Focus on Nutrition
Poor nutrition increases the chances of experiencing specific health problems and can lead to anemia, reduced immunity, and impaired physical and mental development (WHO, 2014). Repeated treatment of malnutrition and related illnesses that burden individuals, health systems and entire societies (The Cost of Hunger, 2014). In fact, the estimated impact on the global economy could be as high as US$3.5 trillion per year. More importantly, malnutrition is one of the biggest contributors to high mortality rates among children in many nations.
Challenges to solving malnutrition are now getting much needed attention. The international community recognizes that policy action is urgently needed (Global Panel on Agriculture and Food Systems for Nutrition). Most recently the Sustainable Development Goals direct our aim toward ending hunger and food insecurity. This will require bringing about change that improves nutrition around the globe. The Scale Up for Nutrition (SUN) movement engages governments to change policy and take action to address malnutrition. There are currently 57 countries that are participating in the SUN movement. (Scroll down to Two Models of Management)
Standard Practice – Models for Managing Acute Malnutrition
If you’ve worked in the nutrition sector, you’ve likely heard of two broad intervention models that emerged in that space for management of malnutrition. The first pilot took place in 2000 during a humanitarian crisis and the results were so impressive that the United Nations adopted the CMAM in 2007. CMAM/IMAM model is now considered the standard of care. The Integrated Management of Acute Malnutrition (IMAM) is a model that works to integrate nutrition measures into existing health systems. IMAM is a tool for health agents (managers and care providers) in the management of both severe acute malnutrition (SAM) and moderate acute malnutrition (MAM). IMAM is a treatment program that tracks and treats severe acute malnutrition cases, providing supplements including micronutrients to aid in treatment. The targeted audience is generally vulnerable populations, such as children under five years of age and pregnant and lactating mothers. The IMAM system is implemented within the confines of the health system and involves treatment of severely malnourished children and pregnant women.
The greatest system of referral takes place between the community and the health facilities. The liaison is the community health worker (CHW). S/he works specific villages and engages the community to ensure the first level of treatment or referral. The first level of treatment is at the community level. The Community Management of Acute Malnutrition (CMAM) was adopted by the U.S. Agency for International Development (USAID) Multi-Sectoral Nutrition Strategy, which endorses the scale-up and strengthening of the CMAM approach. CHWs identify SAM and MAM using Mid-upper arm circumference (MUAC) measurement and identification of bilateral pitting oedema. Identified cases are then referred to a health facility. CMAM has improved the nutrition response in a number of ways, and enabled community volunteers to identify and initiate treatment through referral before illness becomes serious. In some cases, community representatives deliver supplemental foods to hard-to-reach communities.
Ideally, the two models work hand in hand, IMAM and CMAM. We’ve observed that countries have varying levels of tool use. One country plan may involve all elements of CMAM, while another is using some components of the CMAM guidelines. For example in Sierra Leone, community members do not distribute food packets. These are only distributed at health facilities.
Studies have shown the importance of a more integrated approach to acute malnutrition, the requirement of a holistic multi-sector strategies, engaging supply chain, agriculture and economic development providers, can help reduce malnutrition. In addition, governments are recognizing the importance of developing emergency response systems to build cushions that protect against shocks caused by climate change and epidemics such as the Ebola outbreak, which can devastate vulnerable populations.
The CMAM and IMAM approaches to nutrition involve community mobilization, working with outpatient therapeutic programs and policy makers to ensure the full integration of nutrition elements are in place. U.S. Agency for International Development (USAID)
Multi-Sectoral Nutrition Strategy endorses the scale-up and strengthening of the CMAM approach as outlined in the Multi-sectoral nutrition strategy Technical Guidance Brief. The scale-up of CMAM supports a more preventive measure and moves away from the in-hospital treatment approach that was pervasive for many years.
The biggest challenge to large scale community level interventions is the collection of reliable data. Community members usually have a book where records are kept. This information is transferred to the clinic level system.
by Christina Blanchard-Horan, PhD
Nutrition program evaluator