Community-based management of malnutrition ‘a partially realized promise’ 20 years on

Twenty years after community-based management of acute malnutrition, or CMAM, was first piloted, many barriers remain to expanding treatment coverage to all children who are malnourished, nutrition experts said at a virtual conference Monday.

CMAM was endorsed by the United Nations in 2007 and moved treatment for severe acute malnutrition, or SAM, out of a hospital setting and into children’s homes. Along with the endorsement of ready-to-use therapeutic foods, or RUTFs, this shift was supposed to drastically scale up treatment by making it easier to access and deliver.

An estimated 1 million children under 5 die from SAM each year.

“CMAM … was a promise. It was a promise of scale, of access of coverage, and really a promise to make treatment truly universal,” said Saul Guerrero, senior nutrition adviser at UNICEF, during the Concern Worldwide virtual conference on CMAM. “It remains a partially realized promise, and we need to confront that reality.”

One of the ways to do this, Guerrero said, is to produce more cost-effective alternative RUTF products and take them to market at scale.

“If we don’t, we are not optimizing services as much as we’re going to need if we’re going to convince people to invest even more in this kind of initiative,” Guerrero said.

Currently, World Health Organization guidelines state that RUTFs should get at least 50% of their proteins from milk. This month, WHO is set to release the findings of a review of that standard, saying that plant-based recipes do not meet its efficacy threshold to merit recommendation because they do not show the same rate of weight gain as dairy recipes do.

Participants in Monday’s event, held as part of a multiday conference to mark the progress in the 20 years since CMAM was piloted, at times expressed divergent views on the roadblocks to scaling up treatment of wasting, or low weight for height.

Zita Weise Prinzo, WHO nutrition technical officer, said more evidence is needed for the agency to update its RUTF recommendations, given that the guideline must be applicable around the world. She said there isn’t enough evidence that a plant-based recipe developed by Valid Nutrition — which showed promising trial results in Malawi — would work in other areas of the world.

“We’re not developing guidelines for the various countries or regions; it is a global guideline, and the evidence that we had was just not sufficient to change the global guideline,” Weise Prinzo said. “I think there is a need to have various [RUTF] formulations in the market. The call is just to look at these formulations in other settings. … Since it’s global, we have to be clear that it's as effective in different settings.”

Valid Nutrition founder Steve Collins, who helped develop CMAM, argued that other benefits of alternative recipes — such as the one trialled in Malawi, which was shown to be superior to milk-based RUTFs for anemia recovery and the replenishment of body iron stores — cannot be discounted because of the weight gain metric. He said WHO cannot allow “the perfect to block the good.”

“We can’t require recipes to meet every indicator we can possibly think of, even if we don’t know the significance of it,” Collins said. “We have to be sensible, and we have to look at the main constraints, which are cost of ingredients and availability of ingredients to local producers. When local producers are dependent on buying animal-source ingredients such as milk powder, they invariably, in Africa, have to import them.”

Dr. Ferew Lemma, special adviser at the Ministry of Health in Ethiopia, said that in his country, 7.2% of the population is wasted. Ethiopia began piloting CMAM in 2000 and expanded it throughout the nation by 2010. And while its geographic coverage now reaches about 95% of the country, service coverage is not as widespread. At the end of 2020, 438,000 children had been treated for SAM, with a recovery rate of 89%.

To further scale CMAM, including its integration into health care systems, Lemma said countries need continued support from international organizations. Major issues include updating treatment guidelines, monitoring and evaluation to ensure treatment is reaching the right number of children, and supply chain management.

“Supply chains affect our quality of services and our reaching a lot of children at the right time at the right moment,” Lemma said. “The logistics and supply chain system needs to be strengthened and is needed for scaling up CMAM. … In terms of coverage, we need to look at the scale-up to reach a large number of children.”

Lemma said that developing local RUTF products could help countries such as Ethiopia reduce the cost of SAM treatment.

Currently, treatments for SAM and for more moderate forms of malnutrition are done with separate products and by separate U.N. agencies. WHO is currently conducting a review of this process, which aims to provide global guidance on the prevention and treatment of wasting. Some argue that a simplified protocol for wasting —a single product that could be used for both moderately and severely wasted children — is the best way to increase coverage. Others argue that the two conditions are different enough that they require specialized treatments.

The WHO review is examining the identification and diagnosis of moderate and severe wasting, community-based management of moderate and severe wasting, and hospital-based management of severe wasting with medical complications. It will also look at the prevention of wasting and the identification, diagnosis, and management of growth failure in infants under 6 months old.

Amina Abdulla, Kenya country director at Concern Worldwide, said international organizations need to help governments implement malnutrition treatment models they can afford.

“At the moment, it’s very much driven by funding from NGOs. And when funding from these NGOs is pulled out, the system almost always collapses,” Abdulla said.

The number of children who can be treated for SAM is directly tied to the financial resources available, Guerrero said — a situation that is further complicated by the stress the COVID-19 response has put on domestic and donor resources.

“It’s not that we are not asking because we lack the ambition; it’s that there ain’t the resources for us to meet our level of ambition as it is right now. Every year we have to piece it together, right, in order to see how many we can treat every year. And that has got to change,” Guerrero said.

“Part of that is rethinking how we pay for treatment of child wasting and how do we maximize domestic resources, health resources, development resources, and yes, private financing, like never before. We cannot just keep going to the same sources that we have been going for 20 years. … We need to start getting creative.”

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