Community Management of Acute Malnutrition

By the numbers:

  • Nearly half of all deaths in children under 5 are attributable to undernutrition
  • 144 million children suffer from stunting — low height due to malnutrition
  • 47 million children suffer from wasting — low weight due to malnutrition
  • Well-nourished children are 33% more likely to escape poverty

The story of Community Management of Acute Malnutrition (CMAM) is quintessentially Concern: a listen-first approach developed in partnership with communities that balances innovation with simplicity. A whole greater than the sum of its parts.

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The challenge

For years, centralized in-patient treatment centers were the accepted approach for treating acute malnutrition in children under 5. Logical in theory, it was failing in practice. The costs of running these centers were high, as they required 24/7 staffing. The treatments were also perishable, meaning that refrigeration was a must.

The costs also ran high for families seeking care. Mothers would often have to journey —by foot — for days to reach a treatment center. They would also have to leave their work and other children behind. As one mother in Ethiopia, Hekuat Kahsay Fanta, told us: “If I leave my other children at home, I close the door on them. To save one life, I can lose the rest of my children.”

Concern’s International Program Director Anne O’Mahony explains further: “More and more, it became clear that center-based care wasn’t the solution.”

“If I leave my other children at home, I close the door on them. To save one life, I can lose the rest of my children.” — Hekuat Kahsay Fanta, Ethiopia

A world-changing partnership

Concern partnered with Dr. Steve Collins and his humanitarian research organization Valid to find a solution. We soon found that the limiting factor to treating malnutrition wasn’t the medical care itself, but how to access it. We needed to de-centralize treatment centers.

One solution to this came in the form of a simple plastic strip. Traditionally, healthcare workers screened for malnutrition using the standard of weight against height. This is difficult to do on a community level as the equipment is not cheap or portable.

Collins pointed to research that supported mid-upper-arm circumference (MUAC) as a strong predictor of nutrition-based childhood mortality. Using a strip of plastic called MUAC Tape, healthcare workers could screen and diagnose children virtually anywhere with relative ease.

A Concern worker checks a young child for malnutrition.

A Concern worker checks a young child for malnutrition using MUAC tape. With the lack of diverse foods in the region, many children end up with malnutrition with little options for treatment. Concern is the only NGO providing these services in the region. (Photo: Gavin Douglas/Concern Worldwide)

The essential ingredients

Another solution came from peanuts when French pediatrician André Briend developed Plumpy’Nut, a high-calorie peanut-based paste. It was easier to store, had a longer shelf-life, and packed a lot of calories and nutrients in a small amount of food.

There was one other vital ingredient: Creating a treatment approach to bring these two innovations together.

“The idea was to send these children home with the correct food and the care that went with it, so that the mothers could actually take care of them themselves,” says Anne O’Mahony. “This was a mind-blowing idea in some ways.”

“This was a mind-blowing idea in some ways.” — Anne O’Mahony, International Program Director, Concern Worldwide

Putting it all together

This idea became known as Community Therapeutic Care (CTC). With the CTC model, mothers could have their children screened close to home easily and accurately with a community healthcare worker and MUAC Tape. If diagnosed with acute malnutrition, they would be given the first round of therapeutic food that day and return with their child for weekly checkups.

Previous famines had resulted in child mortality rates between 10% and 30%. The pilot program of what would become CMAM saw just 4.5%.

Concern and Valid piloted CTC during a famine in Ethiopia in 2000. While previous famines had resulted in child mortality rates between 10% to 30%, our pilot community saw just 4.5%. We then tested CTC one year later in Darfur, Sudan to similar results.

Setting the standard

Concern Worldwide staff member in South Sudan

CMAM didn’t exist when Simon Piol was a child. In 1998, a humanitarian crisis resulted from Southern Sudan’s ongoing conflict with Khartoum. Hunger was rampant. Simon remembers when Concern staff began visiting his village to cook porridge for malnourished children like himself. Two decades later, life has come full circle. Simon lives in a newly free nation and now works for Concern as a Nutrition Assistant, screening malnourished children at a clinic in Aweil and referring them for treatment. Often, that treatment involves CMAM. The next step for Simon involves going back to school to become a qualified nutritionist, and evolving the treatment of severe acute malnutrition even further. (*Names changed to protect the identity of individuals.)

CTC was initially met with resistance in the humanitarian aid community as it challenged the traditional aid model. Concern and Valid worked with Malawi’s Ministry of Health to pilot CTC at scale in Dowa district. As more mothers bought into this new model of treatment, they told other mothers about how to spot malnutrition and where to get help. The program gained a valuable component: prioritizing individual agency and sharing knowledge.

By 2007, we had treated over 23,000 cases through 21 CTC programs in 4 different countries. More importantly, we reached over 70% of those who needed the care, surpassing the old system’s reach of (at most) 10%.

That same year, the World Health Organization, UNICEF, and the World Food Programme issued a joint statement recognizing what we now call CMAM (Community Management of Acute Malnutrition) as a best practice, setting into motion a transformative approach that over the last two decades has saved millions of children’s lives in dozens of countries.

This revolution would not have been possible without funding from IrishAid and USAID, operational partnerships with UNICEF and other colleagues, and — most importantly — national ministries of health, community leaders, and mothers where we worked.

We’ve continued to work with partners and communities to find more tailored approaches to community-based treatment. CMAM has now grown into CMAM Surge, a way of proactively responding to malnutrition during seasonal “surge” periods throughout the year. Two CMAM Surge pilot tests in Kenya in 2012 saw that the model managed peaks, without undermining other health and nutrition efforts. Since then, we’ve been rolling out CMAM Surge around the world, while also keeping an eye out for ways it can evolve in the future.

One in Six

One in Six is a documentary that tells the story of Concern’s pioneering work with what would become Community Management of Acute Malnutrition (CMAM). Watch the short version below.

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