Sylvester Kathumba, Nutritionist, Malawi Ministry of Health

1. CMAM Advisory Service in Malawi: seven years of scaling up Sylvester Kathumba, Nutritionist, Malawi Ministry of Health Kate Golden, Senior Nutrition Adviser, Concern, Dublin

2. Background: CAS timeline & objectives • 2006: The government of Malawi expressed its intention to • scale up CMAM – for both SAM & lesser extent MAM • 2006: CTC Advisory Services launched jointly by Concern & Malawi MoH; 5-year project (extended to 7) to: • Standardize CMAM service delivery and tools • Develop & roll out CMAM policy and guidelines • Build capacity for CMAM service delivery at all levels • Establish & manage a national CMAM reporting & monitoring system • Advocate for strategic integration of CMAM into the health system • 2013: Concern’s formal support to CAS endedin March • Final evaluation in July/August • Malawi MoH now taking over CAS functions

3. Background: Malawi • Malawi has: • 5 zones • 29 districts • 618health centres • Estimated SAM case load at any time: 39, 062 (under-five prevalence of 1.5%, DHS 2010) • Estimated GAM case load at any time: 104, 167 (under-five prevalence of 4.0%, DHS 2010)

4. Findings: coverage of facilities = 80% • 28,467 SAM children treated in 2012 and 36,122 MAM children • 81% of health facilities in 24 of total 29 districts now provide CMAM services • But, no national survey of beneficiary coverage conducted.

5. Findings: Cure rates above Sphere standards

6. Conclusions: what has worked • Rapid scale up was facilitated by a fairly narrow CMAM focus • CMAM guidelines finalised in 2007, recently reviewed • CMAM included in Essential Health Package & national policies • Standard CMAM training package developed for in-service & (some) pre-service training • A cadre of CMAM trainers at national level (30) & district (290) responsible for ongoing training • A costed CMAM Operational Plan helped coordinate actors • 18 Learning Forums for real time exchanges & review of scale up • Evolution of training curriculum to include practical aspects such as costing CMAM activities - most CMAM costs now included directly in District plans (minimal NGO funding direct to districts)

7. Conclusions: what could be improved • CAS largely achieved objectives, but not enough focus on service quality • Inclusion of CMAM training in pre-service curriculum depends on wider, sometimes complex curriculum development processes • Support strategy focused too much at national level. District support was key, but not enough focus on zonal teams, who have become key players in the decentralisation process. • Still need better monitoring of actual coverage of SAM cases (not just facilities) & strategies to identify & overcome access barriers as part of routine health service monitoring • A costed CMAM operational plan proved useful, but only developed in year 2; commitments & progress not well monitored • Slow integration of CMAM database into HMIS – complex process

8. Conclusions: future direction • MoH will now take responsibility to: • Regularly review the CMAM Operational Plan • Decentralise monitoring to the Zone and district level • Manage the CMAM database & integrate in HMIS • Ensure all core CMAM activities are included in District Implementation Plans • Many of the CAS platforms & mechanisms can now be utilised for scaling up broader nutrition interventions beyond CMAM

9. Zikomo! Thank you to all the partners in Malawi that have made the CMAM Advisory Services & the scale up of CMAM in Malawi a success “This project was made possible by the generous support of the American people through the United States Agency for International Development (USAID) & Concern Worldwide. The contents are the responsibility of  Concern Worldwide and do not necessarily reflect the views of USAID or the United States Government and/or implementing partners.