10 years of CMAM What did we learn ? What are the remaining challenges ? Dr. André Briend, Department for International Health, University of Tampere, Tampere, Finland

10 years ago, the main technical ingredients of CMAM were already there RUTF Admission on MUAC Community mobilisation Some technical fine tuning since (e.g. MUAC for discharge). BUT, We learned it works…

We learned CMAM works and can be integrated into Governement programmes NGO run programmesIntegrated programmes Guerrero S, Rogers E, 2013

Getting a high coverage remains a challenge NGO run programmesIntegrated programmes

A cultural shift needed to address the coverage challenge In the past, clinical excellence was regarded as the most important quality for a programme Quality of care still very important Fine tuning of treatment still needed But clinical excellence without good coverage will have limited impact Need for a public health approach Need for health system strengthening

Priority action: act on factors affecting coverage Early and effective case detection in the community MUAC +++, frequently (every month) Involve frontline workers, mothers Avoid RUTF stock-outs – good planning needed Maintain quality of care

Key message: CMAM is not RUTF dumping Staff, supervision, functioning health system needed to achieve high coverage and good quality of care Budget needed, beyond providing supplies Political will from Governments needed

Lack of political commitment Only a small proportion of all children with SAM get adequate treatment SAM still has low profile in the international health agenda

SAM management not listed in the Global 2025 Nutrition targets 2012 World Health Assembly report. Annex on Child Nutrition < 2 lines on SAM in a 14 page document

WHA supreme decision body in WHO Run by country delegates who approve resolutions 194 delegations Country delegates not aware of SAM public health importance and possibility of treatment Major advocacy failure that SAM treatment did not turn up in the 2025 Global Nutrition Targets

Importance of SAM inadequately perceived by the International Health Community Incidence, not prevalence should be used to assess the burden of an acute condition SAM related deaths underestimated by a factor of 2 to 8 compared to stunting in the 2013 Lancet papers

Oedematous malnutrition ignored by the public health community Limited prevalence data from NGOs Myatt, unpublished

Failure to assess the magnitude of the problem NGOs (on donor requests) have estimated for decades nutritional situation by WFH prevalence surveys. Incidence measures needed A shift from WFH cross sectional surveys to repeated large sample surveys needed or to programme data Only repeated MUAC measures with oedema assessment (as provided by a well run CMAM programme) can give an estimate of the problem magnitude

Large scale MUAC surveys are possible and are highly informative 7000 children measured in 1 month Spatial distribution

What did I learn over the last 20 years ? We live in a conservative world RUTF = 5 years + 5 years = 10 years MUAC as admission criteria = 20 to 25 years + MUAC as discharge criteria ?? SAM burden assessment with incidence not prevalence ?? SAM getting attention from public health community ?? Politicians ??