Managing acute malnutrition at scale: a review of donor and government financing arrangements

This review is concerned with the financing arrangements for programmes that address acute malnutrition at scale through the community-based management of acute malnutrition (CMAM). The CMAM approach is geared towards the early detection, treatment and counselling of moderately and severely acutely malnourished children, in the community, by community agents.

Until the late 1990s, treatment of severe acute malnutrition (SAM) was through therapeutic feeding centres in hospitals and healthcare centres. Performance was poor, coverage was extremely limited (less than 5% of the SAM population), mortality was often in excess of 30% and recovery rates were low. The CMAM approach was first piloted in Ethiopia in 1999 as an alternative to the centre-based model. Development of the approach offered the prospect of dramatically increased access to successful treatment and coverage.

CMAM has been adopted in over 65 countries. In 2011, just under two million children under five years of age with SAM were reported as being admitted to CMAM programmes, compared with just over one million in 2009.1 While this large increase partly reflects improved reporting, it is also indicative of the ongoing scaling up of treatment of SAM. Even so, total reported admissions represent just 10–15% of the estimated 20m global SAM cases annually. Treatment of moderate acute malnutrition (MAM) has not kept pace with the scaling up of SAM treatment, and coverage for in-patient treatment of SAM children with infection and/or oedema is unknown. Many countries with very high caseloads of acutely malnourished children, such as India, Nigeria and Indonesia, have extremely low CMAM coverage.

Scope of this review, definitions and process

This review is a follow-up to an international conference on CMAM co-hosted by the government of Ethiopia and the Emergency Nutrition Network (ENN) in Addis Ababa in 2011, co-funded by the UK Department for International Development (DIFD), the Canadian International Development Agency (CIDA) and Irish Aid.2 At the conference, 24 government representatives from Africa and Asia shared their experiences of scaling up CMAM, and in particular the challenges posed by unpredictable and unsustainable financing arrangements.

This review, co-funded by CIDA and Irish Aid, focuses on financing arrangements for CMAM, both globally and at the national level. It covers humanitarian financing, as well as financing through transitional and development channels. Financing is about much more than the simple flow of resources: ‘Financing affects behaviour, aid architecture, the power and influence of different groups, priorities and capacity development. It signals approval or disapproval. There is no neutral choice – making a financing decision always creates consequences that go far beyond the time scale and scope of the funded activity’,3 and so this review also looks at the management, organisation and funding channels for CMAM.

The review focuses on programmes that identify, treat and prevent acute malnutrition and related mortality at scale. During the review, the interplay between acute and chronic malnutrition (stunting) also emerged as a consideration. For the purposes of this review, ‘at scale’ is defined as the ‘widespread achievement of impact at affordable cost’. Increased impact is a function of the coverage of a population, programme effectiveness (quality of implementation and efficacy of interventions employed), efficiency (cost per beneficiary), sustainability (continuity, ownership) and equity (reaching those in need).

The process of producing this review was three-pronged. First, telephone and face-to-face interviews were undertaken with government and agency (UN, donor, foundations) representatives involved in nutrition policy, financing and CMAM programming. Second, case studies were developed following visits to Kenya and Ethiopia and from interviews carried out by an ENN consultant in Malawi and Nigeria. The case studies explored financing arrangements in greater depth, and were selected based on the extent of CMAM programming, as well as the level of country interest in the review. Third, published and grey literature relating to CMAM and financing was reviewed. The ENN review team made a series of presentations to UN agencies and donors to share the preliminary findings and to discuss emerging issues. These were followed by presentations at a number of high-level nutrition-related meetings. In total, 152 people were interviewed during the course of this review.