CMAM scaled up to 12 districts
2007 Continuation of the scale up process
2008 National workshop on the institutionalisation of CMAM into health systems with DHOs
2009 Scaled up to all 28 districts in the country
2010 Scaling up facility coverage
2001-2 food crisis
MoH identifies need
to revise old
Treatment Paradigm
protocols for SAM
CMAM pilots
(VI/CWW/
St Louis/COM)
Local RUTF
production
• Key indicators on CMAM are reported
through the Health Management
Information System (HMIS).
• Pre-service training curricula of health
professionals include management of acute
malnutrition.
• Effective linkages with other child survival
and HIV programmes are in place.
Policy environment
During the 1990s, nutrition remained largely on
the ‘back burner’ in Malawi, buried amongst
the multitude of health issues that the country
faced. The food crisis of 2001/2 took policy
makers somewhat by surprise, as Malawi had
been considered ‘food secure’ for a number of
years, even exporting many agricultural products
such as beans and maize. This food crisis
focused attention on the neglected problems of
malnutrition within the country.
The increased attention provided the environment
for a slow but steady transformation.
During 2001/2, nutrition in Malawi benefited
from combined forces: a conducive policy environment,
a reasonably well developed NRU
system within MoH structures, some nutrition
‘champions’ within the MoH, and a new revolutionary
treatment for SAM cases, using RUTF.
Malawi was one of the first countries to test and
then adopt the CMAM approach. Evidence of
the successful treatment of thousands of
severely malnourished children through
CMAM gradually helped to convince decisionmakers
that the country had the capacity and
needed to tackle the issues of widespread
malnutrition.
During 2005, a major change was implemented
– coordination of nutrition moved to
the Office of the President and the Cabinet
(OPC). This move ensured that nutrition could
become a cross-cutting issue, an essential step if
the root causes of malnutrition were to be effectively
addressed.
The OPC is responsible for policy direction
and for mobilising resources, while the MoH
has the responsibility for implementation of
these policies, such as the National Nutrition
Policy and Strategic Plan, which was developed
within the wider EHP (Essential Health
Package).
A Nutrition Committee is chaired by the
OPC and meets twice a year. Additionally, there
are multiple technical working groups established
under this committee, such as those
looking at Infant and Young Child Feeding
National CMAM
Meeting:
dissemination
2005-6 food crisis
Scale-up of CMAM
from 2 to12 districts,
More partners (CHAI)
Draft Interim
Guidelines used
National CMAM
Meeting:
Adopts CMAM
approach
Interim
Guidelines
finalized
CMAM Advisory Services:
Training for CMAM,
Support for NGOs
Capacity building of MOH
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