National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan (2017- 2021)

Recommended Citation Ministry of Health (MOH). 2016. National CMAM Operational Plan 2017–2021. Lilongwe, Malawi: MOH. Contact Information Nutrition Unit of the Ministry of Health P.O. Box 30377 Lilongwe 3 Malawi Telephone: +265 (01) 789 400 Fax: +265 (01) 789 431 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 i Preface The Malawi Ministry of Health (MOH) recognises that malnutrition is complex and that addressing it requires a multisectoral approach. The MOH therefore adopted the Community-Based Therapeutic Care (CTC) approach in 2004 (later renamed Community Management of Acute Malnutrition [CMAM]) to address acute malnutrition beyond the nutrition rehabilitation units (NRU). To date, CMAM services have been scaled up and provide care and treatment through four main components: community outreach, the supplementary feeding programme (SFP), outpatient management of severe acute malnutrition (SAM), and inpatient management of SAM. Community outreach is critical in the management of acute malnutrition because of its focus on stimulating the understanding, engagement, and participation of communities in the prevention, identification, and treatment of acute malnutrition. SFP provides a platform for management of moderate acute malnutrition (MAM) through the provision of fortified blended, dry, take-home rations of food. SAM children without medical complications are treated on an outpatient basis using a ready to-use therapeutic food (RUTF), whereas those with medical complications are treated in 24-hour inpatient care facilities, such as paediatric wards and NRUs. Over the years, CMAM service delivery had several successes and challenges. The Ministry of Health, in collaboration with its partners, conducted a bottleneck analysis to synthesise challenges and lessons learnt, and identify solutions and strategies. That analysis guided the development of this CMAM Operational Plan for 2017–2021. This operational plan outlines the overarching determinants of coverage needed to improve the quality of CMAM service delivery and provides guidance on the monitoring and evaluation of the plan’s implementation. Under the leadership of the MOH, all nutrition partners will be instrumental in supporting the implementation of the outlined priority actions over the five-year period of this plan. The Malawi CMAM Operational Plan 2017–2021 will be implemented alongside the National Multi-Sector Nutrition Policy 2017–2021, the National Multi-Sector Nutrition Strategic Plan, and the Health Sector Strategic Plan (HSSP) II. It is envisaged that these concerted efforts will contribute to improvements in national nutrition and health outcomes. Dr. Charles Mwansambo CHIEF OF HEALTH SERVICES Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 ii Acknowledgments The Malawi CMAM Operational Plan 2017–2021 was developed through the technical inputs of numerous stakeholders, including government line ministries, U.N. agencies, nongovernmental organizations, donors, and academic institutions. The MOH extends its appreciation to national-, regional-, district-, and facility-level personnel who offered valuable, first-hand technical views and opinions. We would like to acknowledge the immense contributions of UNICEF/Malawi and the Food and Nutrition Technical Assistance III Project (FANTA)/FHI 360 for their financial, technical, and logistical support in the development of this operational plan. We cannot forget to thank our development partners for their insightful contributions and financial support; notably, the World Bank, the Canadian International Development Agency (CIDA), Irish Aid, and the United States Agency for International Development (USAID). We would also like to thank the Clinton Health Access Initiative (CHAI), the World Food Programme (WFP), and the World Health Organization (WHO) for their valuable technical contributions. The Ministry would like to thank the consultants who facilitated the process of drafting this operational plan, Dr Margaret Akinyi Wagah, Mr Sosten Chilumpha, and Dr John Phuka. Lastly, the Ministry greatly appreciates the policy leadership of Dr George Chithope Mwale, director of clinical services; Mr Felix Pensulo Phiri, director of nutrition; and Mrs Janet Guta, deputy director of clinical services–nutrition. The following people were consulted and provided their technical guidance in the development and finalization of this operational plan: Sylvester Kathumba MOH Dr Jones Kaponda Masi MOH Frank Msiska MOH Humphreys Nsona MOH Blessings Muwalo DNHA Piyali Mustaphi UNICEF Jecinter Oketch UNICEF Patrick Codjia UNICEF Sangita Jacobs UNICEF Kudakwashe Chimanya UNICEF Elsie Mawala UNICEF Emmanuel Saka UNICEF Benson Kazembe UNICEF Taonga Msiska UNICEF Mphatso Mapemba UNICEF Lucy Chirwa Oguguo UNICEF Vitowe Harazi UNICEF Alice Nkoroi FANTA Phindile Chitsulo Lupafya FANTA Dr Jaden Bendabenda FANTA Chawanangwa Jere FANTA Amanda Yourchuck FANTA Violet Orchardson USAID Dr Susan Kambale WHO Mutinta Hambayi WFP Emma Chinzukira WFP Lusungu Chitete WFP Andrews Gunda CHAI Clement Banda CHAI Yuwen Chipatala CHAI Jemma Rowlands CHAI Catherine Mkangama Save the Children Theresa Banda World Vision Happy Botha Valid Nutrition Andrew Chinguwo Valid Nutrition Alima Jimu Project Peanut Butter Julita Manda CIDA/World Bank Mpumulo Jawati Irish Aid Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 iii Contents Preface ..................................................................................................................................................... i Acknowledgments ................................................................................................................................. ii Abbreviations and Acronyms .............................................................................................................. v 1 Introduction ................................................................................................................................... 1 1.1 Background ............................................................................................................................. 1 1.2 Rationale for the Operational Plan .......................................................................................... 1 1.3 Scope of the Operational Plan ................................................................................................. 2 1.4 Goal ......................................................................................................................................... 2 1.5 Objectives ............................................................................................................................... 2 1.6 Guiding Principles .................................................................................................................. 2 2 Process of Developing the Operational Plan ............................................................................... 4 2.1 Desk Review and Stakeholder Consultations ......................................................................... 4 2.2 Bottleneck Analysis ................................................................................................................ 4 2.3 Development of the Operational Plan ..................................................................................... 5 2.4 Costing the Operating Plan ..................................................................................................... 5 3 Operational Plan Strategic Action Areas .................................................................................... 6 3.1 Improve Availability and Access to CMAM Supplies and Equipment .................................. 6 3.2 Increase Competence of Human Resources Involved in CMAM ......................................... 10 3.3 Increase CMAM Coverage ................................................................................................... 12 3.4 Strengthen the Enabling Environment for CMAM Services ................................................ 13 3.5 Improve Monitoring, Evaluation, and Information Management ......................................... 15 3.6 Intensifying CMAM Services to Respond to Emergency and Humanitarian Situations ...... 16 4 National CMAM Monitoring and Evaluation Plan ................................................................. 18 5 Summary of the National CMAM Costs ................................................................................... 29 5.1 Total Cost of Implementing CMAM by Strategic Action Area ............................................ 29 Cost of Treatment per SAM and MAM Child Under 5 ................................................................ 29 6 Guide for Developing District Plan of Action ........................................................................... 31 6.1 Summary of the CMAM Bottlenecks in the Districts ........................................................... 31 6.2 Health Facility and CMAM Resource Mapping ................................................................... 31 6.3 Stakeholder Mapping ............................................................................................................ 31 6.4 Costing of District Operational Plan ..................................................................................... 31 6.5 District Operational Plan ....................................................................................................... 31 List of References ................................................................................................................................ 33 Annex 1: National Bottleneck Analysis Results for SAM ................................................................ 34 Annex 2: National Bottleneck Analysis Results for MAM .............................................................. 36 Annex 3: Critical Bottlenecks and Prioritised Actions .................................................................... 38 Annex 4: Essential CMAM Equipment for OTP and SFP .............................................................. 44 Annex 5: Essential CMAM Equipment for NRU ............................................................................. 46 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 iv Annex 6: Detailed Budgets: CMAM Supplies and Equipment ....................................................... 49 Annex 7: Detailed Budgets: Competence of Human Resources Involved in CMAM ................... 58 Annex 8: Detailed Budgets: Coverage ............................................................................................... 63 Annex 9: Detailed Budgets: Enabling Environment ........................................................................ 64 Annex 10: Detailed Budgets: Monitoring and Evaluation .............................................................. 66 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 v Abbreviations and Acronyms ABC Activity-based Costing BNA Bottleneck Analysis CHAI Clinton Health Access Initiative CIDA Canadian International Development Assistance CMAM Community-based Management of Acute Malnutrition CMED Central Monitoring and Evaluation Division CMS Central Medical Stores COW Community Outreach Worker CSB + Corn Soy Blend fortified (Supercereal) CSB++ Supercereal Plus CTC Community-based Therapeutic Care DHS Demographic and Health Survey DHIS-2 District Health Information Software – Version 2 DHMT District Health Management Teams DNHA Department of Nutrition, HIV and AIDS DIP District Implementation Plan FANTA Food and Nutrition Technical Assistance III Project HMIS Health Management Information System HSA Health Surveillance Assistant HSSP Health Sector Strategic Plan IMCI Integrated Management of Childhood Illnesses IYCF infant and young child feeding LOE level of effort MAM moderate acute malnutrition MICS Multiple Indicator Cluster Survey MBS Malawi Bureau of Standards MDGs Millennium Development Goals M&E Monitoring and Evaluation NCST Nutrition Care Support and Treatment NECS Nutrition Education and Communication Strategy NGO Non-governmental Organization MOH Ministry of Health NRU Nutrition Rehabilitation Unit OP Operational Plan OTP Outpatient Therapeutic Programme PBI Performance-based Incentive PLW Pregnant and Lactating Women PMPB Pharmacy, Medicines and Poisons Board ReSoMal Rehydration Solution for Malnutrition Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 vi RUTF Ready-to-Use Therapeutic Food SAM Severe Acute Malnutrition SDGs Sustainable Development Goals SFP Supplementary Feeding Programme SMART Standardized Monitoring and Assessment of Relief and Transitions SMS Short Message System SUN Scaling Up Nutrition TNP Targeted Nutrition Program TOT Training of Trainers TOR Terms of Reference USAID United States Agency for International Development US$ U.S. dollar WFP World Food Programme WHO World Health Organization Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 1 1 Introduction 1.1 Background Undernutrition poses a major development challenge for Malawi, contributing to high morbidity and mortality among children and other vulnerable groups, such as pregnant and lactating women (PLW). Poor nutrition jeopardized progress on almost all Millennium Development Goals (MDGs), including maternal mortality, child nutrition, education, and gender equality. Stunting among children under 5 remains a serious public health concern. According to the 2014 Malawi MDG Endline Survey, about 42 percent of Malawian children under 5 are stunted and 3.8 percent are wasted (UNICEF 2014). These statistics suggest progress since 2010, when stunting was 47 percent and wasting was 4 percent (NSO and ICF Macro 2011). Despite these achievements, much needs to be done to maintain rates of wasting at less than 5 percent and to improve the care and treatment of children with acute malnutrition. While the prevalence of stunting among children under 5 is unacceptably high, requiring public health attention, wasting also remains a public health concern due to several factors. Firstly, recurring humanitarian emergencies over the past decade have left Malawian children vulnerable. Secondly, the death rate among children with severe acute malnutrition (SAM) in inpatient care is unacceptably high. Data collected through the routine Community-Based Management of Acute Malnutrition (CMAM) programme and the Health Management Information System (HMIS) show that in 2015, the national average SAM death rate in inpatient care was 9.7 percent, with some districts reporting a death rate higher than the recommended Sphere standards cut-off of less than 10 percent. Thirdly, at community level, infant and young child feeding (IYCF) and caring practices are sub-optimal among children under 2, who constitute the majority of those affected by acute malnutrition. Inadequate knowledge about appropriate foods and feeding practices is an important contributor to acute malnutrition in Malawi, where recent data suggest that IYCF practices are not improving. According to the 2010 Malawi Demographic and Health Survey (DHS), only 29.4 percent of children 6–23 months of age met the minimum dietary diversity requirement and nearly half (46.1 percent) did not eat the minimum number of meals per day (NSO and ICF Macro 2011). Similarly, the 2014 Malawi MDG Endline Survey reported that only 26.6 percent of children met the minimum dietary diversity requirement, and 46.8 percent were fed the minimum number of meals per day (NSO 2015). Given these statistics, the Government of Malawi has recognised undernutrition as an important development issue that needs to be addressed. The Constitution of Malawi and the Public Health Act of 1948 advocate adequate nutrition for all Malawians. The Government of Malawi has reinforced that commitment by including prevention and treatment of malnourished children among its critical national development priorities in the Malawi Growth and Development Strategy II (2011–2016). Additionally, the management of acute malnutrition is a priority in the Malawi Health Sector Strategic Plan (2011–2016), the forthcoming Health Sector Strategic Plan (HSSP) II and the National Multi-Sector Nutrition Policy 2017–2021. Through the enabling policy environment created by the Government of Malawi, nutrition interventions, such as CMAM, are supported by diverse stakeholders, including U.N. agencies, nongovernmental organizations (NGOs), and the private sector. 1.2 Rationale for the Operational Plan The first 5-year CMAM operational plan (OP) was developed in 2009 to coordinate and harmonise scale-up of services within the health system and among partners. During the planning period covered by the plan, the Government of Malawi and its development partners invested heavily in CMAM and significant progress was made. Some of the achievements include the development of a national CMAM guideline and job aids; the scale-up of CMAM services to about 90 percent of health facilities in the Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 2 country; capacity strengthening of numerous health workers, health surveillance assistants (HSA), and volunteers across the country; and the establishment of a national CMAM monitoring and evaluation (M&E) system. However, given the poor nutritional status of infants and young children, the favourable policy environment, and the expiration of the operational plan in 2012, the Government determined that it was an opportune time to review and map out new CMAM actions, including alignment to the National Multi-Sector Nutrition Policy 2017–2021 and the forthcoming HSSP II. This CMAM Operational Plan 2017–2021 is grounded in evidence from past achievements, lessons learnt, and analysis of implementation gaps. The operational plan provides guidance to the government and its partners to effectively implement CMAM activities; accelerate the institutionalization and integration of service delivery within the health system; and provide a framework for M&E of CMAM activities over the next five years. 1.3 Scope of the Operational Plan The CMAM Operational Plan guides overall operations at the national level and sets priorities for the next five years. The plan is designed to resolve existing challenges identified through a bottleneck analysis (BNA) of CMAM service delivery, an assessment of the CMAM supply chain, and a review of the 2009–2010 Operational Plan. The plan recognises the practical realities of management of acute malnutrition within the Malawi context; takes into consideration issues of coordination, governance, and advocacy; emphasises the need for measurable indicators with set targets to determine progress; and ensures access to those most in need of the services through its guiding principles. Lastly, the plan outlines the costs needed to implement each of the prioritised actions. 1.4 Goal To contribute to a reduction in morbidity and mortality associated with acute malnutrition in children 0–15 years of age. 1.5 Objectives The following five objectives will help maintain the rates of acute malnutrition in children at less than 5 percent throughout the 5-year period. Each of the objectives has a corresponding strategy and actions outlined in Section 3, and a monitoring and evaluation plan detailed in Section 4.1. 1. Improve availability and access to CMAM supplies and equipment. 2. Increase the competence of human resources involved in CMAM service delivery. 3. Increase effectiveness of CMAM coverage by improving access, acceptability, and utilization of services. 4. Strengthen the enabling environment for CMAM service delivery. 5. Improve monitoring and evaluation and promote the use of data and information to inform CMAM programming and planning. 1.6 Guiding Principles The implementation of the CMAM Operational Plan 2017–2021 will be guided by a set of principles that are relevant to all strategic action areas. These principles are:  Equity: CMAM services shall be provided to all vulnerable population groups in need, including infants, children, pregnant and lactating women, and other marginalised groups.  Gender equality and equity: The design and implementation of CMAM services shall be non discriminatory in addressing the nutritional needs of girls, boys, women, and men. The design and implementation of services shall also promote male involvement in the care of children and women for improved nutritional outcomes. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 3  Health systems strengthening: CMAM services will be provided in an integrated manner that links facility-based and community-based health and nutrition services along a continuum of care. The integrated health systems strengthening approach will involve human resources, health financing, governance, health information, medical supplies and products, and service delivery.  Effective coordination and partnerships: All CMAM activities will be coordinated through the Department of Nutrition, HIV and AIDS (DNHA) and the Ministry of Health (MOH); effective inter- and multisectoral linkages will be created with health and other sectors, such as education, agriculture, and social welfare. The government will also endeavour to build and strengthen partnerships with multiple stakeholders, including the private sector and development partners.  Evidenced-based interventions: CMAM service delivery will be informed by scientifically tested strategies and best practices that are most likely to lead to optimal outcomes.  Community empowerment and participation: Partnering with and empowering communities with knowledge and skills to address the root causes of acute malnutrition will support better outcomes and engender community acceptance and ownership of CMAM services.  Good governance and accountability: Effective leadership and governance from all government and non-government partners will facilitate efficient delivery of CMAM services.  Sustainability: CMAM service delivery is designed to be economically sustainable and not dependent on donor funding. Both the government and the domestic private sector will be pro actively engaged in ensuring the sustainability of service delivery.  Emergency preparedness and response. During emergency and humanitarian situations, delivery of CMAM services will be intensified to meet the nutrition needs of the affected population through earlier case identification, referral, and provision of quality life-saving treatment and care. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 4 2 Process of Developing the Operational Plan The national CMAM Operational Plan 2017–2021 was developed through a participatory process involving national, zonal, and district stakeholders. Four main activities were conducted: a desk review and stakeholder consultation on the current status of CMAM and mapping a way forward; a BNA to understand the determinants of CMAM coverage; a draft of the operational plan using findings of the BNA; and a costing of the operational plan. Each step is described below. 2.1 Desk Review and Stakeholder Consultations Alongside the review of the expired operational plan, several other documents were studied to identify implementation gaps and areas of harmonization with current national policy documents. Those documents included: Assessment of Parallel CMAM Supply Chains for Harmonization and Integration into the National Supply System – Malawi (Traas and Vreeke 2015); National Nutrition Policy and Strategic Plan 2007–2012; Health Sector Strategic Plan 2011–2016 (MOH 2011); and the district implementation plans. The desk review was complemented by national stakeholder consultations conducted between 2014 and 2016. The aim of the desk review and consultations was to understand and document the extent to which objectives set in the retiring CMAM Operational Plan 2009–2012 were achieved and to identify lessons learnt and factors that contributed to the achievement of positive CMAM outcomes. 2.2 Bottleneck Analysis A BNA was undertaken in 2014 by the MOH in collaboration with partners to understand the determinants of effective CMAM coverage and identify problem areas to be addressed. The determinants of coverage were reviewed under the following categories: enabling environment, demand, supply, and quality. For each of the four categories, a set of SAM and moderate acute malnutrition (MAM) indicators were defined and thresholds were set to categorise performance. Data used for the analysis were drawn from inpatient care, outpatient care, and Supplementary Feeding Programme (SFP) reports for the period of January to June 2014. Following this analysis, BNA workshops were held at national and regional levels to review the bottlenecks and identify their root causes and solutions. See Figure 1 for the national SAM and MAM BNA summary and Annexes 1 and 2 for details of the national BNA results for SAM and MAM. Figure 1: National SAM and MAM BNA Summary National SAM Dashboard Summary Supply of ready-to-use therapeutic food (RUTF) Human Resources (HSA) Human Resources (nurses & clinicians) Geographic access – outpatient therapeutic programme (OTP) Outreach Initial Utilization Continuous utilization Quality 36% (Poor) 69% (Acceptable) 29% (Poor) 90% (Good) 24% (Poor) 44% (Acceptable) 42% (Acceptable) 36% (Poor) National MAM Dashboard Summary Supply corn soy blend (CSB) Human Resources (HSA) Human Resources (nurses & clinicians) Geographic access – SFP Outreach Initial Utilization Continuous utilization Quality 48% (Acceptable) 69% (Acceptable) 29% (Poor) 82% (Good) 24% (Poor) 23% (Poor) 22% (Poor) 15% (Poor) Source: MOH/UNICEF 2014, Bottleneck analysis report for the national CMAM operational plan. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 5 Several conclusions were made from the BNA and subsequent causality analysis. Firstly, CMAM commodities—both SAM and MAM—were not in adequate supply. Secondly, adequately trained human resources were lacking, with few clinicians, nurses, and HSAs in service having received comprehensive CMAM training. The lack of adequately trained health care providers was associated with the poor CMAM outcomes at the community and health facility levels. Effective community outreach and mobilization, and appropriate care of acutely malnourished children, require competent CMAM service providers. Thirdly, CMAM volunteers who provide outreach services under the supervision of HSAs were mostly inactive, and less than a quarter of the active volunteers had received training. Fourthly, effective CMAM coverage—defined as the proportion of children who were cured out of the total annual burden of acute malnutrition—was low, at 36 percent and 15 percent of SAM and MAM, respectively. The cumulative effect suggests low geographical coverage, low initial and continuous utilization of services, and poor outcome in SAM and MAM case management. 2.3 Development of the Operational Plan Following the completion of the aforementioned analysis, the findings of the desk review and BNA were synthesised and strategic action areas were identified for the operational plan. The prioritised strategic action areas are based on the theory that the identified gaps in CMAM implementation can be addressed by implementing a set of technical solutions that will lead to the achievement of the operational plan’s objectives. Annex 3 provides details on the critical bottlenecks and prioritised actions. 2.4 Costing the Operating Plan The final step in the development of the operational plan was a costing exercise. The following series of activities were conducted: collection and analysis of programmatic and epidemiological data; stakeholder participation to reach consensus on the costs and assumptions used; and training of national, zonal, and district nutrition managers on the CMAM costing process. A CMAM costing tool, developed by FANTA in February 2012, with adaptations made to fit the Malawi context, was used. 1 The costing tool is a set of Excel spreadsheets that allow users to determine the cost of implementing CMAM at the national or sub-national level. The tool is based on the activity-based costing (ABC) method— combining the “ingredients” and “adaptation” approaches for cost calculations 2 —which provides a more comprehensive picture of the direct and indirect costs associated with an activity. Several assumptions were made prior to the costing exercise. The assumptions made are divided among the scale assumptions (number of facilities and communities delivering CMAM services); epidemiological assumptions (estimated annual SAM and MAM caseload); and programmatic assumptions (number of years CMAM will be implemented; geographical scope for implementation; distances between facilities and districts, zones, and national health headquarters; prices of various commodities required for CMAM; and roles and responsibilities at the national, zonal, district, facility, and community levels of the health system). Stakeholders agreed that costing should be done in U.S. dollars due to the current instability of the Malawi kwacha. Costs presented only cover the direct cost of implementing CMAM at the community, district, zonal, and national levels. They do not include the cost of government or partner staff level of effort (LOE) needed to support service delivery. 1 The CMAM costing tool is available at http://www.fantaproject.org/tools/cmam-costing-tool. 2 The “ingredients” approach details each input that activities are composed of and computing its quantities and unit costs. The “adaptation” approach uses existing costs similar to the ones to be computed for the new or scaled-up activities (e.g., staff costs). http://www.fantaproject.org/tools/cmam-costing-tool Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 6 3 Operational Plan Strategic Action Areas The five strategic action areas of the operational plan align with the specific objectives of this plan. The following strategic action areas are presented in the sections below: improve availability and access to CMAM supplies and equipment, increase competence of human resources, increase coverage of CMAM services, strengthen the enabling environment, and improve M&E. Under each of the five strategic action areas, prioritised actions and estimated costs are presented. Additionally, guidance is provided on how CMAM service delivery can be intensified to respond to the needs of the affected population during emergency and humanitarian situations. Among the recommendations are early identification, referral, and treatment of cases and monitoring of trends and prevalence of acute malnutrition. It is envisioned that District Health Management Teams (DHMT) will prioritise key actions based on district specific needs. Their priorities will be included in the district implementation plans. 3.1 Improve Availability and Access to CMAM Supplies and Equipment Uninterrupted availability of sufficient CMAM supplies, such as ready-to-use therapeutic food (RUTF), therapeutic milk (F-75 and F-100), Rehydration Solution for Malnutrition (ReSoMal), and supplementary foods, such as super cereal plus (CSB++), corn soy blend (CSB +), and vegetable oil, are critical for successful implementation of CMAM services. According to the BNA, two thirds (64 percent) of assessed outpatient therapeutic programmes (OTPs) experienced stock-outs of RUTF during the assessment period. 3 Fifty-two percent of SFP sites experienced stock-outs of CSB. Specific challenges facing the supply chain for RUTF and CSB were identified through the BNA and supply chain assessment. Long turnaround time for quality control and the lack of a local, internationally certified laboratory to conduct quality control checks for therapeutic foods posed challenges to local producers and manufacturers in meeting nationwide demand for RUTF. Despite RUTF being listed in the essential medicines and supplies list, it has not been prioritised in planning or budgetary allocation. There were also logistical problems with delivering supplies of CSB to health facilities. In addition to therapeutic and supplementary food supplies, essential CMAM supplies, including medicines, anthropometric, and other medical equipment, are crucial to achieving optimal health and nutrition outcomes. (See Annexes 3 and 5 for the essential CMAM equipment included in the OTP/SFP and NRU kits and Annexes 4 and 6 for lists of SFP/OTP and NRU supplies, including food products, medicines, and other medical equipment.) Based on the findings of the BNA and the requirements set out in the national CMAM guidelines, this operational plan aims to establish and strengthen systems that will improve availability and access to CMAM supplies and equipment. Prioritised actions towards achieving this goal are listed in Table 3.1. 3 The BNA considers a facility to have experienced a stock-out if they were without RUTF/CSB for at least a 1-week period between January and June 2014. The BNA assessed only outpatient therapeutic programme (OTP) and SFP sites. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 7 Table 3.1: Prioritised Actions to Improve Availability and Access to CMAM Supplies and Equipment 1. Integrate CMAM supplies and equipment into the national health commodity logistics system 2. Advocate to Central Medical Stores (CMS) for increased allocation and long-term funding for RUTF as an essential drug and/or supply 3. Ensure manufacturers and suppliers register therapeutic and supplementary food supplies with the Pharmacy Medicines and Poisons Board (PMPB) 4. Adopt international technical specifications or reference ranges for quality control checks for locally produced therapeutic and supplementary food supplies 5. Perform quality control certification of therapeutic and supplementary food supplies at Malawi Bureau of Standards (MBS) 6. Conduct annual national quantification of CMAM supplies with all stakeholders 7. Procure essential CMAM supplies and equipment based on annual needs 8. Implement a national CMAM supplies real-time monitoring and reporting system at all levels 9. Train service providers and managers on CMAM supplies and logistics management 10. Establish sufficient warehouses and safe storage facilities at central, district, and facility levels 11. Improve efficiency of transport of SAM and MAM supplies to the health facility and beneficiary Below are the summary costs of the prioritised actions to improve availability and accessibility to CMAM supplies and equipment. Detailed costs of these activities are presented in Annex 7. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 8 Table 3.2: Cost of Prioritised Actions: Supplies and Equipment Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Actions 1, 2, 4 & 5 Technical coordination, and advocacy meetings on supply chain management 2,901 2,901 2,901 2,901 2,901 Action 3 Registration of therapeutic and supplementary foods with PMPB 3,100 1,300 1,300 1,300 1,300 Action 6 Annual national review and quantification workshop 8,034 8,034 8,034 8,034 8,034 Action 7 Therapeutic food supplies for management of SAM in children under 54 3,735,202 3,803,728 3,895,137 3,980,340 4,066,859 Therapeutic food supplies for management of SAM in children 5–15 911,817 943,076 974,648 1,006,532 1,038,572 Medicines and other supplies for management of SAM in children under 58 1,228,183 1,549,009 1,005,981 1,021,852 1,037,968 Medicines and other supplies for management of SAM in children 5–15 98,587 100,668 104,023 107,412 110,816 Supplementary food supplies for management of MAM in children under 5 3,119,230 3,192,200 3,268,395 3,347,819 3,430,317 Supplementary food supplies for management of MAM in children 5–15 57,309 59,284 61,266 63,260 65,288 Supplementary food supplies for management of MAM in pregnant and lactating women 699,841 722,003 744,912 768,586 793,040 Medicines and other supplies for management of MAM in children under 5 537,813 550,417 563,565 577,208 591,369 Medicines and other supplies for management of MAM in children 5–15 10,866 11,253 11,622 12,003 12,390 Action 8 Cost of implementing the real-time monitoring system is budgeted for under Strategic Area 3.5, Activity 6. Action 9 Logistics management training for facility-based service providers 298,243 334,515 334,515 334,515 334,515 Logistics management training for managers 153,783 153,783 153,783 153,783 153,783 Action 10 Storage of therapeutic food for SAM—cost of renting space 10,250 10,471 10,742 11,001 11,263 Storage of supplementary food for MAM—cost of renting space 45,223 46,372 47,568 48,810 50,099 4 Also includes HIV+ children under 5 with MAM, per national CMAM guideline treatment protocol. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 9 Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 11 Transport of therapeutic food supplies for SAM 194,473 210,193 210,193 210,193 210,193 Transport of supplementary food supplies for MAM 1,007,152 1,031,785 1,057,301 1,083,711 1,110,976 Total Cost 12,122,007 12,730,992 12,455,886 12,739,260 13,029,683 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 10 3.2 Increase Competence of Human Resources Involved in CMAM An adequate supply of well-trained health care providers is critical to obtaining optimal health and nutrition outcomes. Achieving this goal requires addressing multiple factors: availability of adequate numbers of health care providers, including medical officers, clinical officers, medical assistants, nurses/midwives, HSAs, nutritionists and dieticians; up-to-date training for health care providers; and availability of treatment protocols and other resources. Through the BNA, several gaps in knowledge of human resources contributing to inadequate clinical outcomes were identified. For example, while 69 percent of HSAs had been trained on CMAM within the past year, only 29 percent of clinicians had been. To address these gaps, two levels of capacity development are essential: pre-service and in-service. During pre-service training, nurses and clinicians are not acquiring the competencies required for management of acute malnutrition because CMAM is not included in the medical and nursing curricula. During internships, they are rarely supervised on nutrition related activities, such as CMAM, including the management of SAM with medical complications in paediatric care and treatment. Moreover, in-service training materials have not been updated to reflect the most up-to-date treatment protocols. The prioritised actions outlined under this strategic action area aim to build the competence of the frontline health workforce—such as nurses, clinicians, HSAs, and home craft workers—in the management of acute malnutrition according to the national guidelines. It also calls for continued supportive supervision and mentorship to reinforce knowledge and skills acquired through training. Table 3.3: Prioritised Actions to Increase the Competence of Human Resources Involved in CMAM Service Delivery 1. Establish a practitioners’ committee to ensure nutrition content in health professional pre-service training curricula remains current 2. Review the current pre-service training curricula for health professionals to understand gaps and recommend areas to be updated 3. Provide technical update to the pre-service training curricula for nurses, clinicians and HSAs to include CMAM theory and practice 4. Include management of acute malnutrition as part of the nurse and clinician internship program 5. Conduct CMAM training for pre-service tutors and lecturers teaching in the medical and nursing training institutions 6. Conduct CMAM in-service training for all providers in the NRU, OTP, and SFP sites 7. Conduct CMAM training for all district health management teams (DHMT) 8. Develop a computerized training tracking system for personnel trained in CMAM 9. Develop mentorship and supportive supervision guidelines and tools for facility-based CMAM service providers 10. Conduct mentorship and supportive supervision visits for facility-based CMAM service providers in NRU, OTP, and SFP sites Below are the summary costs of prioritised actions to increase the competence of human resources involved in CMAM service delivery. Detailed costs of these activities are presented in Annex 8. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 11 Table 3.4: Cost of Prioritised Actions: Competence of Human Resources Item Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 1 Pre-service training practitioners’ committee bi-annual meetings 1,934 1,934 1,934 1,934 1,934 Action 2 Assessment of pre-service training curricula for health professionals 23,270 -- -- -- 23,270 Actions 3–4 CMAM technical update workshops with medical, nursing, HSAs and other health professional training schools 8,125 -- 8,125 -- 8,125 Action 5 CMAM training for lecturers and tutors in medical, nursing, HSAs and other health professional training schools 68,751 68,751 68,751 68,751 68,751 Action 6–7 Outpatient care and SFP in-service training of providers 835,020 777,082 683,847 683,847 683,847 Inpatient care in-service training of providers 476,811 1,013,856 406,490 406,490 406,490 CMAM in-service training of trainers and district managers 84,023 84,023 84,023 84,023 84,023 Action 8 To be included as part of real-time monitoring system budgeted for under Strategic Areas 3.5, Activity 6 Action 9 Development/review of mentoring and supportive supervision tools and system 8,034 -- -- -- Action 10 Mentoring and supportive supervision from district to inpatient care, outpatient care, and SFP 129,135 140,088 126,752 126,752 126,752 Mentoring and supervision from national to the district level 6,162 6,162 6,162 6,162 6,162 Total Cost 1,641,265 2,091,896 1,386,084 1,377,959 1,409,354 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 12 3.3 Increase CMAM Coverage Although geographic coverage of CMAM in Malawi is high, with 90 percent of health facilities delivering SAM services nationally, hard-to-reach areas rarely receive much needed services. Some of the districts with low SAM coverage are Kasungu, Karonga, and Mzimba South, which reported a coverage rate lower than 75 percent. Similarly, the geographic coverage of MAM services is high nationally (82 percent); however, Ntcheu, Mulanje, and Nkhatabay districts have a coverage rate lower than 60 percent. Effective community outreach can provide active case identification, referral, and follow-up, helping to increase access to services for underserved groups. Currently, not all cadres of community-based service providers, including volunteers and HSAs, are actively engaged in CMAM activities. There is also a high rate of attrition among trained community volunteers. Correspondingly, the initial utilization of CMAM services—measured as the number of children enrolled in treatment of SAM and MAM compared to the expected annual caseload—was low nationally. Approximately 44 percent of the expected SAM cases were enrolled in outpatient care, while 23 percent of expected MAM cases were enrolled in the SFP—an indication that more efforts are needed to increase case identification and referral for treatment. Support for CMAM at community level therefore needs to be strengthened to improve enrolment. Competent community service providers are important in sensitizing on better health-seeking behaviour and better infant and young child feeding practices. Initiatives to improve community involvement for CMAM are also necessary. The operational plan aims to improve geographic coverage and access to CMAM services through intensified community outreach and mobilization and by establishing and expanding the network of community-based frontline workers who can identify, refer, and follow up cases of acute malnutrition. The plan will also promote awareness and understanding of the causes, consequences, and prevention of acute malnutrition at community level; create and enhance initial demand; and improve utilization of CMAM service through the prioritised actions below. Table 3.5: Prioritised Actions to Increase Coverage of CMAM Services 1. Conduct coverage surveys to determine coverage of CMAM services and barriers to access 2. Re-establish community outreach activities countrywide 3. Conduct training of community-based CMAM service providers, including volunteers 4. Harmonise community mobilization efforts across community groups 5. Institutionalise a harmonised system for incentivizing community volunteers 6. Conduct community sensitization and awareness campaigns on acute malnutrition causes, consequences, prevention, and treatment 7. Develop mentorship and supportive supervision guidelines and tools for community-based CMAM service providers and volunteers 8. Conduct integrated mentorship and supportive supervision visits for community-based CMAM service providers and volunteers Below are the summary costs of prioritised actions to improve the effectiveness of CMAM coverage, including access, acceptability, and utilization of services. Detailed costs of these activities are presented in Annex 9. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 13 Table 3.6: Cost of Prioritised Actions: Coverage Item Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 1 Coverage survey 125,000 -- 125,000 -- Actions 2–5 Community outreach training of community volunteers and leaders 235,606 1,558,905 1,558,746 1,558,746 1,558,746 Action 6 Establishment of community outreach (initial assessment and sensitization meetings) 80,302 449,852 20,867 20,867 20,867 Action 7 No additional cost is required. The cost is already accounted for under Action 9, Section 3.2 Action 8 Mentorship and supportive supervision from district-based and health facility-based health care providers to the communities, and routine outreach activities 11,504,424 16,295,187 9,650,232 9,650,232 9,650,232 Total 11,945,332 18,303,944 11,354,845 11,229,845 11,229,845 3.4 Strengthen the Enabling Environment for CMAM Services Creating an enabling environment that contributes to institutional coherence and engagement at the national, district, facility, and community level is an ongoing challenge. There are two areas that require improvement. Firstly, although the institutional arrangement and coordination structures for the national nutrition and health policy are outlined in the National Multi-Sector Nutrition Policy 2017–2021 and HSSP 2011– 2016, in practice, CMAM activities are insufficiently integrated. Efforts to link CMAM with other ongoing and related programmes, such as HIV care and treatment, remain weak. Linkages between complementary services, such as IYCF, integrated management of childhood illness (IMCI), and livelihood programmes (e.g., social protection and food security), remain weak. These weak linkages are hampering potential synergy in the prevention and management of acute malnutrition. By ensuring that those at risk of malnutrition are referred to complementary services at the facility and community level, new and relapsing cases of acute malnutrition can be prevented. Additionally, service providers of these complementary interventions should be aware of the signs and symptoms of acute malnutrition to ensure early referral and treatment. These actions, taken together, will ensure integration of services within and beyond the health sector. Secondly, some key policymakers do not have comprehensive knowledge about the importance of including CMAM in the package of nutrition interventions and the impact acute malnutrition can have on developmental outcomes across sectors. Decision makers need to understand the critical role nutrition and CMAM play in improving the country’s socioeconomic development. Continued advocacy will prompt stakeholders and policymakers to have a common understanding of the magnitude of the problem and their role in addressing existing gaps in service provision. Advocacy is thus a critical element to raise the profile for CMAM activities, specifically for annual government budgetary allocation for service delivery. Since development partners contribute significantly to CMAM funding, they should also be targeted by advocacy activities. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 14 The operational plan seeks to improve the current institutional arrangement for coordinating CMAM at national, district, facility, and community levels. The plan also seeks to strengthen linkages between CMAM and other nutrition-specific and nutrition-sensitive interventions. Additionally, the plan aims at strengthening advocacy efforts for improved CMAM outcomes, policy formulation, planning, and budget allocation at various levels. Table 3.7: Prioritised Actions to Improve the Enabling Environment for CMAM 1. Update the national CMAM guidelines, ensuring integration with other health and nutrition interventions 2. Integrate implementation of CMAM with other health services, such as IMCI, HIV, WASH, and Scaling Up Nutrition (SUN) initiatives 3. Operationalise the Targeted Nutrition Programs (TNP) technical working group for improved coordination and monitoring of implementation of the operational plan 4. Integrate CMAM advocacy activities into the national nutrition advocacy plan 5. Develop quarterly CMAM policy and technical briefs to share data, best practices, and lessons learnt 6. Conduct advocacy campaigns for increased awareness of CMAM among national level policymakers 7. Advocate prioritisation and funding of CMAM by the government 8. Advocate increased CMAM funding from development partners 9. Increase financial and logistical support for the CMAM focal persons at national, regional, and district levels 10. Establish performance based incentives (PBI) with the CMAM focal persons with clear articulation of targets Below are the summary costs of prioritised actions to improve the enabling environment for CMAM. Detailed costs of these activities are presented in Annex 10. Table 3.8: Cost of Prioritised Actions: Enabling Environment Item Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 1 Update of national CMAM guidelines 27,351 -- -- 27,351 Actions 2–4 Quarterly TNP technical working group meetings 3,868 3,868 3,868 3,868 3,868 Action 5 Development and printing of quarterly CMAM policy and technical briefs 22,000 22,000 22,000 22,000 22,000 Actions 6–8 Advocacy campaigns (2 per year) 22,614 22,614 22,614 22,614 22,614 Actions 9–10 These costs are captured in other activity budgets (e.g., training, supportive supervision, mentoring) Total 75,833 48,482 48,482 75,833 48,482 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 15 3.5 Improve Monitoring, Evaluation, and Information Management Information sharing for CMAM has not been satisfactory. There has been limited use of data to improve quality of care and programming at community, facility, district, and national levels. MOH, UNICEF, and other partners are supporting CMAM data collection and analysis through the national database and the health information management system. However, data is not transmitted in a timely manner or analysed at the source for immediate decision making. Capacity in CMAM data collection and utilization remains a challenge. A knowledge management system needs to be developed and supported across the entire CMAM programme. This strategy aims to generate accurate and reliable monitoring and evaluation data that can inform and improve CMAM service delivery through the prioritised actions listed below. Table 3.9: Prioritised Actions to Improve CMAM Monitoring, Evaluation, and Information Management 1. Identify country-level CMAM operational research questions that address knowledge and implementation gaps 2. Hold annual CMAM dissemination conferences 3. Conduct annual national review of operational plan implementation 4. Conduct midterm and endline evaluations of operational plan implementation 5. Conduct quarterly DHMT review workshops of CMAM data and programme outcomes 6. Establish real-time data management system for CMAM alerts on preparedness and response 7. Conduct CMAM data management trainings, and use of District Health Information Software – Version 2 (DHIS-2) for all district HMIS officers 8. Provide logistical and technical support to districts and facilities in the use of DHIS-2 Below are the summary costs of prioritised actions to improve CMAM monitoring, evaluation, and information management. Detailed costs of these activities are presented in Annex 11. Table 3.10: Cost of Prioritised Actions: M&E Item Year 1 (US$) Year 2 (US$) Year 3 (US$) Year 4 (US$) Year 5 (US$) Action 1 Meeting to identify operational research needs 8,034 -- -- -- Action 2 Annual CMAM dissemination conference 22,334 22,334 22,334 22,334 22,334 Action 3 Annual national review of CMAM operational plan 26,535 26,535 26,535 26,535 26,535 Action 4 Midterm evaluation of CMAM operational plan -- 40,135 -- Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 16 Endline evaluation of CMAM operational plan -- -- -- 40,135 Action 5 Quarterly district data review meetings 452,972 452,972 452,972 452,972 452,972 Action 6 Develop and maintain real-time CMAM monitoring and reporting system 50,000 60,000 65,000 70,000 75,000 Action 7 CMAM data management and DHIS-2 training of managers and information officers 15,722 15,722 15,722 15,722 15,722 Action 8 There is no budget included for logistical support. Cost of internet access and other logistical support to operation of DHIS-2 is provided by the Central Monitoring and Evaluation Division (CMED). Total 575,597 577,563 622,698 587,563 632,698 3.6 Intensifying CMAM Services to Respond to Emergency and Humanitarian Situations Climate change has had an impact on Malawi’s weather patterns, affecting agricultural productivity and household food security. The operational plan includes estimated expenses that will be required beyond regular CMAM operating costs to respond to emergencies and associated increases in SAM and MAM caseloads. The prioritised CMAM actions should be implemented as part of the integrated national nutrition cluster response plan. To estimate additional supply requirements during an emergency, the incidence used to calculate anticipated SAM and MAM caseload was increased from 1.6 to 3.0 for SAM, and from 1.5 to 3.0 for MAM. This change would result in an increased caseload of 54 percent for SAM and 60 percent for MAM. Table 3.11: Prioritised Actions to Intensify CMAM Services to Respond to Emergency and Humanitarian Situations 1. Intensify case finding through community outreach and mobilization 2. Procure additional supplies and equipment to meet the increased SAM caseload 3. Procure additional supplies and equipment to meet the need for increased MAM caseload 4. Conduct refresher training of CMAM service providers on inpatient care, outpatient care, and SFP 5. Intensify the frequency of government and CMAM partner coordination meetings 6. Intensify real-time monitoring and reporting of CMAM service delivery 7. Conduct Standardised Monitoring and Assessment of Relief and Transitions (SMART) nutrition surveys during the emergency and post-emergency period 8. Conduct coverage survey during an identified emergency period Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 17 Below are the summary costs to strengthen the response and management of SAM and MAM cases in emergency and humanitarian situations. The budget below is meant to be illustrative of the annual costs required during an emergency period. Note that the costs should be updated to reflect the annual population and/or caseload for the time period of a declared emergency. Table 3.12: Cost of Prioritised Actions: Illustrative Annual Emergency Budget Item Annual Budget (US$) Action 1 Intensive case finding through community outreach and mobilization 16,295,187 Action 2 and 3 Emergency therapeutic food, storage, and transport for SAM cases— under 5 2,314,434 Emergency therapeutic food and storage for SAM cases—adolescents ages 5–15 61,097 Emergency medical and other supplies for SAM cases—under 5 560,503 Emergency medical and other supplies for SAM cases—adolescents ages 5–15 6,691 Emergency supplementary food, storage, and transport for MAM cases—under 5 2,170,387 Emergency supplementary food, storage, and transport for MAM cases—adolescents ages 5–15 53,585 Emergency supplementary food, storage, and transport for MAM cases—pregnant and lactating women (PLW) 533,969 Emergency medical and other supplies for MAM cases—under 5 354,822 Emergency medical and other supplies for MAM cases—adolescents ages 5–15 7,434 Action 4 Refresher training of CMAM service providers on inpatient care 835,020 Refresher training of CMAM service providers on outpatient care and SFP 476,811 Action 5 Monthly government and CMAM partner coordination meetings 11,604 Action 6 Intensified real-time monitoring and reporting data system 60,000 Action 7 SMART survey—baseline 125,000 SMART survey—endline 125,000 Action 8 Coverage survey 125,000 Total 24,116,544 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 18 4 National CMAM Monitoring and Evaluation Plan Effective and efficient implementation of the CMAM operational plan depends on accurately tracking progress and performance, evaluating impact, and ensuring accountability at all operational levels. To ensure the goal, outcomes, and objectives of the operational plan are achieved, indicators and annual targets have been identified for each prioritised activity. These indicators are included in the M&E framework presented in Table 4.1 below. Data for the indicators detailed below should be collected per the schedules indicated in the tables and complied by MOH on an annual basis. Each district should consolidate its CMAM data, which will then be aggregated at the national level. As detailed in Section 3.5, national and district level stakeholders should use this data to review progress towards operational plan objectives and targets on an annual basis. In addition, a midterm (Year 3) and endline (Year 5) evaluation of the operation plan shall be conducted. Guidance to districts on CMAM data collection is provided in Section 6 of this plan. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 19 Table 4.1: National CMAM Monitoring and Evaluation Plan Objective 1: Improve availability and access to CMAM supplies and equipment Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Annual Targets Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Integrate CMAM supplies and equipment into the national health commodity logistics system Percentage of CMAM supplies and equipment integrated in national health commodity logistics system Measure of the CMAM supplies and equipment managed through the national commodity system. See Annexes 3 and 4 for the list of CMAM supplies and equipment. CMS supply catalogue Year 1 100% 100% 100% 100% 100% 100% 14,505 MOH CMS 2. Advocate increased allocation and long-term funding for RUTF as an essential drug and/or supply to Central Medical Stores (CMS) Percentage increase in funding allocation per year Measure of the percentage increase in funding allocated by the CMS to procure and distribute RUTF as an essential drug and/or supply CMS budget Annually 0.05% 0.04% 0.04% 0.05% 0.05% 0.04% Included under action 1 MOH CMS 3. Ensure manufacturers and suppliers register therapeutic and supplementary food supplies with Pharmacy Medicines and Poisons Board (PMPB) Number of therapeutic and supplementary food supplies registered with PMPB Measure of the therapeutic (RUTF, F-75, F-100, ReSoMal and CMV) and supplementary (CSB++ or CSB+) food commodities registered with PMPB PMPB list of registered suppliers Annual product certification Year 1 Year 2, 3, 4 & 5 7 7 7 7- 7 7 8,300 MOH PMPB 4. Adopt international technical specifications or reference ranges for local quality control checks of locally produced therapeutic and supplementary food supplies Number of locally produced therapeutic and supplementary food supplies with technical specifications Measure of the therapeutic (RUTF, F-75, F-100, ReSoMal and CMVl) and supplementary (CSB++ or CSB+) food commodities with technical specifications developed MBS records Year 1 7 7 -- -- -- Included under action 1 MOH UNICEF WFP, manufactur ers, MBS 5. Perform quality control certification of therapeutic and supplementary food supplies at Malawi Bureau of Standards (MBS) Number of therapeutic and supplementary food supplies registered with MBS Measure of the therapeutic (RUTF, F-75, F-100, ReSoMal and CMV) and supplementary (CSB++ or CSB+) food commodities certified by MBS MBS records Year 1, 2, 3, 4, 5 7 7 7-- 7-- 7-- 7-- Included under action 1 MOH MBS Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 20 Objective 1: Improve availability and access to CMAM supplies and equipment Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Annual Targets Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 6. Conduct annual national quantification of CMAM supplies with all stakeholders Annual quantification workshops held within each MOH fiscal year Measure of the number of annual quantification workshops held with all stakeholders (MOH, national, and district representatives, CMAM partners, RUTF and CSB++/CSB+ manufacturers). See Annexes 3 and 4 for the list of supplies and equipment to be quantified annually. Meeting minutes Annually 5 1 1 1 1 1 40,170 MOH CMS, UNICEF WFP, NGOs, manufactur ers, 7. Procure essential CMAM supplies and equipment based on annual needs Percentage of essential CMAM supplies and equipment procured annually Measure of the quantity of CMAM supplies and equipment procured compared to the national need. See Annexes 3 and 4 for the list of essential supplies and equipment. CMS, MOH, UNICEF, WFP and NGO record of procured commoditie s Quarterly 100% 100% 100% 100% 100% 100% 53,991,666 MOH CMS, UNICEF, WFP, and NGOs 8. Implement a CMAM supplies monitoring and reporting system at all levels CMAM supplies monitoring and reporting system in place Real-time monitoring and reporting system that captures data at the facility, district, and national level in place and interfaced with DHIS-2 MOH records Year 2 1 1 -- -- -- Cost included under real time monitoring system MOH CMS, UNICEF, WFP, and NGOs 9. Train service providers and managers on CMAM supplies and logistics management Number of service providers trained on CMAM supplies and logistics management Measure of the number of facility based service providers trained on CMAM supplies and logistics management, disaggregated by sex MOH and partner training records Annually 3649 657 748 748 748 748 1,636,303 MOH UNICEF, WFP, and NGOs Number of managers trained on CMAM supplies and logistics management Measure of the number of district-, zonal-, and national-level managers trained on CMAM supplies and logistics management, disaggregated by sex MOH training records Annually 1450 290 290 290 290 290 768,915 MOH UNICEF, WFP, and NGOs Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 21 Objective 1: Improve availability and access to CMAM supplies and equipment Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Annual Targets Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 10. Establish sufficient warehouses and safe storage facilities at central, district, and facility levels Percentage of health facilities and districts with adequate storage space for therapeutic and supplementary food supplies Measure of OTP/SFP and NRU site, district, and region with sufficient storage space to accommodate at least 2-month supply of therapeutic and supplementary food for estimated caseload MOH national and district records Quarterly 100% 50% 100% 100% 100% 100% 291,799 MOH UNICEF WFP and NGOs 11. Improve efficiency of transport of SAM and MAM supplies to the health facility and beneficiary Percentage of facilities experiencing stock-outs of essential CMAM supplies Proportion of health facilities reporting stock-out of RUTF, F-75, F 100, ReSoMal, or CSB++/CSB+ on hand for a minimum 1-week period during the quarter Facility records, CMS records Quarterly < 10% < 10% < 10% < 10% < 5% < 5% 6,326,170 MOH CMS, UNICEF, WFP and NGOs Objective 2: Increase the competence of human resources involved in CMAM service delivery Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Establish a practitioners’ committee to ensure nutrition content in health professional training curricula remains current Committee established Year 1 Committee established 1 -- -- -- -- -- MOH Universities, Training Institutions and other partners Number of committee meetings per year Measure of academic staff who participate in the annual meetings Meeting minutes Annually 10 2 2 2 2 2 9,670 MOH Universities, Training Institutions and other partners 2. Review the current pre-service training curricula for nurses and clinicians to understand gaps and recommend areas for update Assessment conducted Measures the number of assessments conducted Assessment report Year 1 (baseline) and Year 5 (post interventio n) 2 1 -- -- -- 1 46,540 MOH Universities, Training Institutions and other partners Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 22 Objective 2: Increase the competence of human resources involved in CMAM service delivery Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 3. Provide technical update to the pre-service training curricula for nurses, clinicians and HSAs to include CMAM theory and practice Number of pre-service curricula updated training Measure of the pre-service training curricula that have been updated for frontline workers (medical officers, clinical officers, medical assistants, nurses/midwives, HSAs) Pre-service training curricula Bi-annually 5 frontline workers curricula 5 5 5 24,375 MOH Universities, Training Institutions and other partners 4. Include management of acute malnutrition as part of the nurse and clinician internship programme Number of interns and students placed in NRUs, OTP, SFP sites, district or national level Measure of the number of students who have an internship or student attachment project on CMAM MOH and training institution records Annually Interns placed per year Included under action 3 MOH Universities and training institutions, UN agencies and NGOs 5. Conduct CMAM training for tutors and lecturers teaching in medical and nursing training institutions Number of tutors and lectures trained per year Measure of the number of tutors and lecturers trained on CMAM, disaggregated by sex MOH and partner training records Annually 175 35 35 35 35 35 343,755 MOH Universities and training institutions 6. Conduct CMAM training for all service providers in the NRU, OTP, and SFP sites Number trained on inpatient care (NRU) Measure of the number of facility-based service providers trained on inpatient care (NRU), disaggregated by sex MOH and partner training records Quarterly 21,850 3,800 8,240 3,270 3,270 3,270 2,710,137 MOH UNICEF, WFP and NGOs Number trained on outpatient care (OTP, SFP) Measure of the number of facility-based service providers trained on outpatient care (OTP), disaggregated by sex MOH and partner training records Quarterly 9,924 2,116 2,057 1,917 1,917 1,917 3,663,643 MOH UNICEF, WFP and NGOs 7. Conduct CMAM training for all district health management teams (DHMT) Number of DHMT trained members Measure of the number of DHMT members trained on CMAM, disaggregated by sex MOH and partner training records Annually 1,925 385 385 385 385 385 420,115 MOH UNICEF, WFP and NGOs 8. Develop a computerized training tracking system for personnel trained in CMAM Training tracking system in place An electronic tracking system in place that captures name, location, and designation of all service providers and managers trained on CMAM MOH record/syste m managed by Nutrition/CM ED Year 2 1 x -- MOH UNICEF, WFP, NGOs and other partners Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 23 Objective 2: Increase the competence of human resources involved in CMAM service delivery Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 9. Develop mentorship and supportive supervision guidelines and tools for facility-based CMAM service providers Guidelines and tools developed for OTP, SFP, and NRU mentoring and supportive supervision A mentoring and supervision guide/tool is defined as an instrument designed to facilitate the process of conducting post training mentorship and coaching or supportive supervision at the district or facility level MOH records Year 1 One mentorship and supervision guide for each of the CMAM components (OTP, NRU, and SFP). X 8,034 MOH WHO, UNICEF, WFP, NGOs and other partners 10. Conduct mentorship and supportive supervision visits for facility-based CMAM service providers in NRU, OTP, and SFP sites Number of mentorship and supportive supervision visits per year A measure of the number of mentorship and supportive supervision visits conducted using the standard guide/tool at the district, OTP, NRU, and SFP MOH records Quarterly x x x x x 680,289 MOH UNICEF, WFP, NGOs and other partners Objective 3: Increase CMAM coverage by improving access, acceptability, and utilization of services Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Conduct coverage surveys regularly to determine coverage of and barriers to access of CMAM services SLEAC/SQUEAC Coverage survey conducted in all districts Measure of the number of coverage surveys conducted Coverage survey report Year 1 and Year 3 2 nationally representat ive surveys 1 -- 1 -- 250,000 MOH UNICEF, WFP, NGOs and other partners 2. Re-establish community outreach activities countrywide Percentage of communities with outreach activities (active case finding, referral and follow-up) re-established Measure of the number of communities that have community assessment conducted, and active case finding, referral, and mobilization activities re-established and conducted on a quarterly basis MOH and partner training records Annually 100% 50% 75% 100% 100% 100% 592,755 MOH UNICEF, WFP, NGOs and other partners Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 24 Objective 3: Increase CMAM coverage by improving access, acceptability, and utilization of services Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 3. Conduct training of community-based CMAM service providers, including volunteers Number of HSAs, community based volunteers, and community leaders trained on CMAM Measure of the number of HSAs, community-based volunteers (care group, CMAM, and health) and opinion leaders trained on CMAM community outreach, disaggregated by sex MOH and partner training records Quarterly 3,515,900 128,0 22 846,97 0 846,9 70 846,9 70 846,9 70 6,470,749 MOH UNICEF, WFP, NGOs and other partners 4. Harmonise community mobilization efforts across community groups Percentage of communities that conduct harmonised activities through care groups Measure of the number of communities that harmonise CMAM activities with care group activities MOH and partner training records Quarterly 100% 50% 75% 100% 100% 100% Included under action 2 MOH UNICEF, WFP, NGOs and other partners 5. Institutionalise a harmonised system for incentivizing community volunteers Percentage of health facilities that provide volunteers with recommended incentive A measure of the number of health facilities that provide community volunteers with incentives, such as a transport allowance during trainings, T shirts, and priority services at the health centre MOH and partner training records Quarterly 100% 50% 75% 100% 100% 100% Included under action 2 MOH UNICEF, WFP, NGOs and other partners 6. Conduct community sensitization and awareness campaigns on acute malnutrition causes, consequences, prevention, and treatment Number of community campaigns conducted per year A measure of the number of outreach campaigns conducted, disaggregated by district MOH and partner training records Quarterly Included under action 8 MOH UNICEF, WFP, NGOs and other partners 7. Develop mentorship and supportive supervision guidelines and tools for community-based CMAM service providers and volunteers Guidelines and tools developed for community outreach mentoring and supportive supervision A mentoring and supervision guide/tool is defined as an instrument designed to facilitate the process of conducting post training mentorship and coaching or supportive supervision at community level MOH and partner records Year 1 One community outreach mentorship and supervision guide x Cost integrate with Objective 2, priority action 8 above. MOH WHO, UNICEF, WFP, NGOs and other partners Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 25 Objective 3: Increase CMAM coverage by improving access, acceptability, and utilization of services Priority Action Indicator Indicator Definition Means of Frequency Total Timeframe Cost ($) Lead Supporting Verification Target Agency Agency Year 1 Year 2 Year 3 Year 4 Year 5 8. Conduct mentorship and Number of mentorship and A measure of the number of MOH and Quarterly x x x x X 56,750,30 MOH UNICEF, WFP, supportive supervision visits supportive supervision visits per mentorship and supportive partner 7 NGOs and for community-based CMAM year supervision visits conducted records other partners service providers and using the standard guide/tool at volunteers, including the community level community mobilization activities Objective 4: Strengthen the enabling environment for CMAM service delivery Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Update the national CMAM guidelines, ensuring integration with other health and nutrition interventions National CMAM guidelines updated National CMAM guidelines that integrate elements of IMCI, HIV, WASH, and SUN MOH and partner records Year 1 and Year 4 Guidelines reviewed and updated in years 1 and 4 x x 54,702 MOH WHO, UNICEF, WFP, NGOs and other partners 2. Integrate implementation of CMAM with other health services, such as IMCI, HIV, WASH, and SUN initiatives Percentage of health facilities that implement CMAM integrated with IMCI, HIV, WASH, and SUN A measure of the number of health facilities that integrate CMAM service delivery with IMCI, HIV, WASH, and SUN MOH records Annually 100% 100% 100% 100% 100% 100% 19,340 MOH UNICEF, WFP, NGOs and other partners 3. Operationalise the Targeted Nutrition Programs (TNP) technical working group for improved coordination and monitoring of operational plan implementation Number of TNP technical working group meetings held per year A measure of the number of TNP technical working group meetings held annually Meeting minutes Annually 20 4 4 4 4 4 Included undue action 2 MOH UNICEF, WFP, NGOs and other partners Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 26 Objective 4: Strengthen the enabling environment for CMAM service delivery Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 4. Integrate CMAM advocacy activities into the national nutrition advocacy plan CMAM activities included in national nutrition advocacy plan National Nutrition Advocacy Plan Year 1 x -- -- -- -- Included undue action 2 MOH DNHA 5. Develop quarterly CMAM policy and technical briefs to share data, best practices, and lessons learnt Number of quarterly CMAM policy and technical briefs produced and delivered Measures the number of CMAM briefs developed and disseminated to policymakers and implementers on a quarterly basis MOH records Annually 20 4 4 4 4 4 110,000 MOH UNICEF, WFP, NGOs and other partners 6. Conduct advocacy campaigns for increased awareness of CMAM among national-level policymakers Number of advocacy campaigns conducted per year A measure of the number of advocacy campaigns conducted and attended by policymakers and development partners annually MOH and partner records Annually 5 1 1 1 1 1 113,070 MOH UNICEF, WFP, NGOs and other partners 7. Advocate for prioritisation and funding of CMAM by the government Percentage increase in funding allocation by government per year Measure of the percentage increase in CMAM funding allocated by the government Government (MOH) budget Annually X% Included undue action 6 MOH DNHA 8. Advocate increased CMAM funding from development partners Percentage increase in funding allocation by development partners per year Measure of the percentage increase in CMAM funding allocated by the development partners Government (MOH) and development partner budgets Annually X% Included undue action 6 MOH UNICEF, WFP, NGOs and other partners 9. Increase financial and logistical support for the CMAM focal persons at national, regional, and district levels MOH UNICEF, WFP, NGOs and other partners 10. Establish working performance contracts that clearly articulate targets with the CMAM focal persons Number of CMAM focal persons with working performance contracts Number of CMAM focal persons with working performance contracts/total number of CMAM focal persons MOH records Annually 100% 100% -- MOH UNICEF, WFP, NGOs and other partners Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 27 Objective 5: Improve monitoring and evaluation and promote the use of data and information to inform CMAM programming and planning Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 1. Identify country-level CMAM operational research questions that address knowledge and implementation gaps Operational research questions identified Meeting held with stakeholders to identify and document CMAM operations research questions Operational research meeting report Year 1 1 x 8,034 MOH Universities and partners 2. Hold annual CMAM dissemination conference CMAM dissemination conference held annually A measure of the number of annual CMAM conferences conducted Conference report Annually 5 1 1 1 1 1 111,670 MOH UNICEF, WFP, NGOs and other partners 3. Conduct annual national review of implementation of the CMAM operational plan CMAM operational plan annual review meeting held A measure of the number of annual CMAM review meetings conducted annually Annual meeting report/brief Annually 5 1 1 1 1 1 132,675 MOH UNICEF, WFP, NGOs and other partners 4. Conduct midterm and endline evaluations of implementation of the CMAM operational plan Midterm evaluation conducted Midterm report Year 3 Midterm evaluation x 40,135 MOH UNICEF, WFP, NGOs and other partners Endline evaluation conducted Endline report Year 5 Endline evaluation x 40,135 MOH UNICEF, WFP, NGOs and other partners 5. Conduct quarterly DHMT CMAM data and programme outcomes review workshops Number of quarterly DHMT CMAM data review workshops per year A measure of the number of quarterly CMAM data and programme review meetings conducted, disaggregated by district MOH and partner records Quarterly 580 116 116 116 116 116 2,264,86 0 MOH UNICEF, WFP, NGOs and other partners 6. Establish real-time data management system for CMAM alerts on preparedness and response Real-time data management system in place MOH, UNICEF, and WFP records Year 1 and during emergenci es 1 X 320,000 MOH UNICEF and WFP Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 28 Objective 5: Improve monitoring and evaluation and promote the use of data and information to inform CMAM programming and planning Priority Action Indicator Indicator Definition Means of Verification Frequency Total Target Timeframe Cost ($) Lead Agency Supporting Agency Year 1 Year 2 Year 3 Year 4 Year 5 7. Conduct CMAM data management trainings and use District Health Information Software– Version 2 (DHIS-2) for all district HMIS officers Number of HMIS officers trained on DHIS-2 Measure of the number of managers trained on CMAM data management, disaggregated by sex MOH training records Annually 175 35 35 35 35 35 78,610 MOH UNICEF, WFP, NGOs and other partners 8. Provide logistical and technical support to districts and facilities in the use of DHIS-2 Percentage of districts with reliable internet access Reliable: without outages of more than 1 week within the quarter DHOs, CMED Quarterly 100% 100% 100% 100% 100% 100% -- MOH UNICEF, WFP, NGOs and other partners Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 29 5 Summary of the National CMAM Costs 5.1 Total Cost of Implementing CMAM by Strategic Action Area The total cost of the operational plan’s prioritised actions is presented below, summarised by strategic action area. Note that Strategic Action Area 6, strengthen emergency preparedness and response, is not included in the costs below, as these are not part of routine CMAM operational costs. Year 1 Year 2 Year 3 Year 4 Year 5 Improve availability and access to CMAM supplies and equipment 12,122,007 12,730,992 12,455,886 12,739,260 13,029,683 Increase the competence of human resources involved in CMAM service delivery 1,641,265 2,091,896 1,386,084 1,377,959 1,409,354 Increase CMAM coverage by improving access, acceptability, and utilization of services 11,945,332 18,303,944 11,354,845 11,229,845 11,229,845 Strengthen the enabling environment for CMAM service delivery 75,833 48,482 48,482 75,833 48,482 Improve monitoring and evaluation and promote the use of data and information to inform CMAM programming and planning 575,597 577,563 622,698 587,563 632,698 Total 26,360,034 33,752,877 25,867,995 26,010,460 26,350,062 Figure 2: Percentage of Total Cost for Each Strategic Action Area Supplies and equipment, 45.6% Competence of human resources, 5.7% Coverage, 46.3% Enabling environment, 0.2% Monitoring and evaluation, 2.2% Cost of Treatment per SAM and MAM Child Under 5 The costs below show the cost of treating an individual SAM or MAM child. These costs include: Human resource time and space at the facility level Therapeutic and supplementary food supplies Medicines and other equipment Storage and transport of food supplies The costs of treatment per SAM and MAM child are below the international average costs of treatment for SAM ($200 per child) and MAM ($80 per child). Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 30 Figure 3: Average Cost of Treating a SAM Child $114.45 $125.21 $115.18 $114.64 $113.45 $116.59 $0.00 $50.00 $100.00 $150.00 $200.00 Year 1 Year 2 Year 3 Year 4 Year 5 Average for the 5 Years $27.52 $27.39 $27.23 $27.16 $27.19 $27.30 $0.00 $10.00 $20.00 $30.00 $40.00 $50.00 Year 1 Year 2 Year 3 Year 4 Year 5 Table 5.1: Total Treatment Cost and National Caseload of SAM Children under 5 Year 1 Year 2 Year 3 Year 4 Year 5 Total SAM treatment cost 6,277,256 7,040,506 6,636,186 6,756,001 6,877,850 Targeted number of SAM cases 54,846 56,229 57,618 58,933 60,623 Figure 4: Average Cost of Treating MAM Child Average for the 5 Years Table 5.2: Total Treatment Cost and National Caseload of MAM Children under 5 Year 1 Year 2 Year 3 Year 4 Year 5 Total MAM treatment cost 5,041,019 5,134,836 5,227,471 5,340,785 5,477,726 Targeted number of MAM cases 183,182 187,468 191,942 196,607 201,452 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 31 6 Guide for Developing District Plan of Action Following the launch of the national CMAM operational plan, all district health management teams will be required to draft and implement specific annual operational plans that will be integrated within their district implementation plans. The plans will be revised on a yearly basis. The following components should be included in developing the annual plan. 6.1 Summary of the CMAM Bottlenecks in the Districts This section will be guided by a district specific BNA and should highlight the corresponding technical solutions to address the bottlenecks/challenges. 6.2 Health Facility and CMAM Resource Mapping This section should document health facilities that provide CMAM services and those that do not provide services, preferably on a colour coded map that highlights the degree of CMAM service performance of each CMAM component (SFP, OTP, and NRU). The map should also highlight those facilities that meet or do not meet the sphere standards (cure, default, and death rates). Finally, the section should summarise resources available to effectively deliver CMAM services, including:  Proportion of staff trained on CMAM in the past 2 years  CMAM stock-out history in the past 3 months  Space/volume for storage of therapeutic and supplementary food supplies  Availability of CMAM job aids, guidelines, and protocols  Availability and functionality of CMAM equipment (see Annexes 3 and 4 for essential supplies and equipment) Additionally, the resource mapping should highlight the number of communities in the districts, those actively conducting and reporting case findings, referral and follow-up activities, and the number of community volunteers and opinion leaders trained and actively supporting CMAM activities. 6.3 Stakeholder Mapping This section should provide an updated list of all CMAM stakeholders, including NGOs in the district, and their role in CMAM. The list should provide a corresponding documentation of the CMAM resources that the stakeholders are contributing to the programme. 6.4 Costing of District Operational Plan Each district should use their “Zonal Costing Report 2017–2021” to review the annual CMAM costs generated through the national costing exercise and review costing assumptions used to ensure that they are still valid. The DHMT should then update the annual projected costs and include them in the district implementation plan. 6.5 District Operational Plan The annual district plan should be presented in table format and include activities aligned to the national strategic action areas: 1) improving availability and access to CMAM supplies and equipment; 2) increasing competence of human resources; 3) increasing coverage of CMAM services; and 4) strengthening the enabling environment at the district level, and improving monitoring and evaluation at the district level. Table 6.1 shows a template for developing a district CMAM operational plan. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 32 Table 6.1: Example of District CMAM Operational Plan Activity Indicator Indicator Definition Means of verification Frequency Annual District Target Timeframe Cost ($) Lead Agency Supporting Agency Q1 Q2 Q3 Q4 Objective 1: Improve availability and access to CMAM supplies and equipment 1. 2. Objective 2: Increase the competence of human resources involved in CMAM service delivery 1. 2. Objective 3: Increase CMAM coverage by improving access, acceptability, and utilization of services 1. 2. Objective 4: Strengthen the enabling environment for CMAM service delivery 1. 2. Objective 5: Improve monitoring and evaluation and promote the use of data and information to inform CMAM programming and planning 1. 2. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 33 List of References Government of Malawi. Malawi Growth and Development Strategy II 2011–2016 (MGDS II). Lilongwe, Malawi: Ministry of Finance and Development Planning. Ministry of Health (MOH). 2011. Health Sector Strategic Plan 2011–2016. Lilongwe, Malawi: MOH. ———. Forthcoming. MOH. Health Sector Strategic Plan II 2017 - 2021. Lilongwe, Malawi: MOH MOH and UNICEF. 2014. Bottleneck Analysis Report for the National CMAM Operational Plan. Department of Nutrition HIV and AIDS (DNHA). 2016. National Multi-Sector Nutrition Policy 2017–2021. Lilongwe, Malawi: DNHA Office of the President and Cabinet (OPC), DNHA. 2009. National Nutrition Policy and Strategic Plan 2007–2012. Lilongwe, Malawi: OPC, DNHA National Statistical Office (NSO). 2015. Malawi MDG Endline Survey 2014. Zomba, Malawi: NSO. NSO and ICF Macro. 2011. Malawi Demographic and Health Survey 2010 (MDHS). Zomba, Malawi, and Calverton, Maryland: NSO and ICF Macro. Traas, Ingeborg Jille; Vreeke, Ed. 2015. Assessment of Parallel CMAM Supply Chains for Harmonisation and Integration into the National Supply System—Malawi. UNICEF/Malawi. NSO. 2014. Malawi MDG Endline Survey 2014, Key Findings. Zomba, Malawi: NSO. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 34 Annex 1: National Bottleneck Analysis Results for SAM District Supply of RUTF Human resources (HSA) Human resources (clinicians) Geographic access OTP Outreach Initial utilization Continuous utilization Effective coverage Balaka 15% 76% 19% 100% 48% 58% 57% 56% Blantyre 25% 99% 95% 100% 10% 98% 92% 79% Chikwawa 91% 82% 21% 88% 10% 62% 59% 54% Chiradzulu 77% 100% 92% 100% 14% 63% 61% 52% Chitipa 100% 12% 11% 100% 8% 6% 6% 6% Dedza 3% 74% 16% 100% 0% 47% 46% 36% Dowa 76% 100% 55% 100% 12% 49% 48% 50% Karonga 55% 99% 89% 65% 42% 20% 19% 18% Kasungu 16% 1% 28% 66% 49% 27% 24% 19% Lilongwe 37% 7% 3% 90% 5% 75% 68% 65% Machinga 0% 78% 28% 100% 99% 115% 112% 94% Mangochi 4% 100% 33% 98% 44% 33% 32% 20% Mchinji 0% 97% 74% 100% 25% 17% 16% 18% Mulanje 18% 87% 20% 96% 71% 243% 236% 196% Mwanza 100% 100% 11% 100% 48% 371% 371% 404% Mzimba North 21% 0% 0% 83% 5% 39% 34% 29% Mzimba South 100% 71% 1% 74% 0% 30% 26% 20% Neno 100% 100% 99% 100% 61% 181% 178% 122% Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 35 Nkhata-Bay 16% 85% 25% 90% 11% 333% 284% 201% Nkhotakota 10% 100% 88% 100% 42% 57% 54% 45% Nsanje 100% 57% 20% 80% 69% 69% 67% 75% Ntcheu 19% 100% 23% 84% 25% 81% 76% 40% Ntchisi 42% 80% 66% 100% 34% 90% 86% 70% Phalombe 0% 92% 81% 86% 44% 43% 38% Rumphi 0% 0% 0% 94% 26% 184% 179% 173% Salima 0% 96% 39% 100% 29% 31% 29% 31% Thyolo 80% 94% 57% 80% 35% 10% 10% 10% Zomba 55% 94% 14% 97% 0% 40% 40% 37% National 36% 69% 29% 90% 24% 44% 42% 36% Green Band >=60% 75%-100% 75%-100% >80% 75%-100% >=60% >=60% >=60% Orange Band 40% -59% 50% - <75% 50% - <75% 40% -<80% 50% - <75% 40% - 59% 40% - 59% 40% -59% Red Band <40% <50% <50% <40% <50% <40% <40% <40% Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 36 Annex 2: National Bottleneck Analysis Results for MAM District Supply of CSB Human resources (HSA) Human resources (clinicians) Geographic access SFP Outreach Initial utilization Continuous utilization Effective coverage Zomba 54% 94% 14% 93% 0% 21% 20% 8% Thyolo 39% 94% 57% 72% 35% 7% 6% 4% Salima 42% 96% 39% 100% 29% 18% 18% 12% Rumphi 0% 0% 0% 94% 26% 44% 43% 34% Phalombe 0% 92% 81% 93% 0% 40% 40% 23% Ntchisi 83% 80% 66% 100% 34% 99% 97% 27% Ntcheu 100% 100% 23% 16% 25% 6% 6% 4% Nsanje 100% 57% 20% 100% 69% 59% 55% 44% Nkhotakota 57% 100% 88% 100% 42% 74% 73% 69% Nkhatabay 100% 85% 25% 57% 11% 36% 31% 28% Neno 23% 100% 99% 100% 61% 39% 39% 26% Mzimba South 100% 71% 1% 97% 0% 52% 47% 36% Mzimba North 52% 0% 0% 79% 5% 42% 39% 26% Mwanza 75% 100% 11% 100% 48% 22% 22% 20% Mulanje 25% 87% 20% 52% 71% 15% 15% 15% Mchinji 56% 97% 74% 100% 25% 15% 15% 9% Mangochi 4% 100% 33% 100% 44% 22% 21% 10% Machinga 0% 78% 28% 100% 99% 47% 42% 32% Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 37 Lilongwe 33% 7% 3% 38% 5% 9% 8% 8% Kasungu 65% 1% 28% 79% 49% 22% 20% 10% Karonga 100% 99% 90% 100% 46% 45% 39% 24% Dowa 76% 100% 55% 100% 12% 10% 10% 8% Dedza 0% 74% 16% 97% 0% 27% 26% 16% Chitipa 56% 12% 11% 100% 8% 7% 7% 4% Chiradzulu 42% 100% 92% 92% 14% 29% 29% 14% Chikhwawa 96% 82% 21% 96% 10% 44% 38% 28% Balaka 15% 99% 19% 100% 48% 28% 28% 12% Blantyre National 48% 69% 29% 82% 24% 23% 22% 15% Green Band >=60% 75%-100% 75%-100% >80% 75%-100% >=60% >=60% >=60% Orange Band 40% to 59% 50% - <75% 50% - <75% 40% -<80% 50% - <75% 40% to 59% 40% to 59% 40% to 59% Red Band <40% <50% <50% <40% <50% <40% <40% <40% Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 38 Annex 3: Critical Bottlenecks and Prioritised Actions 1. Supplies and Commodities Critical bottleneck/s Prioritised actions Stakeholder s Expected outcomes CMAM commodities (RUTF, F75, F100, Super Cereal) not adequately considered in planning, budgeting, and funding Advocate inclusion of CMAM supplies into the essential drugs list MOH and partners Increased Government resource allocation for CMAM supplies Advocate a strengthened procurement and distribution system for therapeutic supplies and equipment within the wider existing system Advocate increased funding for RUTF as an essential drug Strengthen integration of CMAM supplies management into the existing health supplies management system Ensure wide participation of CMAM partners in the national MOH quantification exercise for CMAM supplies Ensure registration of CMAM supplies with PMPB by manufacturers and suppliers Support development of technical specifications of CMAM supplies for Malawi based on international standards Support registration of CMAM suppliers with the Malawi Bureau of Standards Support the development of a CMAM supplies monitoring plan for use at district level and reporting on the CMAM supplies monitoring plan The production capacity of local RUTF does not match country’s total demand Strengthen operationalization of buffer stocks at national, district, and health facility levels MOH, local RUTF manufacturer s and partners Improved knowledge on forecasting and replenishment of buffer stocks Eliminate country stock-outs of RUTF and maintain a favourable pipeline Establish minimum time for conducting and review of RUTF test results Develop a rapid SMS system for stock monitoring and reporting Support learning and adoption of best practices on planning, procurement, and distribution of supplies from other countries, such as Ethiopia Limited safe warehouse/space for stock storage at district and health facility levels Establish sufficient buffer stock warehouses and safe storage facilities at central warehouse MOH and partners Availability of regular buffer stock at central location, district hospitals and the health facilities Increase storage spaces at district hospitals and health facilities Ensure and monitor the warehouse/storage standards from national to health facility level Stock-outs due to delayed transport of RUTF from central warehouse to district hospitals and health facilities Increase MOH logistics support on transport of supplies to the district hospital and health facilities MOH and partners Elimination of stock-outs due to logistical bottlenecks between the central warehouse, district hospitals to health facilities Increase partner participation in transport of supplies to district hospitals and health facilities Where possible and feasible, directly transport supplies to the health facilities from the central warehouse Limited stock monitoring at national, district, and health facility level Develop a guideline/monitoring plan for CMAM supplies control measures and rollout to zones, DHOs, partners, and health workers MOH and partners Reduction of leakages and adequate buffer stocks of CMAM commodities at district and health facility level Harmonised guidelines between CMAM and nutrition care support and treatment (NCST) program to minimise abuse of supplies Increase the frequency of stock monitoring at health facility level Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 39 Closely monitor utilization of stock management tools (stock cards, routine regular physical inventory, and auditing) Develop a rapid SMS system for stock monitoring and reporting Enforce disciplinary action for reported cases of supplies pilferages Support learning and adoption of best practices on planning, procurement, and distribution of supplies from other countries, such as Ethiopia Include all relevant partners in coordination of supply chain management from central warehouse to facility level 2. Increased Competence of Human Resources Involved in CMAM Critical bottleneck Prioritised actions Stakeholders Expected outcomes Pre-service training curricula for health professionals, including nurses and clinicians, has not been informed by up to-date practice on management of acute malnutrition Update the pre-service training curricula for nurses and clinicians to include CMAM theory and practice Medical Council, Nursing Council, College of Medicine, MOH Graduating nurses and clinicians have the required knowledge and skills on CMAM Establish/operationalise medical and practitioners’ committee on nutrition curricula review in health professional training (nurses and clinicians) Include management of acute malnutrition as part of internship supervision programme for nurses and clinicians Not all practicing nurses and clinicians have had in service training on CMAM (inpatient, outpatient, supplementary feeding, and community outreach) Conduct CMAM training for all targeted practicing nurses and clinicians MOH, NGO partners, UN agencies, donors Increased the capacity of practicing health workers to provide CMAM services Develop a computerised tracking system/template for clinician trainings Weak orientation of district health management teams (DHMTs) on CMAM Conduct CMAM training for all DHMTs MOH, NGO partners Improved attitude, knowledge, and skills of DHMTS on CMAM Limited coverage of CMAM training for health workers other than nurses and clinicians Conduct training of all CMAM service providers at the community level, including HSAs, care group members, and volunteers MOH, nutrition partners Improved competency of all CMAM service providers Inadequate support supervision and mentorship and follow-up Develop and implement guidelines for on-the-job training and mentorship to target all CMAM service providers MOH, nutrition partners (e.g., NGOs, UN agencies) Increased capacity of practicing health workers to provide CMAM services Increase frequency and regularised follow-up and supervision of CMAM services at the health facility and community levels Integrate CMAM into the Continuous Professional Development (CPD) protocol Management of acute malnutrition is not perceived as a core function of clinicians and nurses Ensure continuous advocacy through Medical and Nursing Councils on the importance of involving clinicians and nurses in CMAM Medical Council, Nursing Council, College of Medicine, MOH Intensified advocacy for CMAM among nurses and clinicians Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 40 3. Increased CMAM Coverage Critical bottleneck Prioritised actions Stakeholders Expected outcomes Weak national geographic mapping of CMAM coverage to rationalise where CMAM sites are most needed Conduct geographic mapping to ensure all households can access CMAM services MOH, nutrition partners (e.g., NGOs, UN agencies) Increased geographical coverage of CMAM Some social norms, beliefs, and attitudes in the local context serve as barriers to uptake of CMAM and access to CMAM services Conduct community sensitization and awareness campaigns on acute malnutrition causes, consequences, prevention, and health seeking MOH, nutrition partners (e.g., NGOs, UN agencies) Improved knowledge, beliefs, and skills of CMAM among all cadres of community members Reorient community members and leaders on CMAM case identification, referral, and follow-up. Inadequate involvement on CMAM by relevant cadres of community groups (e.g., Community Care Groups) Actively engage and empower community groups (e.g., care groups) on the prevention of SAM/MAM. MOH, nutrition partners (e.g., NGOs, UN agencies) Heightened involvement among community groups in CMAM activities Poor coordination among nutrition partners at community level in community mobilization Harmonise community mobilization efforts across community groups MOH, nutrition partners (e.g., NGOs, UN agencies) Improved community mobilization by all partners Lack of support in active case findings at community level Support and expand active case finding among different cadres of community volunteers, including community care groups MOH, nutrition partners (e.g., NGOs, UN agencies) Increase coverage for both SAM and MAM Support and expand community mobilization initiatives through available channels in the community Ensure increased involvement and participation of additional cadres of community volunteers for CMAM (e.g., mother-to-mother support groups and community care groups) Late presentation of cases due to long distances to health facilities resulting in poor CMAM performance Strengthen outreach services to increase coverage and reach those who are far from health facilities. MOH, nutrition partners (e.g., NGOs, UN agencies) Improved CMAM outcomes (deaths, defaulters, length of stay); increase in recovery rate and coverage Suboptimal follow-up systems at community level Develop and implement well-coordinated supervision and follow-up systems between health facility and community level MOH, nutrition partners (e.g., NGOs, UN agencies) Improved follow-up at community level for active case finding Support and enhance follow-up systems between health facility and community levels Deploy sufficient volunteers in all the districts for CMAM service provision Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 41 High turnover of volunteers due to lack of incentives to motivate them Institutionalise and harmonise a system for incentivizing and motivating community volunteers and recognizing best performing volunteers MOH, nutrition partners (e.g., NGOs, UN agencies) Availability of motivated and skilled volunteers for CMAM service provision Errors in admission into CMAM programmes due to inaccurate screening Training/retraining of health workers and close supervision of screening of children at community and health facility levels MOH, nutrition partners (e.g., NGOs, UN agencies) Proper triage and appropriate treatment protocol assigned to the acutely malnourished Include equipment supervision as part of regular supervision, including proper calibration Children lost to follow up due to lack of effective follow-up at community or household level Ensure weekly supervision of volunteers MOH at district level, NGO partners Reduced loss to follow-ups of CMAM clients Develop and operationalise tools for monitoring volunteers on CMAM service provision Inaccurate screening, misdiagnosis of children, and treatment without following CMAM guidelines Develop and implement CMAM mentorship model for capacity strengthening of volunteers and health workers implementing CMAM MOH, nutrition partners (e.g., NGOs, UN agencies) Adherence to CMAM guidelines and standard operating procedures Training/re-training of frontline nutrition health workers on CMAM guidelines Developing standard tools for health facility supervision for CMAM, as opposed to having different tools by different partners or districts 4. Strengthen the Enabling Environment for CMAM Critical bottleneck Prioritised actions Stakeholders Expected outcomes Weak CMAM integration with health initiatives (e.g., HIV/AIDS, IMCI) and other initiatives, such as WASH, social protection, and food security Link CMAM with Nutrition Education and Communication Strategy (NECS) at community level through the existing multisectoral platform (agriculture, social protection, food security, WASH, and family planning) MOH, UNICEF, NGO partners CMAM functionally integrated into the health system Link CMAM to SUN initiatives and interventions, strengthening its integration and scale-up through the SUN initiatives Ensure that CMAM services are accessible to HIV positive clients Review CMAM guidelines to include identification and treatment of acutely malnourished mothers Harmonise data collection and reporting between HIV and CMAM Weak harmonization between HIV and CMAM Support strengthening of bi-directional referrals from CMAM and HIV service points MOH, relevant line ministries Harmonised for CMAM and HIV services Differing approaches in coordination of the implementation of CMAM Strengthen the operationalization of coordination system from national to community level MOH, nutrition partners (e.g., NGOs, UN agencies) A functional CMAM coordination system from national to Ensure participation of all actors in coordination meetings Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 42 Develop and update who does what, where, and when (4Ws) in CMAM to avoid duplication of support to districts community level and the vice versa Issues of CMAM not considered by policymakers and planners Integrate CMAM advocacy activities into the national nutrition advocacy plan MOH, nutrition partners Increased consideration of CMAM in planning Development of policy and technical briefs on CMAM Advocate increased CMAM funding by the government Nutrition partners, MOH, development partners Advocate increased CMAM funding by development partners MOH, NGO partners, development partners Initiate campaigns to increase awareness of CMAM at national level (to policymakers) and district level Nutrition partners, MOH There is no indication of who is accountable for ensuring that the various components of CMAM are effectively implemented Increased logistical and funding support for the focal person in charge of CMAM at national, regional, and district level MOH, UNICEF Increased accountability and leadership at national, regional, and district level Establish a working performance contract with the CMAM focal point with clear articulation of targets Inadequate funding for CMAM activities in national budget Advocate prioritisation of CMAM in national planning and budgeting MOH, UNICEF, NGO partners Increased funding allocation for CMAM Support and prioritise CMAM in national budget Support development and implementation of resource mobilization strategy for CMAM Monitor funding and utilization allocation for CMAM Support inclusion of CMAM plans and budget in district implementation plans 5. Improve Monitoring, Evaluation, and Information Management Critical bottleneck Prioritised action Stakeholders Expected outcomes Inadequate evidence based information on CMAM bottlenecks and solutions Conduct country-level CMAM operational research that provides specific answers to key bottlenecks Universities, NGO partners, MOH, UN agencies, research institutes Practical and evidence-based solutions for CMAM Limited platforms for sharing information on CMAM Development of quarterly CMAM bulletin to share CMAM experiences, best practice, and lessons learnt MOH, UNICEF, other UN agencies, NGO partners, universities, research institutions Improved CMAM information sharing Hold biannual conferences on CMAM to share best practices within and outside of the country Annual evaluation and review of CMAM operational plan (2016–2020) Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 43 Late reporting as a result of delayed submission of data Establish a real-time system for CMAM alerts on preparedness and response MOH, UNICEF, NGO partners Use of monitoring data for timely and accurate decision making Incomplete and missing data make it difficult to assess situation or make informed decisions Support capacity development (training) in data management at all levels of CMAM Ensure intensified supervision of data capture, management, and submission Limited utilization of data both at the source and central level Training in data analysis and use at district level facilities Not all data have been mainstreamed into DHIS II. The RapidSMS data (surveillance) is still hosted by UNICEF Integrate CMAM indicators and tools into DHIS-2 Train and support district and facility-based HMIS and data officers on CMAM data management through DHIS 2 Institute a ‘one-stop shop’ for data at the MOH (through DHIS2), including RapidSMS data surveillance Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 44 Annex 4: Essential CMAM Equipment for OTP and SFP Tools, materials, and other OTP/SFP supplies Minimum amount per clinic Strong file to store treatment cards 4 Small clock or watch with second hand 2 Bucket (plastic, graduated, lid, 8.5 litres) 2 Jug (transparent plastic, graduated, 1 litre) 2 Marker pens (permanent ink) 12 Notebook 4 Metal spoons 4 Teaspoons 12 Nail clippers 4 Water carrier (plastic, 20 litres) 4 Water jug (with lid) 4 Small metal bowl 4 Thermometer (electronic) 2 Hanging scale with 100 g indications 1 Adult scale/electronic scale 1 Height boards 1 MUAC bands for children 20 Calculators 2 Weight-for-height chart 1 Additional height board 1 Scissors 1 Stapler and staples 1 Beaker (orange plastic, 500 ml) 2 Copy of CMAM guidelines 2 Set of cups and spoons 6 Wooden pallets for food 10 Cooking pots for SFP demonstration 1 MUAC tapes for adults 5 SFP and OTP monitoring cards Based on caseload OTP register 1 OTP report 1 booklet SFP registers; one for children and one for mothers 2 SFP monthly report booklet 1 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 45 Supplementary and therapeutic foods Minimum amount Sugar to make 10% sugar solution 500g RUTF Based on caseload CSB++ Based on caseload CSB+ Based on caseload Vegetable oil Based on caseload Routine medicines for OTP Amoxicillin syrup 125mg/5ml 500 bottles Albendazole or Mebendazole 4 tins Paracheck (malaria rapid test) 200 HIV test kit based on caseload Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 46 Annex 5: Essential CMAM Equipment for NRU Tools, materials, and other NRU supplies Minimum amount per clinic Strong file for treatment cards 4 Small clock or watch with second hand 2 Bucket (plastic, graduated, lid, 8.5 litres) 2 Jug (transparent plastic, graduated, 1 litre) 2 Marker pens (permanent ink) 12 Notebook 4 Metal spoons 4 Teaspoons 12 Nail clippers 4 Water carrier (plastic, 20 litres) 4 Water jug (with lid) 4 Small metal bowl 4 Hanging scale with 100 g indications 1 Adult scale/electronic scale 1 MUAC bands 20 Calculators 2 Weight-for-height chart 1 Height board 1 Scissors 1 Stapler and staples 1 Beaker (orange plastic, 500 ml) 2 Set of communication materials for counselling on health and nutrition 2 Job aids for staff 1 Copy of CMAM guidelines 1 Registration book 1 Monthly reporting forms 1 NRU treatment cards Based on caseload Set of cups and spoons 6 Infant scale with 10 g indications 1 Food scale (up to 10 kg) for weighing milk powder 1 Electric kettle 1 Beds (that can sleep mother and baby) 20 Thermos flask 1 Blankets 1 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 47 Wall thermometers (room thermometer) 1 Hand whisk 1 Syringes (for measuring small milk feeds) 50 Room heater 2 Resuscitator hand, infant/child set 1 Insecticide treated bed nets (ITN) 20 Therapeutic Foods F75 milk Based on caseload F100 milk Based on caseload RUTF Based on caseload Sugar Based on caseload CMV 1 Routine and essential drugs Vitamin A Based on caseload Folic acid Based on caseload Ferrous sulphate Based on caseload Amoxicillin Based on caseload Cotrimoxazole Based on caseload Gentamycin Based on caseload Benzyl Penicillin Based on caseload Cefotaxime Based on caseload Ceftriaxone Based on caseload Ciprofloxacin Based on caseload Cloxacillin Based on caseload Tetracycline eye ointment Based on caseload Chloramphenicol eye drops Based on caseload 1% Atropine eye drops Based on caseload Nystatin (oral suspension) Based on caseload Fluconazole Based on caseload Benzyl benzoate (12.5%) Based on caseload Whitfields Based on caseload Gentian violet Based on caseload Silver sulfadiazine Based on caseload Zinc oxide ointment (10%) Based on caseload Paraffin gauze Based on caseload Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 48 Measles vaccine Based on caseload 10% Dextrose Based on caseload Metronidazole Based on caseload Blood for transfusion5 Based on caseload Albendazole or Mebendazole Based on caseload Anti-malarial drugs—Lumefantrine Artemether - LA (oral) Based on caseload Antiretroviral therapy (ART) Based on caseload TB drugs Based on caseload Medical supplies ReSoMal Based on caseload Malaria test kit Based on caseload HIV test kit Based on caseload Hb test strips Based on caseload IV kits Based on caseload NG tubes Based on caseload Mixing syringes (50–60 ml) Based on caseload Glucometer or glucose test kit 1 IV fluids: half-strength Darrow’s or Ringer’s lactate Based on caseload Thermometer (for measuring body temperature) 1 5 The cost of ART and TB drugs will be covered by the HIV and TB programmes and therefore has not been costed for in the CMAM Operational Plan. Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 49 Annex 6: Detailed Budgets: CMAM Supplies and Equipment Table 6.1: Actions 1–5: Supply Chain Advocacy Meetings Year 1 Year 2 Year 3 Year 4 Year 5 Venue 201 201 201 201 201 Lunch/refreshments 2100 2100 2100 2100 2100 Stationary 600 600 600 600 600 Table 6.2: Action 3: Registration with PMPB Year 1 Year 2 Year 3 Year 4 Year 5 Registration fee for locally produced products 600 -- -- -- Registration fee for imported products -- 300 300 300 300 Annual renewal fee for locally produced products 2500 -- -- -- Annual renewal for locally produced products 1000 1000 1000 1000 Table 6.3: Action 6: Annual National Quantification Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 5600 5600 5600 5600 5600 Venue 134 134 134 134 134 Lunch/refreshments 1400 1400 1400 1400 1400 Stationary 200 200 200 200 200 Printing 700 700 700 700 700 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 50 Table 6.4: Action 7: SAM Supplies and Equipment—Children under 5 Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Therapeutic foods RUTF kg 4.22 807,492 3,407,617 822,305 3,470,126 842,064 3,553,509 860,481 3,631,231 879,183 3,710,153 F-75 kg 5.52 44,176 243,430 44,986 247,904 46,067 253,870 47,074 259,432 48,098 265,080 F-100 kg 6.35 13,253 84,154 13,496 85,698 13,820 87,757 14,122 89,677 14,429 91,626 Medicines and medical supplies Sugar water litre 0.12 37,180 4,462 37,862 4,543 38,772 4,653 39,620 4,754 40,481 4,858 Cotrimoxazole dose 0.79 4,016 3,159 4,090 3,217 4,188 3,295 4,279 3,367 4,373 3,440 Fluconazole dose 1.46 3,012 4,391 3,067 4,471 3,141 4,579 3,210 4,679 3,279 4,780 Silver sulfadiazine tube 1.39 3,012 4,182 3,067 4,258 3,141 4,361 3,210 4,456 3,279 4,553 Zinc oxide ointment (10%) tube 17.35 3,012 52,269 3,067 53,228 3,141 54,507 3,210 55,699 3,279 56,910 Metronidazole dose 4.74 3,012 14,270 3,067 14,531 3,141 14,880 3,210 15,206 3,279 15,536 Ferrous sulphate/fumarate dose 0.46 1,004 465 1,022 473 1,047 485 1,070 495 1,093 506 Cloxacillin dose 0.51 4,016 2,051 4,090 2,089 4,188 2,139 4,279 2,186 4,373 2,233 Chloramphenical eye drops bottle 0.44 4,418 1,942 4,499 1,978 4,607 2,025 4,707 2,070 4,810 2,115 1% Atropine eye drops bottle 0.58 201 116 204 118 209 121 214 124 219 126 Nystatin (oral suspension) dose 0.67 8,032 5,381 8,179 5,480 8,376 5,612 8,559 5,735 8,745 5,859 Paraffin gauze pack 2.60 4,016 10,454 4,090 10,646 4,188 10,901 4,279 11,140 4,373 11,382 Whitfields tube 0.60 1,004 604 1,022 615 1,047 630 1,070 644 1,093 658 10% Dextrose does 0.23 4,016 911 4,090 927 4,188 950 4,279 970 4,373 991 Gentian violet bottle 2.71 456 1,236 1,308 3,545 1,308 3,545 1,308 3,545 1,308 3,545 Benzyl benzoate bottle 2.56 38 97 109 279 109 279 109 279 109 279 Amoxicillin g 0.75 59,584 44,688 60,677 45,508 62,135 46,601 63,494 47,621 64,874 48,656 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 51 Year 1 Year 2 Year 3 Year 4 Year 5 Item Unit Unit Cost Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Requirement Cost Requirement Cost Requirement Cost Requirement Cost Requirement Cost Antimalarial full course 4.43 22,046 97,664 22,450 99,456 22,990 101,845 23,493 104,073 24,003 106,335 Malaria tests tests 0.53 44,092 23,378 44,901 23,807 45,980 24,379 46,986 24,912 48,007 25,454 Albendazole/ Mebendazole 100 mg 0.03 26,709 801 27,201 816 27,859 836 28,473 854 29,095 873 Folic acid dose 0.01 20,080 1,019 20,448 1,049 20,939 1,080 21,397 1,111 21,863 1,141 Gentamicin dose 1.68 19,566 32,823 19,918 33,414 20,393 34,211 20,835 34,953 21,285 35,707 Metronidazole dose 4.92 915 3,176 939 3,250 965 3,336 990 3,418 1,015 3,501 Benzylpenicillin dose 2.38 19,660 47,480 20,015 48,346 20,494 49,505 20,939 50,585 21,391 51,681 Ceftriaxone dose 8.16 3,962 31,926 4,034 32,501 4,130 33,276 4,220 33,997 4,312 34,730 Retinol (100,000 IU) dose 0.08 1,958 148 1,994 150 2,042 154 2,086 157 2,132 161 Retinol (200,000 IU) dose 0.06 3,117 173 3,183 176 3,264 180 3,340 184 3,417 189 Measles vaccine doses 0.27 45,666 12,330 46,509 12,557 47,636 12,862 48,686 13,145 49,751 13,433 Measles syringe syringes 0.05 45,666 2,283 46,509 2,325 47,636 2,382 48,686 2,434 49,751 2,488 Measles mixing syringes syringes 0.05 4,567 228 4,651 233 4,764 238 4,869 243 4,975 249 Disposable syringes Per SAM case 6.42 20,080 128,938 20,448 131,303 20,939 134,456 21,397 137,396 21,863 140,383 HIV test kits tests 1.35 59,584 80,438 60,677 81,914 62,135 83,882 63,494 85,717 64,874 87,580 IV kits each 0.15 2,971 446 2,033 305 2,082 312 2,127 319 2,173 326 Nasogastric (NG) tubes each 0.10 4,827 483 5,081 508 5,204 520 5,318 532 5,434 543 ReSoMal sachets 0.38 13,568 5,156 14,314 5,439 14,658 5,570 14,978 5,692 15,304 5,815 CMV tin 76.19 38 2,895 109 8,305 109 8,305 109 8,305 109 8,305 Other treatment supplies Outpatient (new site) care kits each 1,543 37 57,091 20 30,860 - - - - - Outpatient (established site) care kit each 197 582 114,654 619 121,943 639 125,883 639 125,883 616 121,352 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 52 Year 1 Year 2 Year 3 Year 4 Year 5 Item Unit Unit Cost Annual Annual Annual Annual Annual Annual Annual Annual Annual Annual Requirement Cost Requirement Cost Requirement Cost Requirement Cost Requirement Cost Inpatient care kit (new site) each 8,495 38 322,802 71 603,131 - - - - - Inpatient care kit (established site) each 986 - - 38 37,462 109 107,457 109 107,457 106 104,499 Soap bars 1.00 32,188 32,188 33,228 33,228 33,228 33,228 33,228 33,228 33,228 33,228 Stationary Stock forms and cards form 0.20 8,232 1,646 9,324 1,865 9,324 1,865 9,324 1,865 9,324 1,865 Treatment cards (outpatient care and inpatient care) cards 1.10 59,584 65,542 60,677 66,745 62,135 68,349 63,494 69,843 64,874 71,361 RUTF ration cards cards 0.20 59,584 11,917 60,677 12,135 62,135 12,427 63,494 12,699 64,874 14,180 Table 6.5: Action 7: SAM Supplies and Equipment—Adolescents ages 5–15 Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Therapeutic foods RUTF kg 4.22 212,689 897,546 219,980 928,316 227,344 959,393 234,781 990,778 242,255 1,022,317 F-75 kg 5.52 1,925 10,603 1,991 10,967 2,058 11,334 2,125 11,705 2,193 12,078 F-100 kg 6.35 578 3,668 597 3,793 617 3,920 638 4,049 658 4,177 Medicines and medical supplies Sugar water litre 0.12 4,953 594 4,827 579 4,989 599 5,152 618 5,316 638 Amoxicillin g 1.50 5,786 8,680 6,034 9,051 6,236 9,354 6,440 9,660 6,645 9,968 Antimalarials full course 8.86 2,309 20,453 2,233 19,781 2,307 20,443 2,383 21,112 2,459 21,784 Malaria tests tests 0.53 4,229 2,241 4,465 2,367 4,615 2,446 4,766 2,526 4,917 2,606 Albendazole/ Mebendazole 200 mg 0.06 5,772 346 6,034 362 6,236 374 6,440 386 6,645 399 Cotrimoxazole dose 0.79 393 309 407 320 420 331 434 341 448 352 Fluconazole dose 2.92 295 860 305 889 315 919 326 949 336 979 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 53 Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Silver sulfadiazine tube 1.39 295 409 305 423 315 438 326 452 336 466 Zinc oxide ointment (10%) tube 17.35 295 5,118 305 5,293 315 5,470 326 5,649 336 5,829 Metronidazole dose 10.15 295 2,994 305 3,097 315 3,200 326 3,305 336 3,410 Ferrous sulphate/fumarate dose 0.46 98 45 102 47 105 49 109 50 112 52 Cloxacillin dose 1.09 393 430 407 445 420 460 434 475 448 490 Chloramphenical eye drops bottle 0.44 433 190 447 197 462 203 477 210 493 217 1% Atropine eye drops bottle 0.58 20 11 20 12 21 12 22 13 22 13 Nystatin (oral suspension) dose 0.67 786 527 813 545 841 563 868 582 896 600 Paraffin gauze pack 2.60 393 1,024 407 1,059 420 1,094 434 1,130 448 1,166 Whitfieds tube 0.58 98 57 102 59 105 61 109 63 112 65 10% Dextrose dose 0.49 393 191 407 198 420 204 434 211 448 218 Folic acid dose 0.01 1,966 14 2,033 15 2,102 15 2,170 16 2,239 16 Gentamicin dose 3.59 1,966 7,060 2,033 7,302 2,102 7,547 2,170 7,793 2,239 8,042 Metronidazole dose 10.55 39 415 41 429 42 444 43 458 45 473 Benzylpenicillin dose 5.11 1,966 10,045 2,033 10,389 2,102 10,737 2,170 11,088 2,239 11,441 Ceftriaxone dose 17.49 393 6,877 407 7,113 420 7,351 434 7,592 448 7,833 Retinol (200,000 IU) dose 0.06 242 15 251 16 259 16 267 17 276 17 Measles vaccine doses 0.27 5,834 1,575 6,034 1,629 6,236 1,684 6,440 1,739 6,645 1,794 Measles auto-disable (AD) syringe syringes 0.05 5,834 292 6,034 302 6,236 312 6,440 322 6,645 332 Measles mixing syringes syringes 0.05 583 29 603 30 624 31 644 32 665 33 Disposable syringes per case 6.42 1,878 12,055 1,940 12,453 2,002 12,856 2,066 13,263 2,129 13,669 HIV test care kits for inpatient tests 1.35 5,834 7,876 6,034 8,146 6,236 8,419 6,440 8,694 6,645 8,971 IV kits each 0.15 88 13 91 14 94 14 97 14 100 15 Nasogastric tubes each 0.10 219 22 226 23 234 23 242 24 249 25 ReSoMal sachets 0.38 613 233 634 241 655 249 676 257 698 265 Stationary Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 54 Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Treatment cards (outpatient care and inpatient care) cards 1.10 5,834 6,417 6,034 6,637 6,236 6,860 6,440 7,084 6,645 7,310 RUTF ration cards cards 0.20 5,834 1,167 6,034 1,207 6,236 1,247 6,440 1,288 6,645 1,329 Table 6.6: Action 7: MAM Supplies and Equipment—Children under 5 Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Supplementary food CSB++ MT 860 3,627 3,119,230 3,712 3,192,200 3,800 3,268,395 3,893 3,347,819 3,989 3,430,317 Medicines and medical supplies Albendazole/ Mebendazole 100 mg 0.03 1,188,963 24,666 1,215,558 25,219 1,244,213 25,813 1,274,794 26,448 1,307,276 27,120 Iron and folic acid Tablets 0.02 3,704,758 130,381 3,792,566 133,390 3,883,597 136,566 3,977,532 139,893 4,074,580 143,377 HIV test kits tests 1.35 140,863 190,165 144,204 194,675 147,666 199,349 151,237 204,170 154,925 209,149 Stationary Stock forms/cards form 0.20 5,076 1,015 5,076 1,015 5,076 1,015 5,076 1,015 5,076 1,015 Treatment cards (SFP) cards 1.10 183,183 163,413 187,466 167,277 191,947 171,289 196,607 175,435 201,455 179,724 SFP ration cards cards 0.20 140,863 28,173 144,204 28,841 147,666 29,533 151,237 30,247 154,925 30,985 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 55 Table 6.7: Action 7: MAM Supplies and Equipment—Adolescents ages 5–15 Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Supplementary food CSB++ MT 860 67 57,309 69 59,284 71 61,266 74 63,260 76 65,288 Medicines and medical supplies Albendazole/ Mebendazole 200 mg 0.06 3,364 202 3,484 209 3,598 216 3,716 223 3,836 230 Iron and folic acid Tablets 0.02 87,464 1,749 90,584 1,812 93,548 1,871 96,616 1,932 99,736 1,995 HIV test kits tests 1.35 3,364 4,541 3,484 4,703 3,598 4,857 3,716 5,017 3,836 5,179 Stationary Treatment cards (SFP) cards 1.10 3,364 3,700 3,484 3,832 3,598 3,958 3,716 4,088 3,836 4,220 SFP ration cards cards 0.20 3,364 673 3,484 697 3,598 720 3,716 743 3,836 767 Table 6.8: Action 7: MAM Supplies and Equipment for PLW Item Unit Unit Cost Year 1 Year 2 Year 3 Year 4 Year 5 Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Annual Requirement Annual Cost Supplementary food CSB+ MT 602.80 965 581,428 995 599,840 1,027 618,873 1,059 638,541 1,093 658,858 Vegetable oil MT 1,105.00 107 118,413 111 122,163 114 126,039 118 130,044 121 134,182 Total 699,841 722,003 744,912 768,586 793,040 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 56 Table 6.9: Action 9: Logistics Management Trainings Training Type Year 1 Year 2 Year 3 Year 4 Year 5 Logistics management training for service providers Accommodation (B&B) for trainers 27,840 27,840 27,840 27,840 27,840 Transport for trainees 7,622 8,303 8,303 8,303 8,303 Refreshments for trainees 39,420 44,880 44,880 44,880 44,880 Per diem for trainees 210,240 239,360 239,360 239,360 239,360 Hall hire for training 5,829 5,829 5,829 5,829 5,829 Training materials sets 7,293 8,303 8,303 8,303 8,303 Logistics management training for managers Accommodation (B&B) for trainers 27,840 27,840 27,840 27,840 27,840 Transport for trainees 6,695 6,695 6,695 6,695 6,695 Refreshments for trainees 17,400 17,400 17,400 17,400 17,400 Per diem for trainees 92,800 92,800 92,800 92,800 92,800 Hall hire for training 5,829 5,829 5,829 5,829 5,829 Training materials sets 3,219 3,219 3,219 3,219 3,219 Table 6.10: Action 10: Therapeutic and Supplementary Food Storage Year 1 Year 2 Year 3 Year 4 Year 5 Storage of therapeutic foods RUTF 9,682 9,891 10,149 10,394 10,642 F-75 437 446 457 467 477 F-100 131 134 137 140 143 Storage of supplementary foods CSB++ 35,053 35,880 36,742 37,641 38,574 CSB+ 9,154 9,443 9,743 10,053 10,373 Vegetable oil 1,017 1,049 1,082 1,117 1,152 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 57 Table 6.11: Action 11: Transport of Supplementary and Therapeutic Foods Year 1 Year 2 Year 3 Year 4 Year 5 Transport of therapeutic foods RUTF, F-75, F-100 194,473 210,193 210,193 210,193 210,193 Transport of supplementary foods CSB++ 931,803 954,049 977,100 1,000,960 1,025,592 CSB+ 42,459 43,804 45,194 46,630 48,114 Vegetable oil 32,890 33,931 35,008 36,121 37,270 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 58 Annex 7: Detailed Budgets: Competence of Human Resources Involved in CMAM Table 6.12: Action 1: Practitioner Committee Meetings Year 1 Year 2 Year 3 Year 4 Year 5 Venue 134 134 134 134 134 Lunch/refreshments 1400 1400 1400 1400 1400 Stationary 400 400 400 400 400 Table 6.13: Action 2: Assessment of Pre-Service Training Curricula for Nurses and Clinicians Year 1 Year 2 Year 3 Year 4 Year 5 Venue 134 134 134 134 134 Lunch/refreshments 1400 1400 1400 1400 1400 Stationary 400 400 400 400 400 Table 6.14: Actions 2–3: CMAM Technical Update Workshops Year 1 Year 2 Year 3 Year 4 Year 5 International consultant 9,000 -- -- -- 9,000 National consultant 5,000 -- -- -- 5,000 Meeting to validate data collection tools Accommodation 2,800 -- -- -- 2,800 Venue 335 -- -- -- 335 Lunch/refreshments 700 -- -- -- 700 Stationary 200 -- -- -- 200 Printing 600 -- -- -- 600 Data collection Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 59 Accommodation 3,920 -- -- -- 3,920 Per diem 2,310 -- -- -- 2,310 Meeting to validate results Accommodation 2,800 -- -- -- 2,800 Venue 335 -- -- -- 335 Lunch/refreshments 700 -- -- -- 700 Stationary 200 -- -- -- 200 Printing 600 -- -- -- 600 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 60 Table 6.15: Action 4: CMAM Training for Tutors Training Type Year 1 Year 2 Year 3 Year 4 Year 5 NRU training for tutors Accommodation (B&B) for trainers 2640 2640 2640 2640 2640 Transport for trainees 2395 2395 2395 2395 2395 Refreshments for trainees 7000 7000 7000 7000 7000 Per diem for trainees 30800 30800 30800 30800 30800 Hall hire for training 670 670 670 670 670 Training materials sets 389 389 389 389 389 CMAM TOT for tutors Accommodation (B&B) for trainers 1440 1440 1440 1440 1440 Transport for trainees 2395 2395 2395 2395 2395 Refreshments for trainees 3500 3500 3500 3500 3500 Per diem for trainees 16800 16800 16800 16800 16800 Hall hire for training 335 335 335 335 335 Training materials sets 389 389 389 389 389 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 61 Table 6.16: Actions 5-6: CMAM Training for Service Providers and Managers Training Type Year 1 Year 2 Year 3 Year 4 Year 5 OTP/SFP training Accommodation (B&B) for trainers 30,720 28,320 24,880 24,880 24,880 Transport for trainees 48,227 47,054 43,694 43,694 43,694 Refreshments for trainees 141,760 131,420 115,020 115,020 115,020 Per diem for trainees 567,040 525,680 460,080 460,080 460,080 Hall hire for training 23,785 21,775 18,894 18,894 18,894 Training materials sets 23,488 22,833 21,279 21,279 21,279 NRU training Accommodation (B&B) for trainers 27,920 47,440 20,560 20,560 20,560 Transport for trainees 5,271 13,164 7,357 7,357 7,357 Refreshments for trainees 76,000 164,800 65,400 65,400 65,400 Per diem for trainees 304,000 659,200 261,600 261,600 261,600 Hall hire for training 21,440 37,788 15,276 15,276 15,276 Training materials sets 42,180 91,464 36,297 36,297 36,297 CMAM training for district managers and trainers Accommodation (B&B) for trainers 3,200 3,200 3,200 3,200 3,200 Transport for trainers 1,414 1,414 1,414 1,414 1,414 Transport for trainees 6,472 6,472 6,472 6,472 6,472 Per diem for trainees 47,023 47,023 47,023 47,023 47,023 Refreshments for trainees 23,500 23,500 23,500 23,500 23,500 Training materials 4,277 4,277 4,277 4,277 4,277 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 62 Table 6.17: Action 8: Mentoring and Supportive Supervision Guideline and Tools Development Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 5600 -- -- -- Venue 134 -- -- -- Lunch/refreshments 1400 -- -- -- Stationary 200 -- -- -- Printing 700 -- -- -- Table 6.18: Action 9: Mentoring and Supportive Supervision Training Type Year 1 Year 2 Year 3 Year 4 Year 5 Mentoring of outpatient care and/or inpatient care (by district HQ) Supervisor lunch allowance 30,271 34,516 30,702 30,702 30,702 Transport for supervisor 88,683 93,928 85,279 85,279 85,279 Materials for supervision 10,181 11,645 10,771 10,771 10,771 Supportive supervision of community outreach workers (COW) (by outpatient care site) Supervisor lunch allowance 779,433 4,766,177 2,679,625 2,679,625 2,679,625 Transport for supervisor 1,201,902 7,350,706 3,980,730 3,980,730 3,980,730 Materials for supervision 424,008 2,592,226 1,403,798 1,403,798 1,403,798 Supportive supervision of district HQ staff (by health zone HQ) Supervisor lunch allowance 681 681 681 681 681 Supervisor accommodation 6,640 6,640 6,640 6,640 6,640 Transport for supervisor 5,342 5,342 5,342 5,342 5,342 Materials for supervision 139 139 139 139 139 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 63 Annex 8: Detailed Budgets: Coverage Table 6.19: Actions 2–5: Community Outreach Training and Harmonization Year 1 Year 2 Year 3 Year 4 Year 5 Community outreach training Transport for COWs 100,159 662,811 662,813 662,813 662,813 Training materials 135,447 896,094 895,933 895,933 895,933 Table 6.20: Action 6: Establishment of Community Outreach Year 1 Year 2 Year 3 Year 4 Year 5 Transport 80,190 449,757 20,867 20,867 20,867 Lunch allowance for mid-level district manager 112 96 - - Table 6.21: Action 8: Supervision and Mentorship for Community-Based Volunteers Year 1 Year 2 Year 3 Year 4 Year 5 Transport (outpatient care to community outreach site) 238,090 1,586,078 1,586,078 1,586,078 1,586,078 Supervision of COWs 11,266,334 14,709,109 8,064,154 8,064,154 8,064,154 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 64 Annex 9: Detailed Budgets: Enabling Environment Table 6.22: Action 1: Update of National CMAM Guidelines Year 1 Year 2 Year 3 Year 4 Year 5 Consultants International consultant 6300 -- -- 6300 National consultant 3500 -- -- 3500 Technical working group meetings Venue 201 -- -- 201 Lunch/refreshments 900 -- -- 900 Stationary 200 -- -- 200 Stakeholder consultation meeting Accommodation 5600 -- -- 5600 Venue 134 -- -- 134 Lunch/refreshments 1400 -- -- 1400 Stationary 200 -- -- 200 CMAM guideline 791 -- -- 791 Stakeholder consensus meeting Accommodation 5600 -- -- 5600 Venue 134 -- -- 134 Lunch/refreshments 1400 -- -- 1400 Stationary 200 -- -- 200 CMAM guideline 791 -- -- 791 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 65 Table 6.23: Actions 2–4: Quarterly TNP Meetings Year 1 Year 2 Year 3 Year 4 Year 5 Venue 268 268 268 268 268 Lunch/refreshments 2800 2800 2800 2800 2800 Stationary 800 800 800 800 800 Table 6.24: Action 5: Quarterly CMAM Policy and Technical Briefs Year 1 Year 2 Year 3 Year 4 Year 5 Printing of briefs 20,000 20,000 20,000 20,000 20,000 LOE for designer 2,000 2,000 2,000 2,000 2,000 Table 6.25: Actions 6–8: Advocacy Campaigns Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 19,200 19,200 19,200 19,200 19,200 Venue 134 134 134 134 134 Lunch/refreshments 2400 2400 2400 2400 2400 Stationary 400 400 400 400 400 Printing 480 480 480 480 480 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 66 Annex 10: Detailed Budgets: Monitoring and Evaluation Table 6.26: Action 1: Identification of Operational Research Needs Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 5,600 -- -- -- Venue 134 -- -- -- Lunch/refreshments 1,400 -- -- -- Stationary 200 -- -- -- Printing 700 -- -- -- Table 6.27: Action 2: Annual CMAM Dissemination Conference Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 16,000 16,000 16,000 16,000 16,000 Venue 134 134 134 134 134 Lunch/refreshments 4,000 4,000 4,000 4,000 4,000 Stationary 200 200 200 200 200 Printing 2,000 2,000 2,000 2,000 2,000 Table 6.28: Action 3: Annual National Review of Operational Plan Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 20,000 20,000 20,000 20,000 20,000 Venue 335 335 335 335 335 Lunch/refreshments 5,000 5,000 5,000 5,000 5,000 Stationary 200 200 200 200 200 Printing 1,000 1,000 1,000 1,000 1,000 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 67 Table 6.29: Action 4: Midterm and Endline Evaluation of Operational Plan Year 1 Year 2 Year 3 Year 4 Year 5 Midterm evaluation Accommodation -- -- 20,000 -- Venue -- -- 335 -- Lunch/refreshments -- -- 5,000 -- Stationary -- -- 200 -- Printing -- -- 600 -- International consultant -- -- 9,000 -- National consultant -- -- 5,000 -- Endline evaluation Accommodation -- -- -- -- 20,000 Venue -- -- -- -- 335 Lunch/refreshments -- -- -- -- 5,000 Stationary -- -- -- -- 200 Printing -- -- -- -- 600 International consultant -- -- -- -- 9,000 National consultant -- -- -- -- 5,000 Table 6.30: Action 5: Quarterly District Data Review Meetings Year 1 Year 2 Year 3 Year 4 Year 5 Accommodation 337,600 337,600 337,600 337,600 337,600 Venue 7,772 7,772 7,772 7,772 7,772 Lunch/refreshments 84,400 84,400 84,400 84,400 84,400 Stationary 23,200 23,200 23,200 23,200 23,200 Printing 324,800 324,800 324,800 324,800 324,800 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 68 Table 6.31: Action 7: CMAM Training of Managers and Information Officers Year 1 Year 2 Year 3 Year 4 Year 5 Transport for trainees 1,833 1,833 1,833 1,833 1,833 Refreshments for trainees 2,100 2,100 2,100 2,100 2,100 Per diem for trainees 11,200 11,200 11,200 11,200 11,200 Hall hire for training 201 201 201 201 201 Training materials sets 389 389 389 389 389 Malawi National Community-Based Management of Acute Malnutrition (CMAM) Operational Plan 2017–2021 69