Downloaded - CMAM Forum

Collaborating to improve
the management of acute
malnutrition worldwide
Country Case Study
India
April 2014
www.cmamforum.org
Collaborating to improve the
management of acute
malnutrition worldwide
Country
Case Study
India
April 2014
Acknowledgements
The CMAM Forum team would like to thank Action contre la Faim and Save the Children for their
collaboration in the preparation of the India country case study. We are grateful to all the people who
openly shared their experiences and thoughts on the CMAM Forum during discussions and
participation in the e-survey. It was encouraging to hear the enthusiastic feedback from respondents
who knew about or had newly discovered the CMAM Forum and to hear how they applied knowledge
obtained from the initiative in their work.
Abbreviations
CCS
Country Case Study
CMAM Community-Based Management of Acute
Malnutrition
FAQ
Frequently Asked Questions
FGD
Focus Group Discussion
ICT
Information and Communication Technology
KII
Key Informant Interview
M&E
Monitoring and Evaluation
MAM
Moderate Acute Malnutrition
MCH
Maternal and Child Health
MOH
Ministry of Health
NGO
Non-Governmental Organization
SAM
Severe Acute Malnutrition
Cover photograph:
CMAM Forum Country Case Study:
India. April 2014
1 Introduction
Management of acute malnutrition is critical to reduce child mortality, particularly in high-burden areas.
In 2013 an estimated 52 million children under 5 years of age were acutely malnourished, including 19
million children with severe acute malnutrition (SAM). Treatment of SAM was listed in the 2008 and
2013 Lancet Series on Maternal and Child Nutrition as a cost-effective, high-impact nutrition
intervention. Community-Based Management of Acute Malnutrition (CMAM) was first piloted in 2000
and endorsed by the United Nations in 2007. CMAM interventions have been introduced in 60
countries, almost half of which are expanding service delivery, sometimes countrywide. CMAM was
first implemented in emergency situations and expanded to development contexts, where it is
increasingly offered as a routine child health service in high-burden areas. Despite this expansion,
only 2.7 million children under 5 years of age with SAM, or 14% of the global burden received
treatment in 2012, and lower treatment coverage is estimated for moderate acute malnutrition (MAM).
CMAM Forum Overview
The CMAM Forum was created in 2011 to support scale-up of quality services for the management of
acute malnutrition by collating technical guidance, evidence and learning from the wider nutrition and
health community. The CMAM Forum addresses a critical gap in management of information relevant
to acute malnutrition and ensures the accessibility of up-to-date CMAM information and best practices
to practitioners, policy makers, managers, trainers, researchers and donors (key actors). CMAM
Forum information products include a library of policy documents, peer-reviewed articles, reviews,
conference and workshop reports, guidelines, case studies, training materials, advocacy publications
and updated summaries of on-going research initiatives related to acute malnutrition. The CMAM
Forum also produces Technical Briefs and Frequently Asked Questions (FAQs) on priority themes to
support acute malnutrition-related learning and advocacy. A Monthly Resource Update with links to
new documents and events is shared with members and is available on the website. CMAM Forum
services include responding to requests for information and translations, linking members through a
messaging system, sharing links with discussion forums and e-learning, announcing meetings and
conferences and posting their outputs. All information is available via open access, but users who
become members receive updates by e-mail.
India Case Study
To synthesise learning about efficient and effective ways to disseminate and optimize use of
information related to acute malnutrition, the CMAM Forum is conducting a series of country case
studies (CCSs) in India, Kenya, Niger and Yemen. India has been selected as a case study country
because it has the highest burden of acute malnutrition in the world. Moreover, there is an urgent need
for evidence-based information on the management of acute malnutrition, preferably from Asian
contexts, to support stakeholders with the development of adequate policy responses.
1
CMAM Forum Country Case Study:
India. April 2014
2 Objectives
The objectives of the India case study were to:
1. Assess how effectively CMAM Forum information products and services were disseminated to the
intended audiences, how useful they were perceived to be, and how they were used or adapted to
inform policy, improve services and programmes, enhance education and training and promote
research, and
2. Identify opportunities for the CMAM Forum to improve its information products and services and
enhance the effectiveness of information sharing and improving learning at the country level.
3 Methods
The India case study combined different methods of routine monitoring of website usage for countryspecific website statistics, an e-survey of members, and key informant interviews (KIIs) over the
telephone and Internet, and/or by e-mail1. A country-visit was not conducted. Key informants were
selected from the list of the Nutrition Coalition and participants in the multi-stakeholder CMAM
Consultation on Acute Malnutrition organized by Action contre la Faim (ACF) on February 25, 2014, and
participation depended on their availability. The study indicators assessed audience (members or users,
missing professions or key actors), reach (dissemination of information), usefulness (satisfaction and
perceived quality of information) and use for improved health outcomes (application in work).
The e-survey2 used a standardised questionnaire and the KIIs conducted with key actors at national
and sub-national levels used a semi-structured questionnaire. Because the CMAM Forum provides
links to relevant technical support information initiatives, questions were added about the usefulness
and use of the e-learning course offered by the International Malnutrition Task Force (IMTF) and the
University of Southampton. Annex 1 lists people who were interviewed.
4 Findings
The India CSS provided useful insights into the effectiveness of the CMAM Forum. Below is a
summary of findings related to audience, reach, usefulness and use of CMAM Forum information
members and users and other key actors involved in CMAM and mother and child health and nutrition
in India. Suggestions for improvements are also summarized.
The findings are based on website statistics, e-survey responses from 19 out of 62 members (or 31%)
at the time of the survey, and on KIIs that were held with 11 key actors involved in the management of
acute malnutrition, 3 of whom were CMAM Forum members. For the eight non-members interviewed,
the KII offered the opportunity to promote the CMAM Forum information products and services and the
advantages of membership.
1
2
See the terms of reference: http://www.cmamforum.org/Pool/Resources/CMAM-Forum-CCS-TOR-India-2014.pdf
Survey administered through email or Internet
2
CMAM Forum Country Case Study:
India. April 2014
Audience
At the time of reporting, there were 75 CMAM Forum members in India, representing a slight increase
in members (13) since the start of the study. The 75 members form only a small part of the key actors
targeted by the CMAM Forum. Members did not represent all professional affiliations and professions
involved in the management of acute malnutrition. The distribution of membership by affiliation is
shown in Figure 1. The larger share of international NGO membership is explained by the fact that
they are supporting CMAM pilots that were underway during the CCS. Most respondents to the esurvey and participants in the KIIs were in training and education, management or policy and
advocacy positions or working for an international NGO. In the multi-stakeholder CMAM Consultation
on Acute Malnutrition on February 25, 2014 only 3 of the 36 participants were registered as CMAM
Forum members.
Figure 1: Distribution of CMAM Forum membership in India by affiliation at the start of the CCS
(N = 62)
2% 1% 2%
13%
13%
Government
2%
IFRC/RCRC
8%
Academia
1%
Private Sector
1%
Donors
2%
Independent
10%
UN
0%
Other
25%
NGO
8%
25%
10%
1%
Reach
The study assessed the reach or dissemination of the CMAM Forum information products and
services according to pull (passive distribution), push (active distribution), interactive sharing and
referral.
Pull (passive distribution). Routine CMAM Forum website monitoring showed 3,456 visits and 1,814
page views by users based in India over a 1-year period (Table 1). There were a total of 2,889 unique
IP addresses, a proxy indicator for the actual number of users if we assume that a single person used
a computer (which is not the case in libraries, for example).
Table 1 CMAM Forum website statistics for India in 2013
Visits
Page views
Total in 1 year
3,456
Total page views in 1 year
1,814
Average per day
9
Average page views per day
4
Total unique IP addresses
2,889
Average page views per visits
0.5
More than one-half (58%) of the respondents said they opened the CMAM Forum website once a
month, and 42% said they opened it once a week. At the time of reporting, the India section contained
30 documents.
3
CMAM Forum Country Case Study:
India. April 2014
Push (active distribution). The Monthly Resource Updates are sent to all members of the CMAM
Forum in India and more than half of the respondents said they shared it with other colleagues. The
updates were greatly appreciated because they provided up-to-date information related to acute
malnutrition that they would otherwise have to search for.
Interactive sharing of information. Respondents had not shared documents with the CMAM Forum
for uploading, which was probably due to lack of awareness of this feature, or no one person taking
responsibility and ownership. Some of the respondents did not know about the messaging system
(37%) or the uploading function (21%).
Referral. More than half (11 of 18, or 61%) of the e-survey respondents and all the KII respondents
said they had shared the Monthly Resource Updates with others. About two-thirds (12 of 19, or 63%)
said they had shared information downloaded from the website with others (Table 2).
Table 2 Dissemination of CMAM Forum information products
Source
Consulted
website
Recommended
website
Downloaded
information
from website*
Downloaded
information
from MRU°
Shared
MRU
Shared
downloaded
information
Shared
information
for uploading
e-survey members 19/19
19/19
14/19
13/19
11/18
12/19
5/19*
KII members
1/3
3/3
1/3
0/3
3/3
3/3
1/3
KII users
2/2
2/2
2/2
NA
NA
1/1
0/1
NA: Not available
°MRU: Monthly Resource Update
*1 month prior to the survey
Knowledge of website. While 42% of e-survey members had learned about the CMAM Forum
through the Internet, others had learned about it through colleagues, friends or peers.
Sources of information on acute malnutrition. The most frequently cited sources of CMAM
information in the member e-survey were the CMAM Forum website and the CMAM Forum Monthly
Resource Update, followed by the Emergency Nutrition Network (ENN) , UNICEF, Global Nutrition
Cluster (GNC) and WHO websites.
Knowledge of other services provided on the website. The CCS assessed awareness of the
IMTF/University of Southampton e-learning course ‘Caring for Infants and Young Children with Severe
Malnutrition’. Of the 14 respondents who knew about the e-learning course, 7 had found out about it
through the CMAM Forum and 7 through other sources. Only 4 of the 18 respondents did not know
about this course; 6 had participated in the course and found it useful, and 3 of these 6 reported that it
had improved their practice.
Usefulness
Users and members alike perceived the CMAM Forum website, with its large library of key documents,
as very useful. They appreciated having up-to-date key documents available in one place. The website
was rated as user friendly by 72% (13 of 18) e-respondents, and the country tab for India was rated as
useful by 55% (10 of 18), which was confirmed by the KIIs. No constraints with using the website were
recorded, apart from one respondent who indicated that he or she had problems with computer or
Internet access. The Monthly Resource Updates were also much appreciated.
4
CMAM Forum Country Case Study:
India. April 2014
Most members and users were satisfied with the quality and relevance of the CMAM information
products and services. Those who knew about the technical summaries (e.g., Technical Briefs, FAQs)
rated their quality as high. Respondents unanimously rated the sources of information on the website
as reliable (Table 3). The most frequently used technical summaries were the Use of MUAC and SAM
and Infection. One KII respondent praised the CMAM Forum as a ‘one-stop-shop and a breakthrough;
prior to the CMAM Forum’s existence information was so scattered’. All respondents recommended
the CMAM Forum website to others (Table 3).
Table 3 Perceived usefulness of CMAM Forum information products during the month
before the survey
Source
Satisfied
with
website
Aware of
benefits of
membership
Satisfied
with
technical
summaries
Satisfied
with
quality of
technical
summaries
Satisfied with
relevance of
technical
summary
topics
Satisfied
with
knowledge
gained
Improved
knowledge
and
practices
Positively
appraised
authority,
credibility,
reputation
e-survey
members
14 of 18
NA
14 of 18
14 of 18
16 of 18
NA
17/18
18 of 18
KII
respondents
4 of 4
NA
2 of 4
2 of 3
3 of 4
NA
1 of 4
2 of 4
NA: Not available
In the suggestions box, one e-survey respondent wrote, “I love the CMAM Forum. As a paediatrician, it
has helped me to learn the latest advances and research papers on acute malnutrition”. Another wrote
“The CMAM Forum is doing excellent work in the area of malnutrition by providing the related
resources comprehensively. Congratulations!”
Use
The CCS confirmed that those who knew about the CMAM Forum made effective use of its information
products, mainly to develop training materials and adapt technical documents to the local context, but
also to develop policies and guidelines. Information products adapted to the local context facilitated
collaboration and developed capacity, both of which contribute to the effectiveness and efficiency of
health intervention outcomes3. Examples of facilitated collaboration included guiding technical
discussions on programme design and referring to evidence during technical discussions. Eighteen of
22, or 82%, respondents confirmed that they had used CMAM Forum documents to improve their
knowledge and practice, and almost two-thirds (11 of 18, or 61%) said that the documents had
facilitated collaboration with peers or partners. Almost all respondents (17 of 18, or 94%) said they had
improved their knowledge and practice based on what they had learned through the CMAM Forum
website.
3 ‘Collaboration enables partners to share ideas, leverage resources and jointly develop innovative solutions. Capacity
development strengthens organizations and communities and plays a crucial role in the development of sustainable health
programmes. Both are powerful tools that can mobilize individuals, organizations, communities, and government entities to
solve problems faster and generate long-lasting improvements’. (USAID. Guide to monitoring and evaluating health
information products and services. Washington, DC: USAID; 2007).
5
CMAM Forum Country Case Study:
India. April 2014
Limitations
Due to a combination of not having full contact details for all of the key stakeholders and the time
constraints of others we were unable to carry out the study with the Nutrition Department of the
Ministry of Health and we were unable to get better coverage of the key stakeholders in the KIIs. The
participation in the e-survey and KII is very low in comparison with the Web site usage (on average 9
visits per day). However, this study may be seen as a first contact of the CMAM Forum with the
country stakeholders, and this report may be a tool that will generate further interest and collaboration.
Because CMAM is not implemented in India, the CMAM approach and acronym may not have been
recognised. This may also have been a reason for the limited response to invitations to participate in
interviews.
5 Suggestions for CMAM Forum
Improvement
The following suggestions for CMAM Forum improvements were collected through the e-survey and
interviews and are the views of the respondents.
Suggested themes for technical summaries4
• Specifications for F-100 and F-75 milk for inpatient treatment of SAM
• Specifications for RUTF recipe and alternative products for use in community and their efficacy in
terms of recovery of SAM children
• More advocacy on CMAM as there is limited knowledge on acute malnutrition in India where weightfor-age is used as the official nutrition indicator
• Logical framework template for projects or programmes on CMAM in infants and children
• How to improve infant and young child feeding (IYCF) practices during treatment and after
discharge in the community
• How to link CMAM programming to food security
• Nutritional requirements after facility-based treatment for children upon return to the community
• MUAC versus weight-for-height in South Asia
• Addressing MAM in South Asia
• Integration of CMAM into the existing health system in South Asia
• Use of antibiotics for SAM
• How to design and implement CMAM interventions in urban slums.
Suggested improvements in CMAM Forum information products and services
Globally
• Improve promotion of the CMAM Forum in conferences and workshops to increase membership
• Make CMAM Forum more visible on other key websites by sharing the Web site link and
announcing new CMAM Forum products
• Improve the quality of video downloads
4
Note that several of the suggestions proposed by the e-survey, KII and FGD respondents had been already been posted on
the CMAM Forum website, but respondents were probably not aware of this because of the language barrier or unfamiliarity
with the website. Moreover, some of the proposed themes do not fall directly under the CMAM Forum mandate.
6
CMAM Forum Country Case Study:
India. April 2014
•
•
•
•
•
Provide support to document programme results, in order to generate more evidence
Difficult for one website to cater for all, therefore develop a separate database for policy makers
Provide information on how to design a study to conduct research on a CMAM programme
Share information on different software available for nutritional surveys or coverage surveys
Incorporate a discussion part where people can share their experiences.
India
• Enhance the policy developments around CMAM in India by organising study tours or field visits to
another Asian country with successful CMAM integration in child health services
• Promote the CMAM Forum
• through the Nutrition Coalition5 which is the only nutrition coordination mechanism in India at
national level and includes government
• at the level of State Level Nutrition Coordination groups
• during conferences and meetings and show tools provided by the CMAM Forum (e.g., slides,
Monthly Resource Updates, technical summaries, fliers)
• by using the international and national NGOs that are active in the field of acute malnutrition in
India (ACF, Save the Children and Valid International) to promote CMAM through their networks
• by linking to the recently launched Nutrition Resource Platform (NRP)6, an initiative of the Child
Development and Nutrition Bureau of the Ministry of Women and Child Development (MWCD),
Government of India, developed with the aim to collect, collate and make available resources and
materials on nutrition and child development to diverse stakeholders
http://poshan.nic.in/jspui/index.html
• Raise awareness on the CMAM Forum among:
• Government of India’s SAM Expert Group7
• Universities
• Two influential ministry websites: Integrated Child Development Services Scheme (ICDS)
http://icds.gov.in and the National Health Systems Resource Centre (NHSRC), the Knowledge
Gateway to Public Health www.nhsrcindia.org
• SPHERE project office in India (involved in capacity development)
• National Disaster Management Centre
• National Institute on Nutrition in Hyderabad
• Indian Association of Paediatrics
• Nutrition Society of India
• Encourage professionals to share about CMAM Forum in their own personal and professional
networks (snowballing)
• Use Facebook to promote the CMAM Forum website as Facebook is frequently used for
professional purposes in India.
5
6
7
Save the Children is the secretariat for the Nutrition Coalition and offered to share information on the CMAM Forum during
their meetings. In addition to Save the Children, ACF and Valid International are actively supporting the advancement of the
management of acute malnutrition in India.
The Nutrition Resource Platform (NRP) targets both the general population, especially mothers and families, and nutrition
professionals and policymakers. Its mandate includes:
• Act as a knowledge/resource platform for nutrition and child care
• Collate and provide evidence based policy advocacy
• Facilitate interactive discussions, knowledge and experience sharing on nutrition and related sectors
• Provide linkages to various national and international institutions and organizations
• Assist in evolving a perspective plan on nutrition at State, District and Sub District Level by the Ministry of Women and Child
Development and State Governments
• Be a repository of resource material, researches, Information Education and Communication (IEC) and Inter Personal
Communication (IPC) tools, data on nutrition and information from various sources focusing on maternal and child
This small group meets approximately once per year and advises the government
7
CMAM Forum Country Case Study:
India. April 2014
6 Conclusion
At the time of the study, the CMAM Forum had reached only a small proportion of stakeholders
involved in the management of acute malnutrition in India. However, the study observed great
enthusiasm among those who were aware of the CMAM Forum. These individuals saw it as an
important global and national information-sharing platform, of significant relevance to India.
The study provided an opportunity to identify ways to promote use of the CMAM Forum among other
stakeholders in India and generated important recommendations for reaching out further. The use of
the India country section on the CMAM Forum website has great potential to support transparency and
share experience and developments in acute malnutrition, many of which are little known, and are in
scattered geographical locations. The collaborative characteristic of the CMAM Forum of interactive
sharing of information needs to be better promoted, and its use facilitated.
7 Recommendations
The following recommendations to improve information-sharing at the global and India level are
deducted from the above suggestions, and are:
1. Encourage documentation of CMAM experiences in Asia and information sharing to build the
evidence base
2. Explore ways to raise awareness and expand use and membership, e.g. in conferences and
meetings and through online social networks
3. Provide new information products that offer practical, accessible knowledge, e.g. tools for CMAM
advocacy, a logframe template for CMAM support projects, use of MUAC in Asia, integration of
CMAM in health services
4. Develop and maintain online social networks (e.g., Facebook and LinkedIn)
5. Identify a national focal point for the management of acute malnutrition to link with the CMAM
Forum; establish a link with key NGOs to improve awareness of the CMAM Forum initiative to
facilitate the sharing of information generated in India; identify mechanisms for continuous
information sharing in-country; facilitate to establish a system of information sharing, including
links with relevant websites and initiatives (listed above under Suggestions)
6. Actively encourage the use of the India section for improved information sharing and transparency
in the absence of a national repository for information and knowledge management on acute
malnutrition.
7
This small group meets approximately once per year and advises the government
8
CMAM Forum Country Case Study:
India. April 2014
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CMAM Forum Country Case Study:
India. April 2014
Annex 1 People contacted for KII discussions
Name of people interviewed
Rita Bhatia, Technical Advisor, Valid International
Harish Chand, Nutrition Advisor, World Vision India
Deepika Nair Chaudhery, Programme Manager, Micronutrient Initiative
Umesh Kapil, FAMS, Professor Public Health Nutrition, Human Nutrition, All India Institute of Medical Sciences
Anna Motupalli, World Vision India
Roselyn Mullo, Regional Nutrition Coordinator, European Commission's Humanitarian Aid and Civil Protection
department
Laxmikant Palo, Nutrition Coordinator, Save the Children
Moumita Sarkar, Programme Manager, Terre des Hommes Foundation
SheilaVir, Public Health Nutrition Consultant and Director, Public Health Nutrition and Development Centre
Bhami Vora, Programme Coordinator, Fighting Hunger Foundation/Action contre la Faim Mumbai, India
Unable to respond:
Karanveer, Nutrition Coordinator, UNICEF India (unable to respond due to prolonged travel)
DfID representative
10

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