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Postscript
Valid International, India
Pre School Sessions in Anganwadi Centre,
Sagar District, Madhya Pradesh
evidence on the impact of CMAM in the local
context and inform eventual state-wide scaleup.
If state (as opposed to national) level
implementation strikes some readers as insufficiently
ambitious, it is well to remember the
size of these states. With an under-6 yr old
population of 10 million in Madhya Pradesh
and 5 million in Odisha, Madhya Pradesh may
have over 700,000 SAM cases at any given
moment. Odisha is estimated to have 260,000.
The widespread implementation of the CMAM
model in either state would thus have the
potential to impact significantly on the global
burden of SAM. Logistically, however, this is a
major undertaking and initial pilots are likely to
be implemented at district level or below this,
at what is termed ‘block’ level.
Both Madhya Pradesh and Odisha have
elected to implement CMAM through the ICDS
system of anganwadi centres. These provide
children under 6 years with either a hot meal or
a dry take home ration according to age, and
offers further take home rations to children
identified with growth faltering (weight for
age). This is a very dense network of service
centres, so dense that even in a high prevalence
environment like Madhya Pradesh, the number
of cases per facility at any one time may be only
one or two. Baseline prevalence surveys to be
undertaken in pilot ‘blocks’ will help to determine
whether pilot activities - along with all the
staff training, orientation and community
mobilisation to initiate them - will be required
in all facilities or only a subset situated in pockets
of higher prevalence.
Whilst both MP and Odisha have determined
that the anganwadi centre will be the
focal point for CMAM delivery, they differ in
other important respects, including their
approach to RUTF manufacture, and in the
issues they expect evaluated through the pilots.
Manufacture of RUTF
In Madhya Pradesh, the State government
wishes to explore large-scale industrial production
through publicly owned facilities that
would provide production capacity sufficient to
supply all 50 Madhya Pradesh districts with
RUTF (8,000 tonnes per annum). With the help
of a food technologist from Valid international,
a range of potential suppliers are being
assessed and a business case being developed
for review and possible investment by the State
government. By contrast, the scale of production
being investigated in Odisha is far smaller
(20 tonnes per annum for two blocks) and is
intended to supply the block (sub-district) level
with a milk based energy dense nutrient rich
therapeutic food. A significant feature of the
Odisha plan is that the production facility is to
be staffed and managed by the same local
women’s self-help groups that already produce
take-home rations for local anganwadi centres
under contract to the ICDS. A specialist in
community-level production provided by Valid
International will initially work remotely and
later on site with a food technologist nominated
by a technical committee that has been set up
on CMAM chaired by the DWCD The support
will include refurbishing existing facilities to
standard, ordering the appropriate materials
and equipment, commissioning the facility and
training staff.
Pilot objectives
In Madyha Pradesh, where the system of
Nutritional Rehabilitation Centres (NRCs) has
been greatly strengthened and expanded with
UNICEF assistance, the pilot will evaluate the
cost effectiveness of adding outpatient care
through CMAM to the inpatient care provided
under the NRCs. It is expected that SAM treatment
coverage will be greatly improved,
despite known weaknesses in the anganwadi
system (see India article earlier). However, the
density of the system required may also impose
significant start-up and service provisions
costs. It will be important to weigh costs against
coverage outcomes and through operational
research, investigate how to limit the impact on
costs. Before/after coverage surveys carried out
in each block as the service expands within the
district, are likely to be a major feature of the
pilot, along with rigorous documentation of
treatment outcomes during the first year of
CMAM. In Odisha, the focus of the pilot is
somewhat different, in that it will test the efficacy
of three different modes:
a) different hot cooked meals at fixed intervals
in addition to the hot meals already provided
at the anganwadi centre
b) a specially fortified version of the dry takehome
ration, prepared by women self help
groups, also provided at the anganwadi centre
for younger children
c) a milk based energy rich nutrient dense therapeutic
food also as a take home ration
prepared by women of self help groups also to
be provided from the anganwadi centre
Treatment coverage will also be evaluated to
determine public health impact, although
possibly on a less intensive basis than planned
in Madyha Pradesh.
State-level partnerships
Madyha Pradesh and Odisha each have the
advantage of being able to draw on support
from a DFID-funded technical assistance
support team (TAST) with a permanent presence
in the state. TAST has provided a valuable
point of contact and coordination for external
CMAM technical assistance, given that the
senior state officials who are driving the
CMAM agenda are also extremely busy people.
In Madyha Pradesh, the TAST, together with
UNICEF, was instrumental in developing and
securing high-level endorsement for a state
nutrition strategy that among other things
created official policy space for CMAM pilots.
Above all, however, it is a good understanding
and a shared vision between the senior officials
overseeing the NRHM and the DWCD that has
been responsible for progress to date. These
officials have been clear about what they wish
to see, and have created an inclusive environment
for state-level CMAM planning that
draws in the necessary nutrition expertise both
from within India and abroad. Inputs into
CMAM preparation and discussion in Madhya
Pradesh have been provided at various points
by India’s National Institute of Nutrition,
UNICEF, the Madyha Pradesh TAST, the Right
to Food movement, the Real Medicine
Foundation, and Valid International.
In Odisha, a technical working group for
CMAM, including representatives from
DWCD, NRHM, UNICEF and Odisha TAST,
was established following return from the
Addis conference. The technical working group
has assumed responsibility for reviewing
programme design, recipe formulation, determining
the facility-level staff to be trained in
CMAM, and reviewing both training materials
and guidelines.
DFID has provided funding for an experienced
Valid International CMAM advisor to
spend an extended (2.5 months) period
between the two states, working with stakeholders
on a variety of technical questions, as
well as a local counterpart to be mentored in
CMAM in advance of the pilots. The same
contract has made possible the site visits and
technical appraisal by Valid International’s
local production expert and the recruitment of
local counterpart food technologists.
The demand side
The energy generated out of the Addis conference
comes at a fortuitous time, in that state
level advocacy groups that clamoured for years
for a more effective response to the problem of
SAM deaths are now also being supported to
make tentative steps into nutrition education
and service provision. These community-level
efforts are likely to form an important complement
to SAM treatment services, providing the
demand-side strengthening that is needed to
improve participation in the ICDS (and thus
successful CMAM coverage). Particularly in the
matter of case-finding and referral using mid
upper arm circumference (MUAC), the pilots
will require a more active outreach than is typical
of the ICDS at present if they are to
demonstrate maximum public health impact.
For more information, contact: James Lee,
email: jamie@validinternational.org
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