Community-based Management of Acute Malnutrition (CMAM): Factors affecting rates of defaulting and non-recovery

World Vision has a long history of treating girls and boys with acute malnutrition, also known as wasting. We were early adopters of the Community-Based Management of Acute Malnutrition (CMAM) approach, beginning in Niger in 2005. The programming model has four components:

• In-patient stabilization care for children experiencing acute malnutrition with complications
• Out-patient therapeutic care for children with severe acute malnutrition without complications
• Supplementary feeding for children with moderate acute malnutrition
• Mobilization of community members to prevent, detect and refer cases of acute malnutrition

This work happens through established health facilities and systems, in collaboration with national ministries of health.

Since 2010, in programs implemented by the World Vision Partnership, more than 2.6 million women and children under five have been treated in 32 countries using CMAM. In 2010, we began tracking consolidated Partnership CMAM data using an online database. Every year, we report the number of people treated along with treatment outcomes—rates of recovery, death, defaulting and non-recovery—which we compare to internationally agreed thresholds, known as Sphere standards.

When comparing the treatment outcomes for 2022 against Sphere standards—and considering year-over-year trends—we noted that the 2022 default and non-recovery rates were at their highest point since data tracking began in 2010.

• A child is recorded as “DEFAULTING” from a CMAM program when they miss three consecutive treatment visits.
• A child is recorded as “NON-RECOVERED” when they do not reach the criteria for “discharge as recovered” after four months of treatment.

The graph below shows default and non-recovered treatment outcomes between 2010 and 2022, with elevated default levels from 2020-2022, and a notable increase in non-recovered in 2022. The default rate remains below the Sphere standard, and there is no established threshold for non-recovery, but focusing on the quality of our programming, we wanted to understand the reasons behind these changes.

High rates of defaulting and non-recovery in CMAM programs usually result from a variety of issues and are dependent on the program contexts. Here are the main factors we’ve identified, along with actions World Vision is taking to address them.

1. When the clinical treatment protocol is not followed, children will not recover as expected.

A child with acute malnutrition needs both medical care and nutritional treatment to recover. This involves accurate assessment of the child’s status and registration in the correct treatment stream, along with antibiotics, deworming and ready-to-use therapeutic food (RUTF) —all according to the clinical protocol of the national ministry of health. When this protocol is not followed, a child will not recover as expected.

Noncompliance with clinical protocols may happen at the health worker level, because of insufficient CMAM training or workload constraints. However, this can also occur at the household level, when caregivers do not provide the routine medicine or daily prescribed dose of RUTF, or don’t bring their child for follow-up visits, which are necessary to monitor treatment progress.

OUR RESPONSE: In collaboration with national ministries of health, World Vision supports the capacity strengthening of health workers on CMAM protocols and trains them to support families with home visits and nutrition counselling, helping them adhere to the prescribed at-home treatment. We are now increasing our efforts to support ministries of health with monitoring, quality assurance and supportive supervision.

2. Underlying medical conditions may prevent or complicate recovery.

If a child with acute malnutrition has an underlying medical condition such as HIV or tuberculosis, this complicates recovery—and they may not reach the “discharge cured” criteria while in treatment. These girls and boys will be discharged from CMAM treatment as “non-recovered.” A child’s treatment progress should be monitored carefully, and if they are not recovering from acute malnutrition as expected, further medical investigation is required—which may uncover an underlying condition.

OUR RESPONSE: By training health facility staff on CMAM protocols—including how to track treatment progress and identify underlying issues—we are working to minimize the risk of medical conditions going undetected. This is a continual process, especially considering the frequent turnover of frontline health staff.

3. Supply chain disruptions cause stock-outs of ready-to-use therapeutic food.

Ready-to-use therapeutic food is an essential commodity in a CMAM program—a child with severe acute malnutrition requires an average of 20 sachets of RUTF per week during their treatment, which they collect from the health facility during monitoring visits.

Logistical challenges and shortages within supply chains sometimes cause stock outs of RUTF. When it’s unavailable, families can lose motivation and stop bringing their girls and boys for treatment. This may result in them being discharged from the program as “defaulting.” (Caregivers are encouraged to continue bringing their children to the health facility during stockouts so that their condition can be monitored.)

OUR RESPONSE: World Vision provides supply chain support to national ministries of health, including donations of RUTF and assistance transporting supplies to health facilities.

4. Weak monitoring systems allow for losses in follow up when children are transferred to hospitals.

If a child’s medical condition deteriorates during treatment, they may be transferred to a hospital for care. Once their condition has stabilized, they should return to the health facility to continue treatment for acute malnutrition. However, these follow-ups may not happen if a monitoring system is weak, and as a result, the child may be missed and be recorded as “defaulting” from the CMAM program.

OUR RESPONSE: Our capacity strengthening efforts through national ministries of health include support for routine monitoring systems, coaching staff on record-keeping along with calculating and interpreting outcomes. This helps to minimize cases where follow-up is lost because of transfers.

5. Population movement and a scarcity of health facilities can make it difficult for families to access CMAM services.

Some of our CMAM programming takes place among pastoralist populations, where families are often moving to new locations in search of pasture and water for their livestock. Migration is particularly high during seasons of drought. A child with acute malnutrition may default from a CMAM program when they move with their family to a new location where treatment is not available.

In some areas, the available health facilities are too few and cover a large geographical area, meaning that families must travel long distances to access CMAM services. Girls and boys with acute malnutrition may end up defaulting because the distance is too far for their families to manage.

OUR RESPONSE: To address these challenges, World Vision is scaling up CMAM outreach services—in Kenya, for example, we are running mobile clinics in three drought-affected districts. This will make CMAM services more accessible to families as they will no longer have to travel long distances to health facilities. For families on the move, the expanded outreach services allow them to continue treatment for their child in their new location.

World Vision will continue to monitor treatment outcomes across our CMAM programs with a particular focus on rates of defaulting and non-recovery. At a global level, this involves quarterly data reviews and follow-ups with countries where specific concerns are noted. At the country level, we continue to review data monthly and coordinate with national ministries of health to take action where needed.