Review of Community Management of
Acute Malnutrition (CMAM) in Sindh,
Punjab and Balochistan
VALID INTERNATIONAL
SEPTEMBER 2013
ACKNOWLEDGEMENTS
First and foremost, Valid International would like to thank UNICEF and WFP not only for funding
the review, but also for the excellent briefings and the continued technical and logistical support
provided throughout the visit.
This review would not have been possible without the support of UN staff, government staff and
NGO partners at the provincial level in Sindh, Punjab and Balochistan. It was an honor to work
with such dedicated individuals.
Last, but not least, thanks to the numerous government health and community workers, CMAM
program staff, beneficiaries and community members who so willingly gave up their time to
participate in interviews, discussions and focal groups.
Valid International
Valid Team
35 Leopold Street
Oxford, OX4 1TV
office@validinternational.org
Caroline Grobler-Tanner
Anne Walsh
Theresa Banda
ii
TABLE OF CONTENTS
Summary
1. INTRODUCTION
1.1 Background and purpose……………………………………………………………………………………..
1.2 Objectives and methods………………………………………………………………………………….…..
vi
1
2
2.
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
KEY FINDINGS
Modalities…………………………………………………………………………………………………………...
Mapping and program data……………………………………………………………………………......
Quality of programming……………………………………………………………………………………….
Criteria and exclusion/inclusion……………………………………………………………………..…...
Infant and young child feeding…………………………………………………………………………….
Prevention…………………………………………………………………………………………………………..
Monitoring and reporting…………………………………………………………………………………...
Policy and coordination……………………………………………………………………………………….
4
7
10
14
15
16
17
18
3.
3.1
3.2
3.3
ACTIONABLE RECOMMENDATIONS
Sustainable foundation for CMAM in policy and practice
Program
Monitoring and Reporting
19
20
22
ANNEXES
Annex 1: Team itinerary………………………………………………………………………………………………
Annex 2: Key contacts met………………………………………………………………………………………….
Annex 3: Documents reviewed……………………………………………………………………………………
Annex 4: Review methodology……………………………………………………………………………………
Annex 5: Program data (NIS: January 2011 – June 2013)…………………………………………….
Annex 6: IYCF suggested indicators ………………………………………………………………………
Annex 7: Prevention package………………………………………………………………………………………
Annex 8: Illustrative simplified OTP card……………………………………………………………………..
Annex 9: Illustrative template for reporting and collating Information……………………….
24
26
28
29
32
33
34
35
37
List of Tables
Table 1: Sites visited during the review
Table 2: Standard rations and routine medical treatments in the CMAM program
Table 3: Actual and targeted OTP and SFP sites by 2017 by province
Table 4: Current OTP, SFP and SC sites reported by NIS, July 2013
Table 5:Training conducted January 2011- June 2013
List of Figures
Figure 1: Punjab: Evolution of OTP sites
Figure 2: NIS mapping data: July 2013
Figure 3: Punjab: OTP outcome data: January 2010- June 2013
Figure 4: OTP Outcomes by province: January to June 2013
iii
FREQUENTLY USED ACRONYMS
ANC
ARI
BCC
BHU
C4D
CHARM
C-IMNCI
CMAM
CMW
CPR
DCO
DHIS
DHQ
DoH
EDO (H)
EHH
EPI
FANS
FLA
FP
HANDS
HEB
HH
HMIS
IEC
IP
IYCF
KAP
LBW
LHS
LHV
LHW
LNS
LUMHS
MAM
MICS
MIS
MMS
MNCH
MRP
MUAC
NPPHC-FP
NGO
NIS
NNS
NSP-Sindh
NTT
OPD
ORS
OTP
P and D
Ante Natal Care
Acute Respiratory Infection
Behavioral Change Communication
Basic Health Unit
Communication for Development
Chief Minister’s Attainment and Realization of MDGs (FP and PHC Punjab)
Community based– Integrated Management of Newborn and Childhood Illnesses
Community based Management of Acute Malnutrition
Community Midwife
Community Resource Persons
District Coordinating Officer
District Health Information System
District Headquarter Hospital
Department of Health
Executive District Officer (Health)
Extended Health House
Expanded Program on Immunization
Flood Affected Surveys
Field Level Agreement (WFP)
Family Planning
Health & Nutrition Development Society
High Energy Biscuits
Health House ( of Lady Health Worker)
Health Management Information System
Information, Education and Communication
Implementing Partner
Infant and Young Child Feeding
Knowledge Attitudes and Practice
Low Birth Weight
Lady Health Supervisor
Lady Health Visitor
Lady Health Worker
Lipid-based Nutrient Supplement
Liaquat University of Medical and Health Sciences
Moderate Acute Malnutrition
Multi Indicator Cluster Survey
Management Information System
Multi Micronutrient Supplements
Maternal, Newborn and Child Health
Minimum Reporting Package
Mid Upper Arm Circumference
National Program for Primary Health Care and Family Planning.
Non-Government Organization
Nutrition Information System
National Nutrition Survey
Nutrition Support Program – Sindh
Newborn Tetanus Toxoid
Out Patient Department
Oral Rehydration Salt
Out Patient Therapeutic Program
Planning and Development Department
iv
PC-1
PCA
PDHS
PHC
PINS
PLW
PMU
PRRO
PRSP
PPHI
RAM
RHC
RMNCH
RUSF
RUTF
SAM
SC
SMS
S3M
SLEAC
SRSP
SQUEAC
SUN
TT
UC
WINS
WSB
Planning Commission – Performa 1
Project Cooperation Agreement (UNICEF)
Pakistan Demographic Household Survey (2012/13)
Primary Health Care
Pakistan Integrated Nutrition Strategy
Pregnant and Lactating Women
Provincial Program Management Unit
Protracted Relief and Recovery Organization
Pakistan Rural Support Program
Peoples Primary Healthcare Initiative
Rapid Assessment Method
Rural Health Center
Reproductive Maternal Newborn Child Health and Nutrition Program- Punjab
Ready to Use Supplementary Food
Ready to Use Therapeutic Food
Severe Acute Malnutrition
Stabilization Center
Short Message Service
Simple Spatial Survey Method
Simplified Lot Quality Assurance Sampling Evaluation of Access and Coverage
Sindh Rural Support Program
Semi-quantitative Evaluation of Access and Coverage
Scaling Up Nutrition
Tetanus Toxoid (vaccine)
Union Council
Women and Children/Infants Improved Nutrition-Sindh
Wheat Soy Blend
v
SUMMARY
For many years Pakistan has had persistently high rates of acute malnutrition exceeding emergency
thresholds. Rates of severe acute malnutrition (SAM) are particularly high with a national average of
5.8%. Pakistan is second only to India in contributing to the global burden of SAM. Thus addressing
this burden is critical in meeting MDG 4 (reduction of mortality). The community-based
management of acute malnutrition (CMAM) was initially piloted in Pakistan in 2008/9 and draft
guidelines developed. The widespread floods of 2010/11 resulted in an influx of NGOs and significant
scale-up of CMAM in the affected provinces of Sindh, Punjab and Balochistan. Concurrently political
changes led to devolution of power from federal to provincial level. CMAM in Pakistan is
implemented by the Provincial Department of Health (DoH) and NGO partners with support from by
UNICEF, WFP and WHO.
As the CMAM program seeks to shift from an emergency intervention to a program fully integrated
into ongoing health services, questions have arisen as to how this can be done effectively. An
independent review was conducted by a team from Valid International in July 2013 in Sindh, Punjab
and Balochistan. The specific objective was to uncover what is working well and what is not working
and to make to make evidence based recommendations. The scope of the review was determined
by a committee comprising of UNICEF, WFP, WHO and the Federal Planning Commission. The team
focused on the operational aspects of CMAM with regard to effectiveness, relevance and
sustainability, and sought to expose barriers to effective integration. The team visited 14 sites in
five districts of Sindh and 11 sites in three districts of Punjab. For security reasons, it was not
possible to visit any sites in Balochistan. Selection of stabilization centers (SC’s), Outpatient
therapeutic program (OTP) and supplementary feeding program (SFP) sites was based on various
criteria including; differing operational modalities, cultural and geographical factors and security.
Quantitative and qualitative methods were used to collect and collate data and information. In
addition, the team conducted informant interviews and semi-structured focus group discussions
with program managers, health and community workers, community members and beneficiaries in
order to assess program quality and perceptions. The team reviewed an extensive range of reports,
strategies, guidelines and operational plans at national and provincial level.
Key findings
The CMAM program in Pakistan aims to provide the complete package of components including OTP
for SAM without complications, inpatient care for SAM with complications at a stabilization center
(SC), supplementary feeding for MAM cases and community outreach. The full package also includes
the provision of a food ration for acutely malnourished pregnant and lactating women (PLW) and a
ration for the siblings of children admitted to OTP/SFP. In addition, most programs have an infant
and young child feeding (IYCF) component. While, the CMAM package is standard, implementation
modalities vary considerably. The exception is the SC which follows is integrated into the public
sector model at the DHQ hospital. This is standard in all three provinces.
In Sindh, CMAM is largely implemented by NGO’s with little integration into the existing health
system. Reportedly, a key constraint to integration is the failure to incorporate nutrition
programming into the DoH contract with the People’s Primary Health Care Initiative (PPHI) which
operates the Basic Health Units (BHUs). However, successful integration of OTP/SFP at government
dispensaries was observed. This integration, albeit limited, was found to markedly improve uptake of
other health services. Large scale donor funding to NGO’s in Sindh presents an opportunity to pilot
test innovative and sustainable interventions, and build capacity at the provincial level. However,
vi
this opportunity is not currently being taken. Without effective government leadership, a successful
handover to government led programming seems doubtful.
By contrast, Punjab has recently transitioned from a predominantly NGO implmeted emergency
intervention to government implementation of OTP under the National Program for Primary Health
Care and Family Planning. The factors contributing to this successful transition include; strong
government leadership, effective coordination and a well articulated handover strategy. Integration
of OTP into the health system has resulted in good quality programming and an evident increase in
demand and uptake of other services such as EPI and family planning.
In Balochistan, lack of access to health facilities due to distance requires an adaptation of the
conventional CMAM model. The Health House (HH) of the Lady Health Worker (LHW) is used as the
main site for treatment of children with MAM and PLW supported by WFP. However, there are
currently only 8 OTPs in eight districts of Balochistan. This has resulted in large numbers of
untreated SAM cases. A trained LHW is capable of treating SAM cases without complications at the
Health House as part of her ongoing work. Restricting the treatment of SAM to health facilities is
severely hampering coverage and scale up in Balochistan.
The team found difficulties in accessing data on the CMAM program. There were discrepancies in
both the data and mapping which has implications for the accuracy of reporting, effective analysis
and program management. Impact of treatment programs as determined by available data against
sphere minimum standards was very good. Cure rates were high and death rates extremely low in
OTP and SFP in all three provinces. Default rates for OTP are low in Sindh and higher in Punjab and
Balochistan reflecting a government led program with less intensive outreach. In Sindh point
coverage within selected program areas was found to meet sphere standards. However
geographical coverage is limited in all provinces. Insufficient coverage of LHW’s is the key reason
cited for limited scale up of government led programs. Quality of programming as assessed by safe
treatment practice, appropriate referral and wait times exceeded minimum standards at all SC, OTP
and SFP sites. In Sindh, average MUAC on admission was 11.2cm for SAM cases. This is indicative of
early case finding. However, average length of stay (LOS) was much longer and rates of weight gain
much lower than expected. Confused messages regarding the use of RUTF and issues with discharge
criteria were key reasons. In Punjab, rates of weight gain were much higher due to a more focused
program and better messaging. The sibling ration was found to neither deter sharing nor affect the
LOS or weight gain. Community perceptions of the program are favorable, the exception being
discontent regarding the inclusion/exclusion criteria for PLW. Acutely malnourished infants less than
6 months are particularly likely to be excluded from the program and lost to follow up. Screening
and admission against targets is unnecessary and inappropriate in an integrated program. The team
found no difference in quality between NGO and government implemented programs, but significant
differences in cost.
An IYCF component is included in all CMAM programs with the intended aim of addressing the
underlying causes of acute malnutrition in children less than 24 months. The criterion for who
receives counseling at the sites is not systematic. Counseling that was observed varies from a lecture
style to an effective practical approach. The content and quality of IYCF counseling also varies. Most
counseling sessions addressed early initiation of breastfeeding, positioning and feeding on demand.
Messaging on complementary feeding was frequently found to be inappropriate and impractical.
The most effective counselors were experienced LHW’s with strong inter-personal skills and a highly
practical approach. There is no standard set of indicators to measure the impact of IYCF. Findings
of focus group discussions suggest a shift in breastfeeding practice has taken place in program areas
of Sindh. Early initiation of breastfeeding and exclusive breastfeeding for 2-3 months was common
practice. Appropriate introduction of complementary foods was much less common. All sites visited
vii
had an IYCF component at the site; however, opportunities to extend IYCF to the community are
very under-exploited.
Given the high prevalence of both wasting and stunting, a standard practical prevention package is
essential. Prevention programming tends to become far more complicated than necessary. The key
causes of malnutrition are known. The issue is determining a simple package which is can be
implemented across the board and effectively measured at the community level to determine
impact.
The review uncovered issues with monitoring and reporting. Numerous examples of duplicative
paperwork were found. The Nutrition Information System (NIS) is too complex, and at the same
time ineffective in determining impact and analysis is poor. It is also resource intensive. In looking
towards a sustainable integrated program, it is clear that the NIS will need to be simplified and
indictors revised in order to feed into health information systems.
Coherence to national and global strategies was found to be strong in all provinces at least in
rhetoric. Coordination mechanisms are particularly effective in Punjab. In Sindh, the Nutrition Cell
is not as prominent in leadership and coordination, perhaps in part because the cluster is still
functioning. In Balochistan, a formal coordination mechanism exists but is not currently active.
Actionable Recommendations
1. In order to ensure effective successful integration and scale up of CMAM, a sustainable
foundation must first be established. Thus the following key actions are recommended:





A coordinated effort by donors, WFP and UNICEF to provide human resource and technical
support to the DoH/Nutrition Cell. This will allow the DoH to take a leadership and
coordination role and to develop clear strategic priorities, policies and plans for integration,
scale up and emergency.
Allocate funding to the recruitment and deployment of LHW’s and advocate for the removal
of current barriers that limit increasing their numbers.
Develop clear roles and responsibilities of core staff (LHW, LHV and Community midwife) in
the management of SAM, MAM and PLW.
Promote inter-provincial exchange visits by a DoH led delegation.
NGO’s can play can support government priorities by building capacity particularly at the
community level; assisting government to pilot test sustainable strategies such as in-country
production of RUTF and programming in high burden but low coverage areas.
2. In order to promote sustainable CMAM programming, the following should be investigated,
implemented and tested:




Efficacy and cost effectiveness of in-country production of RUTF.
Sustainable modes of implementation such as the Health House model.
Innovative and cost-effective ways of managing MAM and reducing incidence of acute
malnutrition.
Testing of the ready to use food which is currently under production for PLW.
3. Integrated programming results in increased demand and uptake of other health services.
Parallel programming should be avoided. In seeking to improve program quality and coverage
the following key actions are recommended:
viii







Immediately address the lack of treatment coverage for SAM cases in Balochistan through
programming at the existing 345 SFP sites at the Health House.
Develop and test a pack of simplified standard protocols in Urdu in line with the revised
National Guideline.
Remove the sibling ration from OTP/SFP programs.
Revise messaging to ensure clear communication on the use of RUTF.
Ensure availability of routine drugs.
Follow up and track infants less than 6 months in OTP.
PLW should be managed by the LHV and the CMW at the health facility or LHW at the
Health House and linked to ANC.
4. In order to strengthen implementation practice and broaden the reach and impact of IYCF
interventions, the following actions are suggested:






IYCF counseling should be managed by the LHW or CMW.
All PLW should receive IYCF counseling linked to ANC at the facility and/or through the
Health House at the community level.
Develop and test a standard package of tools for IYCF in Urdu and local languages.
Extend IYCF to the community through effective mobilization and training of peer
counselors.
Revise process and impact indicators for IYCF.
Assess the impact of IYCF at the community level though simple assessment methods
against key baseline indicators.
5. A standard package for prevention is suggested and a focus on simple affordable, feasible
appropriate and practical (AFAP) messaging. The prevention package should be linked to a set of
process and impact indicators and fed into health management information systems (HMIS). As
with IYCF, impact at the community level should be determined through simplified rapid
assessments against key baseline indicators.
6. Current tracking, monitoring and reporting systems require streamlining and simplification to
improve accurate reporting, ease of access to data and improved analysis. Specifically, a simple
format is required that encompasses key data from SC, OTP and SFP in a readily accessible
format in soft and hard copy. Data on PLW should be reported separately. Indicators selected
should include a combination of process indicators for program management and impact
indicators. The minimal package of impact indicators should be incorporated into the DHIS/MIS.
ix
CMAM Review Report
1. INTRODUCTION
1.1 Background and purpose
For many years Pakistan has had persistently high rates of acute malnutrition exceeding
emergency thresholds. 1 Rates of severe acute malnutrition (SAM) are particularly high with a
national average of 5.8%. Pakistan is second only to India in contributing to the global burden of
SAM. 2 The majority of SAM cases are under 24 months with a notably high burden in infants.3
Addressing the persistently high burden of SAM through treatment and prevention programs is
critical in meeting the MDG 4 (reduction of mortality). It requires an integrated approach that is
sustainable. The links between food insecurity and acute malnutrition have been well
documented.4 In addition, inadequate child care and feeding practices are a direct cause of
acute malnutrition in Pakistan.
The community-based management of acute malnutrition (CMAM) was initially piloted in
Pakistan in 2008/9 and draft guidelines developed. 5 The widespread floods of 2010/11 resulted
in an influx of NGOs and significant scale-up of CMAM in the affected provinces of Sindh, Punjab
and Balochistan as a result of high levels of acute malnutrition found in the Flood Affected
Surveys (FANS). 6 Concurrently political changes led to devolution of power from federal to
provincial level. CMAM in Pakistan is implemented by the Provincial Department of Health
(DoH) and NGO partners, with support from by UNICEF, WFP and WHO.
The scale up of CMAM over the last three years has occurred rapidly. This was achieved with
little capacity on the ground. As the CMAM program seeks to shift from an emergency
intervention to a program fully integrated into ongoing health services, questions have arisen as
to how this can be done effectively. Internal evaluations of CMAM have been conducted
including a recent case study in Khyber Pakhtunkhwa (KP).7 However, a more systematic and
objective review was felt to be needed in the three provinces of Sindh, Punjab and Balochistan.
The review was timely as there is considerable attention to the scaling up nutrition in the global
policy arena. Pakistan has recently become a member of the global initiative - Scale Up Nutrition
(SUN). Provincial governments are finalizing three year plans for health and nutrition and the
Planning Commission-Perfoma 1 (PC-1) documents are at the pre-implementation stage. Supply
of Ready to Use Therapeutic Food (RUTF) is secured by UNICEF for three years. WFP expects to
have funding under the Protracted Relief and Rehabilitation Operation (PRRO) unitl 2015 for the
continuation of supplementary feeding programs (SFP) in many areas. In addition, donors have
provided significant funding to NGO’s for nutrition in Sindh in three districts. This funding
platform affords the opportunity for long-term planning and sustainable programming.
1
National Nutrition Survey (NNS). Planning Commission/UNICEF/Aga Khan University, 2011. Draft.
Based on a SAM rate of 5.8% and an under five population of approximately 21.4 million (180m pop), Pakistan has an estimated
1.5million SAM cases
3
26% of SAM cases are in infants less than 12 months. In Sindh and Punjab, the proportion of acutely malnourished infants less than 12
months is approximately 40% of caseload (NNS Data and caseload data).
4 Balagamwala ,M., Gazdar H., Breaking the Logjam of Undernutrition in Pakistan IDS Bulletin Volume 44 Number 3 May 2013.
5
National Guidelines for the Community Based Management of Acute Malnutrition. DRAFT. Ministry of Health, 2009.
6 FANS, Sindh. UNICEF/ACF, November 2010; FANS, Punjab. UNICEF ACF/Government of Punjab. January 2011.
7 Evaluation of CMAM, Pakistan Country Case Study of KhyberPakhtunkhwa (KP) Province. UNICEF. September 2012.
2
1
Valid International
2013
CMAM Review Report
An independent review of CMAM was conducted by a team from Valid International in July 2013
in Sindh, Punjab and Balochistan. The overall aim of the review was to uncover what is working
well and what is not working and to make to make evidence based recommendations. The
Itinerary can be found in Annex 1. Key contacts and people met during the review can be found
in Annex 2.
This report presents the key findings of the review and actionable recommendations. Case
studies and success stories from the three provinces which capture lessons learned and
examples of good practice are available as a separate document. The team was also asked to
provide input to the review of the National Guidelines for CMAM. This is also a separate
document. The scope and time limits of the review did not permit analysis of the costs of
CMAM or supply chain management.
It is anticipated that the review findings will be used by provincial and national governments, UN
agencies and implementing partners to strengthen existing programs and move towards an
integrated and sustainable model of CMAM programming.
1.2 Objectives and methods
Objectives
As a review and not an evaluation, the team was asked to focus on the on the operational and
practical aspects of CMAM with regard to effectiveness, relevance and sustainability. The policy
climate was also taken into account. The review did not focus on any particular organization or
institution. The scope of the review was agreed by a Review Committee comprising of UNICEF,
WFP and the Federal Planning Commission.8 Specifically the team explored the following key
areas:






The strength and weaknesses of different program modalities at provincial level.
Quality and consistency of data and information.
Program relevance and appropriateness and potential for sustainability.
Adherence to national and provincial policy and guidelines.
Provincial coordination and leadership.
Critical gaps and/or issues that prevent integration and scale-up.
Due to security issues, only one team member visited Balochistan. It was not possible to visit
any CMAM sites in Balochistan. Thus the collection of data and information at field level was
compromised and the team had to rely on secondary reports and interviews with practitioners.
The review was conducted during Ramadan. This occasionally affected opening hours of health
facilities and CMAM sites.
8
Terms of Reference. UNICEF/WFP Review of CMAM in Sindh, Punjab and Balochistan). May, 2013.
2
Valid International
2013
CMAM Review Report
2013
Methods
The team used quantitative and qualitative methods to collect and collate data and information.
The essential principles for determining effective and quality CMAM programming were
assessed according to the OECD/DAC criteria.9 In addition to site visits, the team conducted
informant interviews and semi-structured focus group discussions with program managers,
health and community workers, community members (both male and female) and beneficiaries
in order to assess program quality and perceptions. The team also explored issues of
inclusion/exclusion in programming. The team collected and reviewed a range of reports,
strategies, guidelines and operational plans at national and provincial level. A list of documents
reviewed can be found in Annex 3. The methodology used during the review can be found in
Annex 4.
The selection of stabilization centers (SC’s), outpatient therapeutic program (OTP) and
supplementary feeding program (SFP) sites was chosen in discussion with the Review
Committee and implementing partners. Sites were selected based on various criteria including
differing modalities, cultural and geographical factors, security constraints and access. The
team visited some sites without pre-arrangement. Sites visited by the team are noted in Table 1.
Table 1: Sites visited during the review
Province
Districts
SCs
OTP/SFP
OTP only
Implementing partner (s) at sites visited
Sindh
Umerkot
TMK
Hyderbad
S. Benazirabad
Thatta
5
8
1
SC at DHQ hopsital
Government and some NGO’s.
Operated by doctors and nurses
Supported by WHO
Punjab
Lahore
Multan
Rajanpur
Muzuffargarh
Layyah
Balochistan
Noshki*
4
2
5
OTP/SFP at community centers, schools and
government dispensaries
Shifa, Save the Children, HANDS, ACF, Merlin.
Operated by NGO recruited staff
Supported by UNICEF/WFP
SC at DHQ Hospital
Government (DoH) supported by WHO or UNICEF
Operated by nurses and LHV’s
OTP at BHU (and in some cases RHC and Health House)
Government (DoH) supported by UNICEF
Operated by LHV’s (in some cases also CMWs)
N/A
SFP at BHU
Government (DoH) supported by WFP
Operated - same as OTP
SFP at health House of LHW
Government (DoH) supported by WFP
Operated by LHW
*Lady Health Workers, Lady Health Supervisor and district staff met with the team. Sites were not visited.
9
Organization for Economic Cooperation and Development/ Development Assistance Committee. Principles for Evaluation of
Development Assistance, 1991.
3
Valid International
CMAM Review Report
2013
2. KEY FINDINGS
2.1 Modalities
The CMAM program in Pakistan seeks to provide the complete package of components as per
the traditional emergency model. This includes OTP for SAM without complications, inpatient
care for SAM with complications, supplementary feeding for MAM cases and community
outreach. The full package also includes the provision of a food ration for acutely malnourished
pregnant and lactating women (PLW) and a ration for the siblings of children admitted to
OTP/SFP. In addition, most programs have an IYCF component. Ration levels and routine drug
protocols are standardized. However, the availability of drugs for the routine medical treatment
in OTP is erratic. The complete ration for PLW is not always available.
Table 2: Standard rations and routine medical treatments in the CMAM program
Component
SC
OTP
SFP
PLW
Target group
0-59 months
SAM with
complications
6-59 months
MAM
Nutritional
treatment
Standard according to
WHO protocol
6-59 months
SAM without
complications
MUAC < 11.5cm
Standard
RUTF by weight
according to National
Guideline
Pregnant (2nd trimester)
women and lactating with
infant < 6 m with
MUAC <21cm
WSB 5kg/month
Oil 2.25kg/month
Sibling ration
1.2kg/15 packs HEB’s
every 15 days
Use and availability
of routine drugs
erratic
Weekly and
sometimes every 15
days
UNICEF
WFP sibling ration
UNICEF
Sibling ration
Same as OTP
Medical treatment
Standard according to
WHO protocol
Operating
24/7
Supply and logistics
WHO
Technical support
WHO and
UNICEF in Punjab
MUAC <12.5cm
Acha Mum
1.50 kg/15 sachets
Not systematic
Mostly absent
Every 15 days
WFP
WFP
Iron /folate erratic
Multi micronutrient tabs
erratic
Every month
WFP
UNICEF medical treatment
WFP
While, the CMAM package is standard, the implementation modality varies considerably. In all
three provinces, SCs are integrated into government run health facilities at the district level. SC’s
are supported by WHO and in some cases UNICEF. WHO aims to support one SC per district.
The review team found significant differences in the modalities in the community based
management of SAM without complications and MAM.
In Sindh, nearly all sites have the ‘full CMAM package’ of services as described above in Table 2.
In rare instances where SFP is not operating, it is due to pipeline breaks or administrative issues
with Field Level Agreements (FLA’s). CMAM is largely led by NGO’s with PCA/FLA’s with
UNICEF/WFP. There is little integration into the existing health system. The program has very
good outcomes (see quality of programming) but operates in emergency mode and
implementation is resource intensive.
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CMAM Review Report
The lack of integration is largely due to a failure to incorporate nutrition programming into the
DoH contract with the People’s Primary Health Care Initiative (PPHI) which operates the Basic
Health Units (BHUs). However, the team found examples of successful integration where these
obstacles had been circumvented at the district level. In Thatta district for instance OTP/SFP had
been successfully integrated into government dispensaries. The team found some evidence that
this integration improved uptake of other health services. In Thatta district, 87% of mothers of
children in the OTP/SFP reported also using family planning services.
The PC- 1 for Sindh suggests a government implemented pilot OTP program in 7 districts
operated by Lady Health Visitors (LHV’s) at health facilities and Lady Health Workers (LHWs) at
Health Houses. WFP will continue to provide the ration for MAM and PLW’s. There is, as yet, no
plan for how this would be implemented and no scale up plan with details on the number and
location of sites. In addition, The European Union (EU) is supporting NGO implemented CMAM
programming in three districts under the Women and Children/Infants Improved Nutrition in
Sindh (WINS) program.10
The team found the absence of a strong leadership and clear vision were issues in hampering
transition to a government led implementation. Parallel programming has resulted in overly
complicated monitoring and reporting systems and varying policies regarding implementation
and staffing. Large scale donor funding to NGO’s in Sindh presents an opportunity to pilot test
innovative and sustainable interventions, and specifically to build capacity at the provincial
level. However, this opportunity is not currently being taken. 11
In contrast, Punjab has recently transitioned from a predominantly NGO led emergency
intervention to government implementation of OTP under the National Program for Primary
Health Care and Family Planning. Factors contributing to this successful transition include;
strong government leadership, effective coordination and a well articulated hand-over strategy.
Importantly, the DoH contract with the Pakistan Rural Support Project (PRSP) included nutrition.
Thus the incorporation of OTP into primary health care activities at the BHU has not been an
issue.
The Punjab Government PC-1 is a fully integrated document. OTP is fully integrated into the
primary health care system with functional links to the National Maternal Newborn and Child
Health (MNCH) program and the Chief Minister’s Health Initiative for Attainment and
Realization of MDGs (CHARM). The PC-1 includes a clear phased scale-up plan to integrate OTP
into 931 BHUs and regional health centers (RHCs) (30% of all health facilities) in 30 of 36 districts
by 2017 (Figure 1). Punjab has recognized the issue of urban malnutrition and the scale- up plan
includes the treatment of SAM in nine mega cities. LHW’s will be trained to manage SAM as well
as other health activities through and Extended Health House (EHH). The EHH will be pilot
tested prior to scale up.
10
The WINS project (€30million over four years) supports ACF, Merlin and Save the Children CMAM programming in Dadu, Thatta and
Shikarapur and aims to treat 284,593 children and 507,675 PLW).
11 Nigel Nicholson. European Commission Nutrition Advisory Service ( EC-NAS). Mission Report Pakistan. 10 to 21 June 2013
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Figure 1: Punjab: Evolution of OTP sites
WFP had SFP programs in seven districts
until the end of 2012. Currently WFP is
operational in two districts. Thus SFP is not a
core component of the package. It is
1000
important to note that this is due to a
OTP
prioritization on the part of WFP and is
sites
500
BHU
indicative of the erratic nature of SFP
RHC
implementation which occurs only when
0
funding and food supplies are available. It is
2011 2012 2013 2014 2017
Year
thus viewed as not sustainable by the DoH.
A prevention package will be fully
implemented at facility and community level
through the LHWs. The review found that integration into the primary health system has
resulted in an in demand and uptake of other services such as EPI and family planning.
Balochistan is the largest province and the least densely populated. The distance and access to
health facilities requires adaptation to the conventional CMAM model. The Health House of the
LHW is used as the main site for treatment of children with MAM and PLW. Currently there are
354 SFP sites at the Health Houses (HH) supported by WFP. This program provides the standard
WFP ration from at the HH. Reportedly the program is working well with good weight gains but
this could not be verified by the team and there is no evidence suggesting that the current
program has reduced incidence of SAM or MAM.
Geographical coverage of SFP is good in the target districts. However, coverage of treatment for
SAM is extremely low. There are currently only eight OTPs in health facilities in Balochistan. This
has resulted in large numbers of untreated SAM cases. The review team interviewed LHVs and
LHWs as well as District Health staff who reported that they are indentifying SAM cases and
making appropriate referrals to SC and OTP. However, due to distance and access, most of these
cases are lost to follow up. A trained LHW is capable of treating SAM cases without
complications at the Health House as part of her ongoing work. 12 Restricting the treatment of
SAM to health facilities is severely hampering coverage and scale up in Balochistan.
Several key points emerge from the three provinces regarding modalities:

The impact of the large scale treatment program for children with MAM and PLW has not
been determined and thus there is no evidence that the current program modality is cost
effective means of reducing incidence of acute malnutrition.

All three provinces cited insufficient coverage (and absolute numbers of) government Lady
Health Visitors at health facilities and particularly Lady Health Workers in the community as
the main reason for limiting scale up and integration. This human resource constraint limits
integration, coverage, impact and implementation of the prevention package.
12
Kate Sadler, et al. Community Case Management of Severe Acute Malnutrition in Southern Bangladesh. Save the Children/Feinstein
Famine Center, June 2011. http://sites.tufts.edu/feinstein/2011/community-case-management-of-severe-acute-malnutrition-in-southernbangladesh
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
2013
Effective coordination and leadership of the DoH are the hallmarks to successful integration.
The DoH has a critical function in setting priorities for programming and strategic direction.
Current CMAM sites and the planned target number of sites as noted in PC-1 plans can be found
in Table 3. In the pre implementation stage, considerable focus must be given to developing
these plans and ensuring a strategic framework and implementation plan is put in place.
Table 3: Actual and targeted OTP and SFP sites by 2017 by province
Province
District
No.
Sindh
23
Rates %
NNS
Baseline
SAM 6.6
MAM10.9
Goal key
performance
Indicator
30% reduction
in SAM cases
Current sites and planned targets to meet goal
SC
SC
OTP
OTP Target
Current
Target
Current
22
23
221
Unclear
15 districts
Punjab
36
Balochistan
32
SAM 4.8
MAM 8.9
-OTP sites at
30% of all BHU/
RHCs
By -80% indentified
enti SAM cases
treated
SAM 7
30% reduction
MAM 9.1
in SAM cases
25
36
144
7 districts
10 districts
NGOs: 4
districts
DoH: 6
districts
931
30 districts
9
20
8
8 districts
DoH/Doctor
Unclear
7 districts
Unclear
SFP
Current
221
SFP
Target
Unclear
15 districts
NGOs
10 districts
NGOs: 4
districts
DoH :6
districts
Unclear
345
7 districts
DoH/LHW
58
2 districts
Unclear
Data sources: SC data (WHO and UNICEF); OTP/SFP Provincial Nutrition Cell: Targets: PC1 documents
Sindh: PC1 2013-16 Nutrition Support Program (NSP): ($43m)
Punjab: PC1 2013-16 Integrated Reproductive Maternal and Child Health (RMNCH) and Nutrition Program:( $98m)
Balochistan: PC-1 2013-16 Balochistan Nutrition Program for Mothers and Children (BNPMC): ($16 m)
2.1 Mapping and program data
Mapping
Current mapping is done in conjunction with the Nutrition Information System (NIS). During the
review the team found it challenging to get a grasp on the number of sites past, current and
planned. For example the PC- 1 for Sindh reports 463 OTP sites and 463 SFP sites in 20 districts.
At some point this changed and the current number is reported by the NIS in Sindh is 221
OTP/SFP sites (as of July 2013). WFP reported functional OTP/SFPs in Sindh as 252, an additional
30 sites compared to the NIS. In Balochistan, the number of SFP sites reported by the NIS is 289
as shown in Table 4. According to WFP and the DoH Nutrition Cell, there are currently 345 SFP
sites in Health Houses. There is also discrepancy regarding the current number of SC’s in Sindh.
While the most recent NIS report at time of review showed 16 SC’s, WHO reported to the team
that there were 22 SC’s. Similarly in Punjab, the NIS reports 15 SC’s while WHO and UNICEF
data reports show 25 SC’s currently functioning. This disparity in Punjab is in part due the fact
that UNICEF is supporting some SC’s which are not reported in the total by WHO.
The number of planned OTP and SFP sites for Sindh and Balochistan is unclear and could not be
obtained from the PC-1 or the NIS. Thus the basic information required for supply planning and
human resource projections is not readily available.
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Table 4: Current OTP, SFP and SC sites reported by NIS, July 2013
Province
Punjab
#Districts
#Tehsils
#UC
Areas
#SFPs
#OTPs
#SCs
12
43
219
58
144
15
7
24
111
190
219
16
10
17
43
289
8
10
Sindh
Balochistan
Figure 2: NIS mapping data: July 2013
Mapping is useful in determining
geographical coverage. Thus it is
important to specify and color code the
type of site. The current mapping used in
the NIS as shown in Figure 2 does not
differentiate between SFP and OTP sites
and OTP only sites. This is important. In
Balochistan for example there are
currently only 8 OTP sites but 345 SFP
sites. They are not the same sites or in the
same locations.
It should be immediately evident when looking at a map that coverage of treatment of SAM in
Balochistan is extremely low and action is urgently needed. Coverage of LHW’s and LHV’s
should also be mapped. This would aid considerably in planning scale up.
Program data
The team found it very difficult to access basic data on programming outcomes and key
indicators. The NIS is the main source for data. In addition NGO partners, UN agencies have
their own systems. WHO reports separately on Stabilization Centers through the Health
Management Information System (HMIS). Importantly there is very little analysis of NIS data
particularly regarding data trends so that comparisons over time cannot easily be made. The
exception is Punjab where the NIS is not used. In Punjab, data analysis for the last three years
was readily available as shown in Figure 3. The accuracy of data is questionable largely because
recording data at the base (at health facilities) is in accurate.
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2013
Figure 3: Punjab: OTP outcome data: January 2010- June 2013
3%
From the start of the program in 2010,
123,223 children have been admitted
to OTP.
1%
1%
18%
Cured
Default
Deaths
Non-Responder
Other
77%
With handover of the program at the
end of 2012, outcomes have remained
constant. Lower admission rates are
attributed to fewer sites, less
community screening and a reduction
in caseload.
Data Source: UNICEF Punjab
Data outcomes by province for the last six months from the NIS are shown in Figure 4. Data for
all program components can be found in Annex 5. Coverage surveys to determine point
prevalence have been conducted in six districts of Sindh using SQUEAC methodology. Findings
reveal average point coverage of 40-65%. 13
Figure 4: OTP Outcomes by province: January to June 2013
Sindh: Admissions: 19,611.
Cured 96%, default 4%, deaths < 1%
Cured
Punjab: Admissions: 4,245:
Cured 82%, default 17 %, deaths 1%
Cured
Balochistan: Admissions: 6,550
Cured 85%, default 14%, death 1%
Coverage is reported as Default
geographical coverage only in Default
the NIS and is very inaccurate.
Cured
Default
Deaths
Deaths
Deaths
Non-Responder
Non-Responder
Non-Responder
Data source: NIS
A considerable amount of training has been conducted for health workers and community
workers. This is reported in the NIS. Current training is mainly CMAM specific. Only the number
of those trained is reported. The team looked at the total trainings provided in the last two and
half years. The type of community worker is not specified so it is not possible to find the
number of LHV’s or LHWs trained in identification and treatment of SAM and MAM or IYCF. In
addition, many ‘master trainers’ have been trained but the quality and impact of this training is
not known. It is clear that considerable capacity has been built in the last few years as shown in
Table 5. However, much of the training has been conducted in an ad hoc manner and not part of
a coherent scale-up plan.
13
Coverage Monitoring Network/ACF. SQUEAC Report. TMK District, Sindh Pakistan, February 2013. ACF SQUEAC Report, Dadu District,
Sindh, April 2013.
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Table 5: Training conducted January 2011- June 2013
Province
Sindh
Punjab
Balochistan
Trainings for health workers
31
740
Not available
Trainings of community based workers
1465
740
Not available
Staff/Counselors trained in IYCF
448
18485
6380
Data source: NIS
2.3 Quality of programming
Quality of CMAM programming as determined by outcomes is very good as shown above in
Figure 4.14 In all three provinces cure rates for SAM and MAM exceed SPHERE minimum
standards. Default rates are low for OTP in Sindh and higher in Punjab and Balochistan which is
likely a reflection of distance and less intense community outreach. Default rates for MAM are
within SPHERE standards. The mortality rates for OTP and SFP are very low reflecting extremely
good and early case finding and effective treatment. However, deaths occurring in the
stabilization centers are not recorded separately through the government health information
system. Thus it is not possible to determine the impact of the overall SAM treatment program.
Accurate SC data was very difficult to access. Where it was available, the team attempted to find
an approximate mortality rate. Given the available data, the rate appeared to be very low at less
than 2% (data WHO Sindh, Punjab and Balochistan). Many cases of SAM are lost to follow-up in
Balochistan due to the lack of access to OTP treatment.
Coverage of treatment for SAM and MAM is difficult to determine since surveys have only been
conducted in select areas of Sindh. Geographical coverage by province does not yet meet
SPHERE standards of >50%. In addressing coverage, it will be essential to reach marginalized
communities, urban areas and far flung areas where rates of SAM are high.
Large numbers of children screened and referred for treatment during ongoing active case
finding and mass screening during campaigns and child health days. In some cases Community
Resource Persons (CPRs) and other volunteers are engaged in screening and outreach activities.
In Sindh, NGO recruited and paid nutrition assistants play a key role in community outreach.
This accounts for the early case finding and low default rate in Sindh. In Punjab and Balochistan,
the LHW has the primary responsibility for case finding.
The team found little difference in overall program quality between international and local
NGOs and government led programs. However, there was a considerable difference in costs
according to PCA budgets. A local NGO was approximately five times cheaper than an
international NGO. The DoH in Punjab reported that government costs for SAM were
considerably less than an NGO. This does not account for support from UNICEF and WFP in
supplies and logistics but reflects transport costs, overheads and staffing. 15 These findings are
indicative. A detailed analysis is required to look at the cost effectiveness of programming
factoring in economies of scale.
14
Sphere Minimum Standards (2011). SAM (cure >75%, default < 15%, deaths < 10%). MAM (cure rates >75%, default <15%, deaths <3%)
www.sphereproject.org.
15 RUTF accounts for 33% of the overall cost in OTP programs.
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Treatment of SAM (OTP)
In the last two (January 11- June 2013) over 32, 000 cases of SAM have been treated in the three
provinces. In Sindh, The average MUAC on admission in Sindh and Punjab is 11.2cm.16 Given
this early presentation and the low rates of oedema (less than 1%), most cases should recover
within 60 days (to current discharge criteria). However, length of stay (LOS) of 81 days is much
longer than expected in Sindh. This has significant cost implications. The long LOS is in part due
to frequent absences and sharing. However, recording errors were also a factor. Many cases
were found when the child had met the discharge criteria several weeks before. Some OTP staff
had been instructed by their agency to keep children in the program longer as a policy or
because of pipeline breaks in the SFP. Weights were not always recorded accurately, thus
calculating average weight gain was challenging. The team found that the messages regarding
the use of RUTF were not accurately conveyed or understood and other foods are often given.
There was a high correlation between sites giving confused messages on the use of RUTF and
low weight gains in both Sindh and Punjab. The converse was also true. In sites with good
messaging and accurate recording in Punjab, weight gains were 400-600 g/week. Therefore
clear messaging on the use of RUTF and community follow up is critical. It is clear that the
sibling ration does little to impact weight gain or LOS.
The RUTF pipeline is stable and reliable. Interviews with community members suggest default is
primarily due to distance in Balochistan and workload of the mother in Sindh and a combination
of both factors in Punjab. The low default rate in Sindh, as noted above is primarily due to
strong community outreach and relatively short distances to the OTP. In some cases where
OTP is operating every two weeks, there is confusion regarding the definition of default. Supply
of routine drugs is however erratic. At the time of the review there was very ad hoc availability
of amoxicillin due to issues in the supply chain. This is important to rectify but is likely not a
major factor in LOS.
OTP operates weekly and in some cases every two weeks. Static sites may be open 6 days a
week, satellite sites are operated 2-3 days a week. Caseload is variable depending on how long
the site had been open. Caseload ranged from 6-80 a day in Sindh and from 10-100 a day in
Punjab. Experience in Punjab suggests that a caseload of 10 cases per day is manageable by the
LHV as part of primary health care. In Balochistan, LHW’s estimate that average caseload would
be 3-6 SAM cases/week in the Health House. The number of staff required to manage the
quality treatment of SAM was found to be:



1 LHV at the health facility or 1 LHW at the HH.
1 CMW or nutrition assistant trained in IYCF counseling and prevention.
As part of the government system a cleaner, store keeper and pharmacist are found at
the facility level.
Most OTP’s had reasonable wait times with the exception of one agency in Sindh that turned
beneficiaries away due to very restricted opening times. Efficiency was variable with the best
examples, managing new admissions of SAM first. Most sites managed SAM and MAM cases
together successfully. In some cases the PLW component added confusion and crowding making
it challenging to effectively provide clinical treatment. Quality of care and patient interaction
varied from excellent to reasonable. For the most part the admission parts of the OTP card are
16
Calculation based on 200 OTP cards from six sites in Sindh and 7 sites in Punjab.
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correctly filled out. However the clinical assessment is rarely conducted fully and the boxes
checked without assessment. Weight is also not always taken or recorded correctly and thus
weight gain numbers are random. Workload requirements were found to impact on the
accuracy of recording on the individual OTP cards making the data unreliable.
Competency in use of the Action Protocol to determine referral of SAM with complications was
good. Referrals were made appropriately. In Sindh, IP’s frequently provided transport and funds
were also provided to caretakers to offset the opportunity cost of staying in the SC. No
transport or funding assistance was provided in Punjab. In all sites visited referrals to SC were
less than 5% of the caseload.
Treatment of MAM (SFP)
The treatment of MAM cases is managed in the following way:


At the same site and by the same staff at OTP in Sindh and two districts of Punjab
At the HH managed by the LHW in Balochistan.
Program outcomes are generally good. While SFP has reportedly treated over 380,000 MAM
cases over the last two years in the three provinces, there is no means of gauging impact.17
Whilst anecdotal evidence suggests weight gain and improved outcomes in communities, it is
unclear if the large-scale and costly investment in treatment of MAM has reduced incidence of
MAM or SAM.
The program operates every two weeks and occasionally monthly in remote locations. The
pipeline of Acha Mum is reliable, but the short shelf life (6 months) means transport and storage
in far flung places is challenging and results in waste. WFP is seeking means to extend the shelf
life. Programs with clear and transparent criteria and good messages can effectively handle
both SAM and MAM cases. In Punjab, sites with both OTP and SFP were busier than OTP only
sites. This affected workload and the accuracy of recording, but it did not affect outcomes.
Treatment of PLW (SFP)
The SFP also includes the treatment of acutely malnourished PLW (MUAC < 21cm). The ration of
WSB and oil is widely shared among women and children in the household. The program is
popular and the food ration well-liked. The team found frequent complaints regarding the
erratic availability of oil. As a high value commodity the oil is a particular draw. During the
review, the WFP ration was doubled for same beneficiaries as shelf life of commodities was
expiring. This caused confusion among staff and beneficiaries and increased resentment among
those receiving nothing.
The WSB ration is packed in 2.5kg or 5kg bags aids in distribution. The ration acts as a draw to
health facilities. This has both advantages and disadvantages. In those few districts in Sindh
where CMAM is implemented in a health facility, there is evidence of uptake of ANC services
and family planning, and TT vaccination. It also provides an opportunity for IYCF counseling.
However, the large amount of food and crowding at the site detracts from clinical management
of SAM and MAM cases. The team found the distribution of iron/folate and/or micronutrient
17
Data provided by the NIS (2011-13) indicates over 600,000 admissions in the three provinces and approximately 350,000 treated with
approximately 29,000 defaults and 44 deaths.
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supplements to be erratic and mostly absent from sites visited. The impact of the program is
impossible to gauge. Most reach a MUAC of 21cm but stay in the program a long time.
Anecdotal reports suggested improved weight gains among PLW and indirect benefits gained
from the opportunity to conduct IYCF counseling.
The team believe that micronutrient fortified a ready to use product would be a more
appropriate ration for PLW. This should be distributed through ANC or at the Health House with
clarity on the purpose of the program and target group. WFP are currently developing a locally
produced lipid-based nutrient supplement (LNS) PLW.
Stabilization Centers
Stabilization Centers are working well in terms of efficiency and effectiveness and safe
treatment.
The pipeline of supplies (F75, F100) was good and when not available for a short period, staff
was able to successfully use the local recipes in the National Guideline. Staff has been well
trained in the management of SAM with complications. In some cases the SC was too overmedicalized with far too many doctors. In one SC in Sindh, the team found five doctors for 2
patients and no nursing staff. Reports of frequent staff absence and difficulties in
communication between partners operating OTP and SC hospital staff in Sindh could not be
verified by the team. In Punjab, SC was operated by an LHV or nurse with a doctor on rotation.
Referrals to and from the SC were problematic in some cases. This is less of a problem when an
LHW specifically followed the case. WHO is currently piloting an SMS referral system to attempt
to make referrals more efficient.
The vast majority of cases at the SC do not come from OTP, but come via the outpatient
department at the hospital (OPD). The average SC caseload was found to be on average 715month. On the whole, SC staff understands the purpose of the SC is to follow WHO steps 1-7
until a child is stabilized. However, some staff are using the old TFC protocols and keep children
until they reach WFH <1Z. Most SC’s had a functional OTP attached to the SC ward or in a
different part of the hospital. This helped considerably in follow up. A few cases from remote
areas where follow- up at the hospital OTP was difficult were provided with RUTF rations for up
to a month.
Most SC’s claimed to be able to manage infants effectively. This was observed in two cases
where supplemental suckling technique (SST) was used successfully. The quality of IYCF
counseling was variable and for the most not highly practical. Two excellent examples of SC
good practice stood out. In Lahore, the SC at the Ganga Ram Hospital is led by LHVs who also
work in the community. The SC is linked to the breastfeeding counseling center next door.
Attention is given to addressing the underlying causes of SAM with complications including
psycho-social support and bonding. The SC at Thatta DHQ Sindh had a high caseload of infants
under 6 months and provided SST very successfully. SC staff led a mother-mother support group
to address the key reasons for malnutrition in their infants. As a result staff had successfully
reduced the re-admission rate among infants.
The amount of paper work for SC staff is extremely cumbersome and impacts on staff time for
quality clinical care and support. In several sites, five cards and patient reports were being
completed when one card would be sufficient.
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During the review, several NGOs discussed their intention to open additional SC’s in Sindh.
Given the small number of cases, the opening of additional SC’s by NGO partners beyond WHO’s
planned scale up should be avoided. This is not an effective use of resources and is not
sustainable. Efforts are much better focused on early identification of SAM.
2.4 Criteria and exclusion/inclusion
The team found good adherence to the National Guideline. Understanding and application of
discharge criteria varied with some IPs in Sindh keeping children in the program after they had
met discharge criteria (15% weight gain and MUAC >11.5cm) and some sites in Punjab
discharging children at 6 weeks irrespective of whether they had met the discharge criteria.
MUAC was used for indentifying SAM and MAM cases and PLW and for admission to OTP and
SFP. In a few cases weight for height was also used at the OTP site. This creates error and is
labor intensive and unnecessary. Weight for height should not be used in any community based
program. There is also no need for weight for height at the SC. The use of MUAC only would
create harmonization between program components. The use MUAC only does not exclude
SAM cases in need of treatment. 18
The use of MUAC for PLW is problematic in that it is not clearly understood by beneficiaries.
Several cases of manipulation of the MUAC tape were observed in Sindh. An immediate solution
is to use a color coded tape for PLW to increase transparency. However, the large food ration
given to some PLW and not others in the same community was raised as an issue by community
leaders, community groups and by pregnant and lactating women not in the program. In part,
this confusion regarding the target criteria stems from the long-time inclusive blanket feeding
programs for PLW in Sindh and Punjab. In Balochistan, where the PLW program is managed at
the Health House with beneficiaries individually known to the LHW, this is somewhat less of an
issue.
Infants less than 6 months are particularly likely to be excluded in OTP. Whilst some cases are
referred to SC as per current protocol, many do not go or drop out. Infants less than 6 months
are currently not followed in the OTP/community outreach if they refuse SC or if they default
from the SC. As a result, they are lost to follow up
The allocation of rations is linked to targets as is the renewal of a PCA/FLA. The allocation of
rations is determined according to targets. In several cases the targets for SAM had been
exceeded in new sites. One IP had stopped screening and referring children for fear of running
out of supplies. Others had not met targets due to a low caseload. Over time the incidence of
SAM and MAM should reduce assuming a program is effective. It should be clear to IPs that
supply is based on admissions and they will not be penalized for exceeding or not meeting
targets. Screening against targets is unnecessary. Screening, or rather active case finding should
18
Save the Children, ENN, ACF and UNHCR. Mid Upper Arm Circumference and Weight for Height as indicators for severe acute
malnutrition. A consultation of operational agencies and academic specialists to understand the evidence, identify knowledge gaps and
inform operational guidance. Final Review Paper. December 2012. www.ennonline.net
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be role of the LHW. MUAC should be routinely recorded in the LHW register. The use of
screening sheets is not necessary.
2.5 Infant and young child feeding
An IYCF component is included in all CMAM programs with the intended aim of addressing the
underlying causes of acute malnutrition in children less than 24 months through improved
feeding and care practices. High rates of acute malnutrition in infants are correlated with very
low rates of exclusive breastfeeding, early introduction of other foods and liquids such as tea
and inadequate feeding frequency and lack of diet diversity after 6 months. The high rates of
low birth weight (LBW) babies are also important to note as these babies are more prone to
becoming acutely malnourished as well as stunted.19 These causal factors are well documented.
However, addressing these causes in the context of a CMAM program has proven challenging.
Most programs have a dedicated staff member for IYCF. In Sindh this is either a recruited paid
staff member or less often an LHW (given a top up incentive). In Punjab, IYCF counseling is
carried out by the CMW running ANC and/or the LHV/LHW operating the OTP. In Balochistan,
the LHW provides IYCF counseling as part of her ongoing work. The implementation of the IYCF
component is extremely variable. IYCF counseling takes place at the OTP/SFP site in a
designated corner. In some sites the standard hospital curtain rail and label of ‘breastfeeding
corner ‘existed only as a function. The criterion for who receives counseling at the sites is not
systematic. At some sites all PLW and mothers of children in the program who are breastfeeding
are referred for counseling. At other sites, only those thought to have issues were referred. At
two sites visited, only those who volunteered themselves were counseled. The counseling itself
varies from a dictatorial approach to an inter-personal practical approach.
The content of the IYCF counseling also varied. Some implementing partners use a rapid
assessment tool to determine IYCF issues. Most counseling sessions addressed early initiation of
breastfeeding, positioning and feeding on demand. Very few attempted re-lactation or could
deal effectively with complicated issues. Messaging on complementary feeding was frequently
found to be inappropriate and impractical. Several staff advised mothers to use Cerelac, eggs
and meat when at home there was only bread, potato, curdled milk and chili peppers. The
most effective counselors were experienced LHW’s who know the community well. Several
LHWs gave very practical advice to mothers using food readily available in the house and how to
barter and exchange items to increase diet diversity. The IYCF component for the most part
does not include the care of PLW in terms of nutritional counseling and micronutrient
supplementation.
While there are many IEC materials in circulation, much of this is not useful. In Sindh, the team
heard about an IYCF training box including tools for counselors, but what was in it was a mystery
since we were not able to find it. There is no standard package of IYCF tools in Urdu.
All sites visited had an IYCF component at the site. However, opportunities to extend IYCF to the
community are very under-exploited. Several IPs had breastfeeding support groups at the site
but not at the community level. IP’s in Sindh were implementing a ‘bottles for cups’ exchange.
19
LBW (< 2.5kg) rates: Punjab: 27.8, Sindh, 14.5 Balochistan: 24.8, NNS data 2011.
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Bottle feeding is pervasive so the idea is a good one. The bottle which is highly valued was
replaced with a cup without a lid. The team found many mothers who stood out as natural
leaders and would make good peer counselors in the community. This would help change
practice and build sustainable capacity at the community level Other innovative ideas were
suggested by the Village Development Committees (VDC’s). When asked how the community
could better support women to feed and care for their babies while at work in the fields, they
suggested crèches and breast feeding shelters. Both ideas were accepted as feasible by the
landlords interviewed in Sindh.
In urban areas, IYCF is critical, yet there are few examples of CMAM/IYCF in the mega cities. The
team found an excellent model of at the Ganga Ram Hopsital in Lahore The center is a drop in
and caters for all women in the nearby urban slum areas. Counseling is personal and extremely
effective. The center is linked to the SC/OTP and also emphasizes psycho-social aspects of
bonding and mother/baby well being.
The team attempted to gauge the impact of the IYCF component. In talking to mothers and
grandmothers, it emerged that that a significant shift in breastfeeding practice has taken place
in program areas of Sindh. Early initiation of breastfeeding and exclusive breastfeeding for 2- 3
months were common practice. Exclusive breastfeeding to 6 months and appropriate
introduction of complementary foods was much less common.
There are currently no simple indicators to measure the impact of IYCF. The only indicator used
in the NIS is ‘the number of IYCF counseling sessions.’20 This indicator revels little about the
quality or impact of the IYCF counseling and is thus by itself quite meaningless. Indicators used
must be simple and in line with the goals of PC-1 and integrated into the HMIS. No KAP surveys
were reported at the time of the review and/or findings were not yet available. At the time of
the review and IYCF consultant made recommendations for IYCF indicators. These have been
revised by the team and can be found in Annex 6.
2.6 Prevention
Given a focus on treatment and IYCF, other activities such as health, hygiene and micronutrient
deficiency prevention have taken a back seat. Currently, prevention interventions range in both
content and style. The team found a lecture style dictatorial approach on the virtues of handwashing at one site, while at another site an inter-active group discussion included practice of
hand washing and the distribution of soap. The use of micronutrient sachets (sprinkles) is
another example of variance. The use of sprinkles in practice is extremely erratic. The target
group was unclear with IP’s providing them variously to children under five, to children less than
24 months and to PLW who were not enrolled in the CMAM program. Some provided them for 7
days and some for 15 days and many did not provide them at all. The use of sprinkles for 15
days is not effective. It requires at least 2- 3 months to treat or prevent micronutrient
deficiencies. The sachets were given more as compensation than a prevention strategy.
There is no standard prevention package. Given the high prevalence of both wasting and
stunting, a standard prevention package is essential. The team was unable to gauge the impact
20
Total IYCF counseling sessions (Jan 11- June 13 Sindh = 29,784, Balochistan: = 1326 Punjab: = 928. NIS data July 2013.
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of current prevention activities. Thus there is a need both for a standard prevention package
and a set of impact indicators. A suggested standard treatment and prevention package and
impact indicators can be found in Annex 7.
The team did observe linkages to food security and livelihood programs in practice.
Implementing partners in Sindh reported that their programs under WINS included (or planned
to include) one or more of the following prevention activities aimed to reduce wasting and
stunting:



Home gardens for to increase diet diversity at household level.
Cash transfers for households in the poorest quintile with children 6-18 months
social safety net program for PLW and/or infants of 6-24 months whose access to food
currently depends on gifts/donations
2.7 Monitoring and reporting
Monitoring
The team found numerous examples of multiple form filling and redundancy. The issue with
paperwork overload can be partly resolved by removing redundant forms and streamlining
paperwork. For example there is no need for an OTP or SFP card and a register. There is no
need for a ration card, screening forms, or charts registering the numbers of children attending.
In addition several agencies had their own forms. At the SC, multiple forms where being filled
out when one SC monitoring card would suffice.
Workload has resulted in OTP cards being completed inaccurately. Therefore a simplified OTP
card is required that is short enough to be filled out accurately to give better quality monitoring
and more reliable data. This will simplify recording at the site and thus increase the accuracy of
reporting from the base to the district level. A simplified OTP card can be found in Annex 8.
Reporting requirements across all the MCH activities also need to be streamlined to give health
workers more time with patients.
In Punjab, the LHW monitors MUAC of all children in the register book, this allows for effective
tracking and early intervention.
Reporting
The Nutrition Information System (NIS) is complex, difficult to access to those not specifically
trained to use it and resource intensive. In looking towards a sustainable integrated approach
for CMAM, it is clear that the NIS will need to be simplified. An NIS ‘lite” has been developed
and this is a good basis for a simplified reporting system that can be used in all provinces for
harmonization.
The NIS currently records individual children. There is no need for individual child monitoring
outside of a research program. In Punjab, the NIS is not used. Instead, a simple hard and soft
copy format is used for reporting is used which makes data much more readily accessible and
easier to understand and analyze.
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SC data is reported separately through the HMIS since SC’s are based in government hospitals.
In an integrated program, the harmonization of data becomes a government concern and not a
cluster issue. There is a need for a simple template for data to be collated in one place. The
format for collating data must include SC data. A minimal package of indicators is also needed.
This package can be informed by the Minimum Reporting Package (MPR), but only one report
format is essential. The indicators used should feed into the HMIS at district and provincial level.
An example of a template for collating/presenting data can be found in Annex 9.
Effective monthly coordination led by the DoH in an integrated manner can help avoid these
data issues. A simplified system should ensure a common monitoring and reporting tool used by
all programs whether government or NGO. It should also aid in analysis.
2.8 Policy and coordination
Coherence to national and global strategies was found to be strong in all provinces at least in
theory. National and global strategies such as the Pakistan Integrated Nutrition Strategy (PINS)
have been adapted to provincial level. All three provinces plan to increase ‘nutrition sensitive’
programming. In practice, this policy framework is unlikely to have direct impact on CMAM
outcomes. The focus for CMAM must be on integration in the health system and a clear
strategic plan for scale up.
Coordination mechanisms are effective in Punjab. In Sindh, the Nutrition Cell is not as
prominent in leadership and coordination, perhaps in part because the cluster is still
functioning. In Balochistan, a formal coordination mechanism exists but is not currently active.
Leadership and coordination by the provincial DoH is essential for the integration and scale up
of CMAM and is now more appropriate than the cluster coordination mechanisms which is
being phased out.
There is currently no evidence that feasible plans are in place to provide surge capacity to assist
with an increased caseload of SAM in the event of an epidemic and/or natural disaster. The
model for surge capacity will need to change over time as CMAM is scaled up. Government
should be in a position to redeploy already trained staff to affected areas and to work with
UNICEF, WFP and NGOs for additional human resources, RUTF, supplementary food, and
logistical support to be able to respond to acute emergencies. For example, in the 2011 the
Ethiopian emergency, although weak in several sectors, health was able to respond to increases
in acute malnutrition by supporting the government with additional supplies, logistics, and M&E
to enable frontline health workers to treat more children within existing services and facilities.
(see: DEC Ethiopia Real time Evaluation Report:www.alnap.org/pool/files/1381.pdf)
At the central level, the Planning Commission is the focal point for coordinating the nutrition
agenda. The Nutrition Development Partners Group has taken forward the nutrition agenda
including the formulation of steering committees, the technical working groups and policy
guidance notes at provincial level. Inter-sectoral nutrition strategies have been developed as a
basis for scaling up nutrition (SUN) membership. It is important to note, that any policy
regarding CMAM must have must have buy-in at the provincial level. Thus the revision of the
National Guideline for example should be informed by the significant practical experience of
integrated programming at the provincial level.
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3. ACTIONABLE RECOMMENDATIONS
3.1 Sustainable foundation for CMAM in policy and practice
In order to ensure effective successful integration and scale up of CMAM, a sustainable
foundation must first be established. Thus the following key actions are recommended:
Human resource and technical support to the DoH/ Nutrition Cell

A coordinated effort by donors, WFP and UNICEF to provide human resource and technical
support to the DoH/Nutrition Cell. This will allow the DoH to: [A] Take a leadership and
coordination role. [B] Develop clear strategic priorities and policies including the essential
incorporation of nutrition into contracts with partners operating BHU’s. [C] Develop clear
phased plans for integration and scale up including human resource and training needs. [D]
Develop emergency contingency plans for surge capacity.

Promote inter-provincial exchange visits by a DoH led delegation. This should include those
directly responsible for decision making as well as technical staff responsible for
programming. Specifically the exchange visits could benefit from: Successful integration of
OTP into primary health care (Punjab) and government dispensaries (Sindh) ; Effective NGO
handover, coordination and leadership (Punjab) and sustainable program modalities that
potentially provide good coverage at the community level in rural and urban areas such as
the Health House (Balochistan) and Extended Health House model (Punjab).

NGO’s should avoid parallel programming including opening of SC’s outside the government
structure. NGO’s can support government priorities by: building capacity particularly at the
community level; assisting government to pilot test sustainable strategies and programming
in high burden but low coverage areas including urban areas.

CMAM policy is largely determined at the provincial level. The revision of the National
CMAM Guidelines should be informed by the significant practical experience of integrated
programming at the provincial level. The Guideline should be a standard national document.
However, the protocols and tools will likely be taken and adopted and if necessary adapted
and translated to suit the local context.
Capacity building

Allocate funding to the recruitment and deployment of LHW’s and advocate for the
removal of current barriers that limit increasing their numbers.

Develop clear roles and responsibilities of core staff (LHW, LHV and CMW) in the
management of SAM, MAM and PLW.

Pre-service and in-service training of these core staff should include the management of
SAM, IYCF and the prevention package. Master trainers responsible for the training of
practitioners in CMAM must have practical experience themselves.
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
Pre-service training for nurses includes a practical rotation at the SC. This training should
also extend to OTP to give nurses a better practical experience of the management of
SAM at community level and referral mechanisms.
Pilot testing effective models
In order to promote sustainable CMAM programming, the following should be pilot tested as an
immediate priority:

Efficacy and cost effectiveness of in-country production of RUTF. The experience of local
production of RUSF should prove a good basis from which to begin investigations, but any
lower cost RUTF recipes a will require effectiveness trials in order to ensure efficacy in
reatment of SAM.

Sustainable modes of implementation that potentially provide good coverage such as the
Health House model.

Innovative and cost-effective ways of managing MAM and reducing incidence of acute
malnutrition. The use of one product (RUTF) for SAM and MAM could be explored.
Specifically, the use of short- term RUTF when MUAC is 12– 12.5cm for 7 days could be
tested and analyzed to determine the impact and potential cost savings in reducing
incidence over time.

Innovative means of promoting diet diversity at the household level such as home gardens
small scale animal husbandry and systems of barter and exchange.

The use of a ready to use food for PLW. The LNS product under development by WFP for
PLW should be tested and linked to use at ANC and the Health House.

The use of an Action Protocol specifically for acutely malnourished infants less than 6
months to determine which infants need referral to SC and those that can be managed in
the community.
3.2 Programming
Quality
Integrated programming results in increased demand and uptake of other health services.
Parallel programming should be avoided. In seeking to improve program quality and coverage
the following key actions are recommended:

Immediately address the lack of treatment coverage for SAM cases in Balochistan
through programming at the Health House.

Focus on integrated programming at the BHU/dispensary in Sindh and Punjab in the
immediate term and pilot test the Health House model to promote further coverage.
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Develop and test a pack of simplified standard protocols, monitoring and reporting tools
in Urdu in line with the revised National Guideline.

Weight for height should not be used in CMAM programming or in community based
surveillance. MUAC should be used for identification and admission to treatment. MUAC
should also be used in all surveys. Use of MUAC only at the SC is simple and preferable.
MUAC and weight should be used for individual child monitoring.

Remove the sibling ration from OTP/SFP programs.

Revise messaging to ensure clear communication on the use of RUTF. RUTF only should
be consumed for the first three weeks of treatment. Thereafter, other family foods may
be added AFTER RUTF and breastfeeding.

Ensure availability of routine drugs.

Follow up and track infants less than 6 months in OTP (see testing of an Action Protocol).

The nutritional and preventative care of PLW should be managed by the LHV and the
CMW at the health facility or LHW at the Health House and linked to ANC.
IYCF
In order to strengthen implementation practice and broaden the reach and impact of IYCF
interventions, the following actions are suggested:

IYCF counseling should be managed by the LHW or CMW.

All PLW should receive IYCF counseling linked to ANC at the facility and/or through the
Health House at the community level.

Develop and test a standard package of tools for IYCF in Urdu. Core content should include:
Breastfeeding counseling aids; suggested ideas for establishing mother to mother groups;
key messages for complementary feeding with ideas for adapting these messages to the
local context in order to ensure they are, appropriate, feasible, affordable and practical
(AFAP); simple report form, ANC referral slip, routine prevention treatments for PLW.

Extend IYCF to the community through effective mobilization and training of peer
counselors. Specifically this should include; a) Mobilizing a cadre of mothers to become peer
counselors and leaders of mother to mother support groups; and b) Mobilizing Village
Development Committees and landlords to support interventions that support
breastfeeding mothers while working.

Revise process and impact indicators for IYCF (Annex 6).
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
Assess the impact of IYCF at the community level though rapid assessment methods and KAP
‘lite’ against key baseline indicators. Coverage methodology such as SLEAC and 3SM can
effectively be used to collect information on behavioral change.
Prevention

Develop a standard treatment and prevention package linked to a set impact indicators. The
content of the package should be in line with the prevention activities outlined in the PC-1’s
and address the key causal factors of malnutrition and child illness (Annex 8 ).

Prevention messages should be feasible and practical. No more than five core messages
should be given related to IYCF and health and hygiene specifically hand-washing with soap
and use of ORS. These messages must be repeated often at facility, community level and
practiced. Content can be informed through positive deviance investigation, focus groups
and community based surveys and surveillance.

The LHW is responsible for the health and nutrition prevention in the community. In this
role, she can be assisted by the various health and development committees at the local
level. NGOs can assist in the development and implementation of creative approaches
including; the promotion of family health action groups, the training of peer counselors and
promotion of dietary diversity.

The widespread availability of mobile phones, satellite TV and radio provide ample
opportunity for prevention messages via the media. Messaging should be simple and
practical with a focus on breastfeeding and complementary feeding.

A baseline is required against which to determine impact. This may exist already without the
need for laborious and complex baseline surveys. Impact assessment of behavior change
can be conducted through KAP ‘lite’ surveys and rapid assessment methods as well as
through ongoing sentinel/nutritional surveillance sites.
3.3 Monitoring and reporting
Monitoring
Current tracking, monitoring and reporting systems require streamlining and simplification to
improve accurate reporting, ease of access to data and improved analysis.

Simplify the OTP card so that it can be filled out accurately to give better quality monitoring
and more reliable data (Annex 8). The simplified card should be field tested.

Reporting requirements across all the MCH activities also need to be streamlined to give
health workers more time with patients.

Revise LHW registers to include the tracking of MUAC. This routine monitoring allows for
early identification of acute malnutrition
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
Streamline and remove redundant paperwork at the OTP/SFP site. The following are
unnecessary: registers, attendance sheets, ration cards and screening forms.

At the SC, one card can be used to monitor inpatients. There is no need for a register.
Reporting

Simplify reporting tools for LHV at the health facility and LHW at the community level to
ensure accurate reporting from the base.

Develop a simple report format that encompasses key data from SC, OTP and SFP in a
readily accessible format in soft and hard copy (Annex 9). PLW data should be reported
separately.

As the DOH/Nutrition Cell takes the lead in coordination (rather than the cluster), monthly
report summaries should be compiled by the DOH.

Indicators used for monitoring will include a combination of process indicators for program
management and impact indicators which will be a minimal package of indicators
incorporated into the DHIS/MIS. The MRP can be used to inform the minimal package of
indicators but the focus must be on simplification not the addition of further reporting
mechanisms.



Effective methodology such as S3M should be used to map coverage on a large scale as well
as collect information on behavioral change to measure impact of IYCF and prevention
interventions.
Mapping of sites must include analysis of trends past, current and planned. This is critical for
planning and accurate supply management. Mapping of sites will be color coded to clearly
designate OTP only sites from OTP/SFP sites and SFP only sites. This will assist in
determining geographical coverage (current and planned). Mapping should also include
LHW coverage overlaid with site coverage since this is essential foundation to the scale up of
CMAM.
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ANNEX 1: Valid International Review Team Itinerary
DATE
TRAVEL
ACTIVITY
LOCATION
TEAM
July 7
July 8
Travel to Islamabad
Meeting with UNICEF
Discussions with UNICEF/WFP Review Team
Meeting with IYCF Consultant
Meetings with ACF, Save the Children and Merlin
Meeting with CMAM Task Force
Meeting with Nutrition Cluster
Meeting with Planning Commission
Meeting with National Disaster Management Authority
Islamabad
Tanner/Walsh
Team
Travel to Karachi
Meetings with UNICEF staff
Meetings with Nutrition Cell
Field visit preparations
Meetings with Shifa
Night visit to Umerkot DHQ SC
Umerkot DHQ SC
Umerkot DHQ OTP/SFP Shifa
Interviews with outreach workers
Interviews with mothers
Shifa OTP/SFP site at Kunri Memon
Breastfeeding support group at site
Focal group with Landlords and VDC
Focal group in community
Save the Children OPT/SFP site at Bostan
Observed OTP/SFP/Screeningand EPI
Community visits of beneficiaries in programme
TMK DHQ SC
ACF supported OTP/SFP at DHQ
IYCF counseling
Observation of SFP and screening
ACF OTP/SFP site at Mazar Pur
Focus group discussions with PLW
OTP review
ACF OTP/SFP at Jansan Sombro
Interviews with mothers and grandmothers
ACF Field Office meeting
SC 1 at LUMHS
SC 2 at LUHMS
HANDS OTP sites
IYCF interviews
OTP review
Focus groups discussions with caregivers
HANDS OTP site at Sakrand
OTP review
Observed breastfeeding lecture
Interviews with mothers and CPRs
Briefing and field office meeting Hands
Meeting with Merlin at Field office
Merlin OTP/SFP site at Sher Ali Shah
Discussions with staff at dispensary
Focus group with beneficiaries in the community
Merlin OPT/SFP site at Var
Observation and review of OTP/SFP
Discussions and interviews in the community
Karachi
Team
Umerkot
Team
Walsh/Banda
Walsh
Banda/Tanner
Walsh
Banda/Tanner
Banda/Tanner
Tanner
Banda
Banda/Tanner
Walsh
Walsh
Walsh
Walsh
Banda/Tanner
Tanner
Banda
Tanner/Walsh
Banda
Walsh
Banda/Walsh
Tanner
Team
Team
Team
Debrief presentation
Discussion with Nutrition Cell, UNICEF, WFP
Meeting with HELP staff/DS Akram
Karachi
July 9
July 10
SINDH
July 11
July 12
July 13
July 14
Travel to Umerkot
July 15
July 16
Travel to TMK
July 17
Travel to Benazir Abad
July 18
Travel to Thatta
TMK
Benazir Abad
Thatta
Travel to Karachi
July 19
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Tanner
Tanner
Banda
Walsh
Walsh
Walsh
Walsh
Team
Team
Tanner
Tanner
Tanner
Walsh/Banda
Walsh
Banda
Team
Tanner
Team
Team
CMAM Review Report
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PUNJAB
July 20
July 21
Travel to Lahore
July 22
Meeting with UNICEF and WFP
Document review and field trip planning
Lahore
Team
Multan
Walsh/Banda
Tanner
Walsh/Banda
Meetings with Director General Health Services, Provincial
Director National Program
SC and Breastfeeding Centre/Sir Ghanga Ram Hospital
Meeting with CMAM implementing partners
July 23
July 24
July 24
Travel to Multan
Travel to Quetta
Travel to Rajanpur
July 25
Travel Muzuffargrah
July 26
Travel Layyah
Travel
Lahore/Islamabad
BALOCHISTAN
July 24
Travel to Quetta
July 25
SEE BELOW
OTP at BHU Saleem abad
OTP at BHU Bukhra
BHU/RHC at Kot Mittan
Meeting with EDO Health and Nutrition Focal Point
OTP at BHU Jadday Wala
OTP at BHU Jaggatpur
SC at Kot Addu
Meeting with EX-PD of Health Sector Reformt and DCO
Meeting with EDO Health, DCNP Muzuffargarh
SC at Children’s Hospital
OTP at BHU 36/TDA
OTP at BHU Jharkil
SC DHQ Layyah
Meetings with EDO Health and Nutrition Focal Point
Debriefing
Rajanpur
Muzuffargra
Multan
Layyah
Multan
Walsh/Banda
Walsh Banda
Quetta
Tanner
July 27
July 26
Travel to Islamabad
ISLAMABAD
July 28
July 29
July 30
July 31
Depart Islamabad
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Meetings with UNICEF and WFP
Meetings with district level staff from Noshki (LHS, LHWs,
LHV District Coordinator, Medical Officer)
Meeting with implementing partners
Meetings with Nutrition Cell
Meetings with Director General - Health
Meeting with Provincial Coordinator National Programme
Tanner
Presentation preparation
Debrief with key stakeholders
Guideline review and recommendations/CMAM Task
Force
Debrief with UNICEF and next steps
Meeting with NIS Task Force
Follow up on Guidelines
Islamabad
Team
Tanner
Team
CMAM Review Report
2013
ANNEX 2: Key Contacts
ISLAMABAD
Government- Federal
Mohammed Yahoob
Ali Ahmad Khan
Dr Aslam Shaheen
Dr. Sabrina Durrani
UN Agencies
Silvia Kaufmann
Sayed Saed Qadir
Qutab Alam
Megan Gayford
Teshome Feleke
Kim Blechynden
Mona Shaikh
Ghulam Abbas Abass
Tahir Namwaj
Mamoona Ghaffar
Margarita Lovon
Natiq Kazhi
Hadia Nusrat
Implementing Partners
Dr. Ibrahim Feyissa
Erin Rae Hutchinson
Shahid Faizal
Dr. Asif Iqbal
Onno van Manen
Dr. Qudsia Uzma
Asma Badar
Dr. Farhat Munir
Aliya Taylor
Dr. Wisal Mohammad Khan
Other Organizations
Abdul Reham
Clemantine Catoni
Nutrition Advisor
Federal Nutrition Officer
Chief Nutrition
Deputy Director DRR II/ Nutrition Cluster Co-Chair
Planning Commission
Planning Commission
Planning Commission
National Disaster Management Authority (NDMA)
Chief Nutrition
Nutrition Officer
NIS Officer
National Nutrition Coordinator
Nutrition Officer
Consultant IYCF/CMAM
Nutrition Officer
Nutrition Officer
Nutrition Officer
Nutrition Officer
Consultant Stunting Prevention Study
Information Officer
Gender Equity Advisor
UNICEF
UNICEF
UNICEF
UNICEF
UNICEF
UNICEF
WFP
WFP
WFP
WFP
WFP
WFP/NIS Working Group
UN Women
Country Nutrition Coordinator
Country Director
Nutrition Coordinator
Nutrition Manager
Director Program Development
Director Health and Nutrition
IYCF Advisor
Senior Program Officer
Program Coordinator
Nutrition Coordinator/ CMAM Task Force
Johanniter International
ACF
ACF
Save the Children
Save the Children
Save the Children
Save the Children/Lead IYCF Task Force
National Rural Support Program (NRSP)
Community Development Organization Pakistan
Merlin
National FFP Officer
Technical Advisor
USAID/FFP
ECHO
Provincial Nutrition Focal Point
Nutrition Program Officer
Nutrition Focal Point
Nutrition Cell (Dept Health)
Nutrition Cell (Dept Health)
Umerkot District
Cluster Coordinator
Child Survival and Development Specialist
Nutrition Officer
Nutrition Information System
Provincial Nutrition Officer
Provincial Nutrition Officer
Nutrition Officer
UNICEF
UNICEF
UNICEF
UNICEF
WHO Sub Office
WHO Sub Office
WFP
Field Director
Nutrition Coordinator
District Program Coordinator
Field Coordinator
Merlin Thatta
Shifa Foundation
HANDS
ACF Sindh
Program Manager
Project Coordinator
Dean of Faculty
Health and Education Literacy Program HELP
HELP
LUHMS Hyderbad
Director General Health Services
Provincial Coordinator
Nutrition Officer
Program Manager
Lady Health Visitor Breastfeeding Counsellor
Department of Health
National Program for FP and PHC
National Program for FP and PHC
Food and Nutrition /DOH
Sir Ganga Ram Hospital/Breastfeeding Support Centre
Head of Provincial Office
UNICEF
SINDH
Government
Dr. Dureshehwar Khan
Dr.Zaineb Parvez
Dr. Abdul Sattar
UN Agencies
Dr. Mohammed Najeeb
Eleonora Genovese
Dr. Mazhar Alam
Asim Younis
Dr. Nisar Ahmed Memon
Dr. Leesham Noor Shaikh
Dr Yasit Ihtesham
Implementing partners
Dr. Hanif Memon
Shiaster Jaabeed
Sayeed Jawd Iqbal
Gaetan Pietquin
Other Organizations
Dr. Yasmeen Shakeel
Dr. Amara Shakeel
Professor Salmah Shaikh
PUNJAB
Government
Dr Tanwir Ahmad Shaiq
Dr. Akhtar Rasheed
Dr. Amara Khan
Dr. Mohammed Ahmed
Sadia Shauket
UN Agencies
Dr. Ketsamay Rajpinthon
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Dr. Qurrat-ul Ain
Uzma Khurram Bukhari
Salma Yaqub
Shahzada Rashid Mehmood
Dr. Sadia Azam
Other Organizations
Dr. Munir Akhtar Saleemi
Dr. Farhat Munir
Abdul Nauman
Kalim Kirmani
Nutrition Officer
Nutrition Officer
Nutrition Officer
Chief Provincial Officer
Nutrition Officer
UNICEF
UNICEF
WFP
WFP
WHO
Professor
Senior Programme Officer
Programme Coordinator
Programme Coordinator
Dept Social /Preventive Paediatrics, Sir Ganga Ram
National Rural Support Program (NRSP)
Johanniter International
Muslim Aid
Director General
Provincial Coordinator
Deputy Director
Provincial Coordinator
Information Management
Data Analyst
Social Mobisation Expert
Medical Superintendent
Coordinator
District Nutrition Coordinator
Lady Health Worker
Lady Health Worker Supervisor
Lady Health Visitor
Health Services
National Program for FP and PHC
Nutrition Cell
Nutrition Cell
Nutrition Cell
Nutrition Cell
Nutrition Cell
District Nushki
National Program, Nushki
District Noshki
District Noshki
District Noshki
District Noshki
Health and Nutrition Specialist
Nutrition Officer
Provincial Nutrition Officer
Program Officer
Nutrition Officer
UNICEF
UNICEF
WHO
WFP
WFP
Program Coordinator
Program Manager
Director
Nutrition Officer
Program Manager
Poverty Alleviation Organisation
Poverty Alleviation Organisation
Society for Communication Action Process
Society for Communication Action Process
Global Movement of Children and Women
BALOCHISTAN
Government
Dr. Masood Nousherwani
Dr. Noor Qazi
Dr. Ali Nassar Bugti
Habibur Rahman
Mohammed Sheraz
Zaheer Khan
Sidra Khusid
Dr. Zafarullah
Dr. Fareed Ahmed
Zahoor Ahmed
Meena Kumari
Sahira Younas
Ms. Irum
UN
Dr. Mohammed Amjan Ansari
Dr. Mohammed Faisal
Kulsoom Bugti
Zoheb Qasim
Nicole Carn
IPs
Sharaf Ud-Din
Sheraz Ali Baloch
Hassan Hasrat
Qari Khan
Mahir Ali
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ANNEX 3: Documents Reviewed
Food Insecurity in Pakistan. Sustainable Policy Institute/SDC/WFP. 2009.
National Rural Support Program Review and Update. April 2013.
National Nutrition Survey. Planning Commission/UNICEF/Aga Khan University, 2011.
Pakistan Integrated Nutrition Strategy (PINS) 2011.
Sindh Intersectoral Nutrition Strategy (2012).
Punjab Integrated Nutrition Strategy (2012.)
Nutrition Cell, UNICF/WFP/WHO. Nutrition Highlights, 2012.
Nutrition Cell Balochistan. Brief of Nutrition Program, 2013
Strengthening Comprehensive Nutrition Intervention for Women and Children of Balochistan. AusAID/UNICEF 2012.
Punjab Tehsil Based Multiple Indicator Cluster Survey (MICS), UNICEF 2007-8.
Punjab Multiple Indicator Cluster Survey (MICS) Bureau of statistics, Planning and development Department, UNICEF
2011,
Punjab Nutrition Response Plan. Department of Health, Government of Punjab, 2012
Punjab Nutrition Guidance Policy Note. December, 2012
Pakistan Demographic and Health Survey (PDHS) Preliminary Findings 2012-13.
Department of Health, Government of Punjab. Integrated Reproductive Maternal Newborn & Child Health (RMNCH) and
Nutrition Program. Planning Commission – Performa 1: 2013-16
Government of Sindh, Department of Health. Nutrition Support Programme for Sindh (NSP), Planning Commission
Performa 1: 2013-16
Department of Health, Government of Balochistan. Balochistan Nutrition Programme for Mothers and Children.
Planning Commission Performa 1: 2013-16
Flood Affected Surveys (FANS), Sindh. UNICEF/ACF, November 2010
Flood Affected Surveys (FANS), Punjab. UNICEF ACF/Government of Punjab. January 2011.
Nutrition Cluster Evaluation Pakistan Flood Response. September, 2011.
Evaluation of CMAM, Pakistan Country Case Study of KhyberPakhtunkhwa (KP) Province. UNICEF. September, 2012.
Department of Health, Punjab. Chief Minister’s Health Initiative for Attainment and Realization of MDGs (CHARM).
Provision of 24/7 EmONC Services at Selected Health Facilities. National Program for FP and PHC. Annual Reports 2011,
2012.
World Food Programme Nutrition Bulletins 2012, 2013.
World Food Programme. Protocol for MAM and PLW, 2013.
National Guidelines for the Management of Acute Malnutrition (Draft Form), 2009.
Punjab Nutrition Programme Brief September 2010- June 2013. UNICEF and WFP. July, 2013.
World Health Organization. Draft Recommendations for the Outpatient Management of SAM, 2012.
Nigel Nicholson. European Commission Nutrition Advisory Service ( EC-NAS). Mission Report Pakistan. June, 2013.
Nutrition Cluster Evaluation Pakistan Flood Response. September, 2011.
Evaluation of CMAM, Pakistan Country Case Study of KhyberPakhtunkhwa (KP) Province. UNICEF. September, 2012.
Department of Health, Punjab. Chief Minister’s Health Initiative for Attainment and Realization of MDGs (CHARM).
Provision of 24/7 EmONC Services at Selected Health Facilities. National Program for FP and PHC. Annual Reports 2011,
2012.
World Food Programme Nutrition Bulletins 2012, 2013.
Coverage Monitoring Network/ACF. SQUEAC Reports. TMK District, Sindh Pakistan, February 2013
ACF SQUEAC, Dadu District, Sindh, Pakistan April 2013
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ANNEX 4: Methodology
Quantitative data:
The team compiled and reviewed quantitative data from secondary sources including current and
previous survey reports to determine trends. The Nutritional Information System (NIS) was used to
attempt to assess incidence, current caseload, seasonal variation caseload and trends over time.
Other data information systems in current use such as the WHO SC reporting system, the Minimum
Reporting Package (MRP) for CMAM), Management Information System (MIS), and Distinct
Information Systems (DIS) were also assessed for validity, appropriateness and possible duplicity.
Coverage survey reports were reviewed to determine quality and program effectiveness. To date
one report from two districts in Sindh is finalized. Another survey has recently been completed in
three further districts in Sindh and findings are pending. Data on the number of trainings conducted
for health workers and community staff such as LHWs was also be collated.
Qualitative data and information:
The team conducted semi- structured interviews with the key stakeholders at national and provincial
level and at the program implementation level. This included meetings, discussions and interviews
with the Planning Commission, Ministry of Health Services, National Disaster Management Authority
and Department of Health at provincial level, bilateral donors, international and national NGO
implementing partners, CMAM Task Force, Nutrition Cluster, UNICEF and WFP. Field level informant
interviews and semi-structured focus group discussions will be held with program managers, health
and community workers, community members (both male and female), mother support groups and
beneficiaries in order to assess quality of the program The team explored community perceptions
regarding CMAM and issues of inclusion/exclusion in programming. Qualitative data found in the
SQUEAC coverage surveys will be analysed and verified to determine barriers to access and uptake
of services. Knowledge Attitude and Practice (KAP) surveys or equivalent were looked at (where
they existed) in order to determine behavioral changes at community level.
Informative and contextual information:
The team looked at existing strategic frameworks and operational plans such as the Inter-sectoral
Nutrition Strategy (2012) and the Pakistan Integrated Strategy (2012), and current Planning
Commission 1 (PC-1) operational plans at the Provincial level. The team will also investigate and
assess the appropriateness and relevance of current and proposed operational research. The team
reviewed the current National Guideline and existing protocols as well as the proposed d integration
of a chapter on IYCF in the National Guideline.
Triangulation:
The combined multiple sources of quantitative and qualitative data and information to circumvent
bias that comes from single informant, data source or concept. The extent to which donor
requirements and priorities are harmonious or conflict with national and provincial priorities was
also appraised by exploring multiple viewpoints. In order to avoid bias and ensure key issues were
addressed, the team used quick assessment checklists at the program site and community level.
Where access was and for gender or language reasons, the list was given to a local staff member
travelling with the team and later cross-checked with a team member to derive the critical
information
Data and Information collection methods
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Objective
Source of data/information
Purpose
Nature of
data
Program relevance
and
appropriateness
Strategies, policies, proposals and
reports at national and provincial level
Appropriate and relevant response to needs and
priorities and possible redundancy/duplicity of
strategies and operational plans
Appropriate response to need as determined by high
levels of acute malnutrition in specific target groups
Informative/
contextual
Observation of intervention modalities
and activities
Informant interviews with program
staff, beneficiaries and community
NIS data and reports
SQUEAC survey reports
Target and screening figures (NIS)
Program
effectiveness and
coverage
Program efficiency
and quality of
services
Sustainability and
30
Relevance to local authorities and communities,
caregivers (perceived need)
Determine program effectiveness by outcome and
coverage data
Determine referral between components
Accuracy and use of targets and screening
Caseload data
Incidence rates for SAM and MAM
Training sessions for health workers,
LHW’s and community workers
Contribution of program to capacity building of health
system
KAP surveys, causal analysis
Extent to which IYCF, IEC and prevention components
have impacted on caring and feeding practices
Effectiveness of training and mentoring applied in
practice
Observation of treatment at
SC/OTP/SFP sites/attitude of staff
SQUEAC survey analysis
Barriers to access and uptake of services and reasons
for default
Interviews and focus group discussions
at community level
Cross check extent to which IYCF, IEC and prevention
components have impacted on caring and feeding
practices and identify gaps and cultural constraints
Reliable supply pipeline management
NIS supply data
Track NIS reporting mechanism from
site to provincial and national level
Suitability of current monitoring and reporting
mechanisms, identification of gaps and need for
streamlining
Review of SC/OTP/SFP admission and
discharge cards
Cross check on reliability of data, reasons for default
Observation and key informant
interviews on regularity of OTP
services
Observation of supply pipeline and
storage of RUTF/RUSF/WSB/HEB and
F75/100/Essential drugs and
equipment such as MUAC tapes
Verification of reliable supply pipeline, storage, quality
of nutritional treatment
Observation of use of nutritional
products/medications at household
level and key informant interviews
Analysis of demand driven service and quality of
components from user view and possible reasons for
default
Focus groups on community
understanding of services (wait times,
criteria, access, rations)
Observation and key informant
interviews regarding innovations to
improves efficiency or quality
Tracking of NIS data from site to
Possible reasons for absence and default/use and
misuse of treatment/rations
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Qualitative
Quantitative
Qualitative
Quantitative
Qualitative
Utilization and effectiveness of nutritional treatment,
sibling ration, key messages and impact on
breastfeeding/complementary feeding
Seek out best practice and lesson learned and factors
contributing (or not) to quality standards
Informative/
contextual
indentify gaps and assess the need for streamlining of
Quantitative
CMAM Review Report
scale up
Program Impact
(actual and
potential in raising
nutrition profile)
Cross cutting issues
Policy issues
31
provincial level
monitoring and reporting
Tracking supply chain and long term
commitments to procurement/local or
in-country production
Feasibility of scale up
Observation and interviews on of
RUTF/essential drugs use and
availability
Reliable and sustainable supply pipeline and channels
Observation at SC/OTP/SFP sites at
health facility
Feasibility of CMAM integration into health services
such as BHU in given context
Observation and interview with
community health workers and
community key informants
Determination of capacity at community level for
potential scale up
Interviews with provincial and national
government
Analysis of funding cycles (NGO,
WFP/UNICEF PCA/FLA and provincial
PC1
Determination of capacity gaps at government level
Analysis of funding allocation by
district and program component
Determine feasibility ad appropriateness of funding
prioritization of components, target groups and districts
Observation and key informant
interviews in the community
Program contribution to raising awareness of acute
malnutrition in the communities and health sector
Historical trends and interviews with
program staff
Extent to which CMAM program has placed nutrition on
the policy and development agenda and uncovering of
gaps potentially hindering sustainability and scale up.
Semi- structured interviews with key
stakeholders at national and provincial
and district level
Observation of and participation in
coordination mechanisms
Commitment to national and global scale up initiatives
(e.g. SUN)
Observation at sites and in the
community
Equity issues in service delivery, participation/access
and staffing
Analysis of available causal analysis
information
Observation and cross check on use of
national protocols at site
Assessment of principle causes of acute malnutrition
(food insecurity/care/health)
Adherence or adaptation to national guidelines and
identification of need for adaption to the national
guidelines
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Determine availability of government/donor to assess
financial feasibility of scale up
Frequency and effectiveness of vertical and horizontal
coordination and involvement of other sectors in
planning and implementation and coordinated
response to demonstrated needs.
2013
Qualitative
Informative/
contextual
Qualitative/
Informative
CMAM Review Report
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ANNEX 5: Program Data (NIS January 2011 – June 2013)
SINDH
BALOCHISTAN
PUNJAB
YEAR
11
12
13
Total
11
12
13
Total
11
12
13
Total
OTP sites
223
170
224
617
13
85
08
106
135
240
144
519
Admissions
32,992
51,942
19,611
10,4545
4,624
9,578
6,550
20,752
76,096
33,439
4,245
76,096
Cure
12,273
20,474
7,419
40,166
3,722
8,271
5,135
17,128
25,296
20,643
5,202
25,296
Default
962
2029
243
3,234
677
1,270
843
2,790
6,749
4,044
1134
6,749
Death
26
85
32
143
38
49
35
122
23
24
74
23
SFP sites
223
170
190
583
N/A
215
345
560
135
240
58
519
Admissions
91,538
148,793
36,972
277,303
37,053
28,116
65,169
248,504
97,255
25,869
248,504
Cure
40,515
62673
12,805
115,993
26,678
10,483
37,161
80,608
61,539
5753
80,608
Default
1,579
2,878
124
4,581
5,372
2,271
7,643
11,707
6,914
229
11,707
Death
20
6
6
32
Not
available
Not
available
Not
available
Not
available
N/A
0
0
0
12
9
0
12
Not
available
Not
available
Not
available
Not
available
N/A
18,515
20,102
3,8617
137,503
61,078
13,090
13,7503
14071
6,518
20,589
40,904
40,768
1915
40,904
2221
1,099
3320
5,948
4,533
225
5,948
0
0
0
4
2
0
4
07
10
10
Not
available
Not
available
Not
available
Not
available
3,542
888
1,795
3,195
706
1,496
277
39
114
49
2
2
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
Not
available
0
PLW
Admissions
44,518
76,722
17,973
139,213
Cure
15,228
19,460
5,341
40,029
Default
317
742
18
1,077
Death
0
6
1
7
SC sites
9
16
16
41
Admissions
879
1,251
956
3,086
Discharges
623
1,092
797
2,512
Default
4
108
55
167
Death
1
17
8
26
Data extracted from the NIS (July 2013)
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ANNEX 6: IYCF Indicators
Recommended by IYCF Consultant
Suggested by review team
Health facility: maternal nutrition & IYCF interventions
MCHN registers at health facilities / OTP/ MAM card
% relevant health staff trained on counseling


Mother counseled on exclusive breast feeding
Mother counseled for appropriate complementary feeding
% health facilities with HR assigned for IYCF counseling
% of caretakers of under two children who received IYCF
counseling
ANC register (Pregnant women)
% of mothers attending ANC who received iron – folic acid
supplementation


Community IYCF counseling
% targeted pregnant women in last trimester counseled for
early initiation and exclusive BF
% targeted mothers with child <6months counseled for
exclusive breast feeding
Received iron/folate
Counseled in early initiation of BF and exclusive breastfeeding
LHW register



Mother counseled on exclusive breast feeding
Mother counseled for appropriate complementary feeding
PLW Counseled in early initiation of BF
% targeted mothers with child 6-23month counseled for
appropriate complementary feeding
Communication
Report format
Process indicators
% of Health committees (out of the total) in the targeted
area which provided messages on IYCF
#% Mothers counseled on exclusive breast feeding
%of PLW and Mothers of children <2 in the targeted area
reached with IYCF message.
#%Mothers/caretakers counseled for appropriate complementary
feeding
#/% PLW counseled in early initiation of BF and exclusive
breastfeeding
Impact indicators ( HMIS)
% mothers initiating breastfeeding within one hour of birth
% mothers exclusive breastfeeding until 6 months
% Children 6-23 months fed in accordance with three practices
(food diversity, feeding frequency, consumption of breast milk or
animal milk)
#/% PLW receiving iron/folate
Note: ANC data on PLW is reported separately in an integrated system. The following indicators should be reported
through ANC:
# % of pregnant women attending ANC who received iron – folic acid supplementation
#/%#/% PLW counseled in early initiation of BF and exclusive breastfeeding
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Annex 7: Treatment and Prevention Package
Treatment
What
Where
Suggested Impact indicators (HMIS)
Treatment of SAM without
complications
BHU/RHC
Health House
% cured
Treatment of SAM with
complications
Stabilization Center
DHQ Hospital
Breastfeeding promotion, support
and counseling
BHU/RHC
Health House
Community though peer
counselors and support
groups
% death
IYCF
Complementary feeding from 6
months
Deficiency Prevention
Micronutrient sachets (sprinkles)
6-24 months for 2-3 months (All
children not enrolled in OTP/SFP)
Deworming all children 12-59
months
Hand-washing and soap
distribution
% mothers initiating breastfeeding within
one hour of birth
%mothers exclusive breastfeeding to 6
months
% of children 6-23 months fed in
accordance with 3 practices (food
diversity, feeding frequency, consumption
f breast or animal milk
BHU/RHC (ANC)
Health House
Iron/folate, to all Pregnant
women (all married women in
Punjab)
Vitamin A to post partum women
and children 6-59 months
% coverage
% reduction in anemia (against baseline) 624 months
% reduction in anemia (against baseline)
PLW - married women
Campaigns/health days
% vitamin A coverage (against baseline)
% children dewormed (against baseline)
Health and Hygiene
BHU
Health House
Community groups
% reduction in watery diarrhea against
baseline
BHU/RHC
Campaigns/ health days
% vaccination coverage against baseline
Water purification
ORS and Zinc to children < 5 with
diarrhea
Measles vaccination all children
above 6 months
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ANNEX 8: Suggestion for Simplified OTP Card (front)
ADMISSION DETAILS: OUTPATIENT THERAPEUTIC PROGRAM
Name
Reg. No
Address
Age (months)
Sex
Direct from
Community
Admission
M
F
Date of Admission
From SFP
From SC
From OPD
SC Refusal
Admission Anthropometry
Weight (kg)
Oedema
MUAC (cm)
0
++
+
+++
Other reason for
admission (specify)
History
Diarrhoea
Yes
No
Cough
Yes
No
Good
Poor
Yes
No
Appetite
Mother counseled on
breastfeeding
Stools / Day
.4-5
>5
Breastfeeding
Yes
No
Mother/caretaker counseled on
complementary feeding
Yes
No
Yes
No
None
1-3
Any relevant history
Physical Examination on ADMISSION
Respiration Rate
(# min)
<30
30 - 39
40 - 49
50+
Chest Retractions
Temperature (0C)
Routine Medication
Drug
35
Date
Dosage
Drug
Vitamin A
Amoxicillin
Mebendazole
Anti malarial
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CMAM Review Report
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ANNEX 8: Simplified OTP Card (Back)
FOLLOW UP: OUTPATIENT THERAPEUTIC PROGRAM
Registration
Number
Name
Week
ADM
2
3
4
5
6
7
8
9
10
11
Date
Anthropometry
Weight (kg)
Weight loss * (Y/N)
*
*
MUAC (cm)
Oedema
(+ ++ +++)
* Weight changes: Marasmic : if below admission weight on week 3 refer for home visit.
If no weight gain by week 5 refer to SC.
Clinical Exam and Action
Is child clinically well?
Yes/No? If not note date,
problem, and action taken
Transfer to SC (write T SC
and date of transfer)
RUTF and IYCF
RUTF Test Good/Poor/Refused
RUTF
(# sachets)
Mother counseled on breastfeeding (Y/N)
Mother/caretaker counseled on comp.
feeding (Y/N)
Name of Examiner
OUTCOME ***
*** A= absent D= defaulter (3 consecutive absences) T SC= transfer to SC X= died SFP= discharged cured
RT= refused transfer HV= home visit
NC= discharged non-cured
** Additional notes
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ANNEX 9: Illustrative Template for Reporting and Collating Information
OTP REPORT
Month
Total in program at beginning of month
IN
Returning from SC
OUT
Transferred to SC
NEW
Oedema
MUAC <11..5cm
Infant < 6 months
Other
TOTAL ADMISSIONS
EXITS
Discharge cured
Death
Default
Non-responder
TOTAL EXITS
TOTAL IN OTP AT END OF MONTH
SFP REPORT
Month
Total in program at beginning of month
NEW
MUAC 11.5-12.4 cm
Other
TOTAL ADMISSIONS
EXITS
Discharged cured
Death
Default
Non Responder
TOTAL EXITS
TOTAL IN SFP AT END OF MONTH
SC REPORT
Month
Total in program at beginning of month
Transfers from OTP
Transfers back to OTP
NEW
Oedema ++/+++
MUAC< 11.5cm
Infants < 6 months
TOTAL ADMISSIONS
Transfers from OTP
EXITS
Discharged
Death
Default
Referred out of SC for medical care or non
response
TOTAL EXITS
TOTAL IN SC AT END OF MONTH
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Suggested additional information for report formats
OTP (circle)
Weekly
Every 15
days
Other
SFP (circle))
Every 15 days
Every month
Other
Number of OTP sites
Current
Planned
Number of SFP sites
Current
Planned
IYCF
Number of mothers counseled on exclusive breast feeding
Number of mothers/caretakers counseled for appropriate
complementary feeding
Prevention
Number of children 6-24 months receiving micronutrient sachets for 2
months
Number of children receiving ORS/Zinc for diarrhea
Training
Number LHWs trained in management of SAM and active
Number of LHWs trained in IYCF counseling
Number LHW’s provided IYCF tool kit
Number CMWs trained in IYCF
Number LHV’s trained in management of SAM and active
Notes
This is illustrative. A final format will need to be developed and tested

Data and information on PLW and associated impact indicators should be reported separately

Report data does not need to be segregated by gender. This has proven to be redundant
information and is time consuming to collate.

Rates of weight gain and length of stay should not be included in a simple report format.
Where weight gain is investigated and reported during monitoring/supervisory visits, it should
be by g/week not by day.
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