Rahinatou Hachimou, Head of Koweit Health Facility presents the CMAM Surge charts during a supervision session, Tahoua. Photo: Apsatou Bagaya/Concern Worldwide
Rahinatou Hachimou, Head of Koweit Health Facility presents the CMAM Surge charts during a supervision session, Tahoua. Photo: Apsatou Bagaya/Concern Worldwide
CMAM Surge
Approach

Community-Based Management of Acute Malnutrition (CMAM) Surge

Helping health systems more effectively deliver services for children with acute malnutrition.

Overview

This page has been created as a point of reference on the CMAM Surge Approach, to support practitioners to adapt, set-up, and implement the Surge approach. It includes tools, orientation guides, evaluations and publications. Given the rapid scale up of the approach across increasingly diverse contexts, there is a need to ensure that technical integrity is maintained and that learning is captured and used to further strengthen and refine the approach. This repository of information aims to facilitate this community of learning, which is supported by taskforces/technical working groups at a global, regional and national level.  

What is the CMAM Surge Approach?

The CMAM Surge Approach was designed to help health systems more effectively deliver services for children with acute malnutrition. The approach is based on the observation that in many contexts the number of children seeking treatment for acute malnutrition tends to peak during certain months of the year. These seasonal ‘surges’ in demand are driven by many overlapping factors, including, for example, the pre-harvest hunger gap, increased incidence of malaria or diarrhoea during the rainy season, women’s workload patterns, and movements associated with grazing livestock. It is during these caseload surges that the potential to save lives is greatest, yet government health systems and the wider humanitarian sector are often not able to provide timely, effective response.

The CMAM Surge approach complements routine CMAM services by improving health staffs’ use of facility data and knowledge of the local context to better anticipate, plan for, respond to, and bounce back from these increases in demand for acute malnutrition treatment services. 

The 8 Steps of CMAM Surge

The CMAM Surge approach uses eight steps to help government health teams respond to relative changes in capacity and caseloads. The eight steps are summarised below.

The CMAM Surge Approach
The CMAM Surge Approach
  1. 1

    1Trends and Situation Analysis

    Historical morbidity data from the Health Facility (HF) is gathered and plotted on a wall chart, alongside a seasonal and events calendar. This information is contrasted with malnutrition trends, with the objective of identifying potential risk factors for malnutrition in that community.

  2. 2

    2Capacity Review

    The capacity of the HF to manage CMAM services during normal times is assessed and gaps are identified. The HF also reflects on its past experience of managing peaks in demand for CMAM services.  

  3. 3

    3Threshold Setting

    Specific thresholds are set at each HF, based on their capacity to maintain quality of care with increasing new Severe Acute Malnutrition (SAM) admissions. Generally, four phases (normal, alert, serious, emergency) are defined, based on the incremental level of support that would be required to protect the quality of service delivery. 

  4. 4

    4Defining and Costing Surge Actions

    Specific ‘Surge’ actions are defined for alert, serious, and emergency phases as part of the Surge package. In the ‘normal’ phase, prevention and preparedness actions are defined, in addition to actions to address the gaps identified during the capacity review. Actions which have a cost implication are budgeted.

  5. 5

    5Formalising Engagements

    Agreements are made between the HF and both government and non-government actors to identify who will provide support for the specific actions if a threshold is breached. 

  6. 6

    6Monitoring Trends

    Thresholds are monitored on an ongoing basis by HF staff using routine data to ensure action is taken as soon as a caseload increase is detected. On a monthly basis, other morbidities are tracked and the seasonal and events calendar is updated. If a risk factor is identified, preparedness or prevention actions may be triggered.

  7. 7

    7Scaling Up and Scaling Down

    When a threshold is crossed the HF moves from routine implementation into a higher phase of action (alert, serious, emergency) based on the severity of the shock, triggering the pre-agreed-upon actions and capacity support (‘scale up’). Once the situation stabilises the actions are ‘scaled down’.

  8. 8

    8Review

    Ongoing review is critical to the success of CMAM Surge. Capacity, thresholds and Surge actions are all reviewed on an ongoing basis, and adapted as needed. In addition, the HF completes ‘post-Surge’ evaluations to review the impact and efficiency of a Surge response.

The status of each health facility is also monitored by the higher-level health authority (e.g. district health management team) that can, in turn, monitor trends across a wider geographic area and call for higher-level regional or national response if the situation continues to deteriorate. The same 8 steps can be used to set up Surge at a district level.

Health Surge

The Health Surge approach aims to strengthen health facilities management capacity and contribute to reinforcing health systems. It applies the 8 CMAM Surge steps to other morbidities and was first piloted in Sierra Leone in 2017. The focus is largely on managing caseloads of child wasting, malaria, diarrhoea, and acute respiratory infection (ARI), as these tend to fluctuate most throughout and between years.

Health Surge supports the real-time monitoring by MoH staff of their health facility data of key illnesses and capacity changes so that the planning and allocation of resources to address caseload and capacity fluctuations can be flexible and occur before a health facility is overwhelmed.

Key learning documents on the Health Surge approach, outlining progress and countries of implementation, can be found in the Learning and Evaluations section below.

CMAM Surge Mapping

CMAM Surge is currently being implemented in 12 countries with technical assistance to governments provided by multiple NGO and UN partners. Concern has introduced and supported implementation of the CMAM Surge approach in more than six country programmes. The map below illustrates to the best of our knowledge where the CMAM Surge approach has been implemented. Please contact cmam.surge@concern.net if you have any updated information.

  1. Burundi

    In 2018 a CMAM Surge pilot was set up and supported by Concern Worldwide, but is not currently active.

  2. Burkina Faso

    CMAM Surge has been implemented since 2017, supported by Action Against Hunger (ACF) and Terre des Hommes (TDH).

  3. Cameroon

    In 2019 CMAM Surge was set up in one health facility with the support of the French Red Cross (CRF).

  4. Chad

    CMAM Surge has been implemented since 2018, supported by Concern Worldwide, French Red Cross (CRF) and Action Against Hunger (ACF).

  5. Kenya

    The first pilot of CMAM Surge was set up and supported by Concern Worldwide in 2012. Subsequently there has been expansion and support by Action Against Hunger (ACF), Christian Relief Services (CRS), Kenyan Red Cross, World Vision, Save the Children International (SCI), and International Rescue Committee (IRC). The IMAM Surge toolkit was later integrated into county strategic planning documents including the County Nutrition Action Plan (2019-2023) and the County Integrated Development Plan (2018-2022).

  6. Mali

    CMAM Surge has been implemented since 2017. Since then, there has been expansion and support by Action Against Hunger (ACF), Alima, ACTED, COOPI, International Rescue Committee (IRC) and Terre des Hommes (TdH). There is a national CMAM Surge Taskforce led by the Ministry of Health with the technical support of Save the Children International (SCI) to support coordination. In 2019, CMAM Surge guidelines adapted to the Malian context were published.

  7. Ethiopia

    CMAM Surge has been implemented since 2017, supported by Concern Worldwide and GOAL.

  8. Mauritania

    CMAM Surge has been implemented since 2018, supported by the French Red Cross (CRF) and Action Against Hunger (ACF).

  9. Niger

    CMAM Surge has been implemented since 2016, supported by Concern Worldwide. Since then, there has been expansion and support by Action Against Hunger (ACF), ALIMA, COOPI, GOAL, HELP, International Rescue Committee (IRC) and Save the Children International (SCI). In 2019 a national CMAM Surge Taskforce was established by the Ministry of Health with the technical support of Concern. In 2021, a national strategy for the scale up of CMAM Surge was validated.

  10. Nigeria

    In 2022, CMAM Surge pilot was set up and supported by the International Rescue Committee (IRC).

  11. Pakistan

    In 2018, CMAM Surge was set up with the support of Concern Worldwide and the World Food Programme (WFP).

  12. Senegal

    In 2018, CMAM Surge was set up and supported by Action Against Hunger (ACF), but is not currently active.

  13. Somalia

    In 2021, a CMAM Surge pilot was set up by Concern Worldwide, in collaboration with Action Against Hunger (ACF).

  14. South Sudan

    In 2021, an adapted CMAM Surge pilot was set up by Concern Worldwide in one health facility.

  15. Uganda

    In 2016 CMAM Surge was set up and supported by Concern Worldwide, and subsequently is supported by UNICEF.

  16. Sudan

    In 2022, a CMAM Surge pilot was set up with the support of Concern Worldwide.

Implementation guides and tools

Concern developed CMAM Surge Global Guidance documents in 2016 to support the implementation of CMAM Surge. The core knowledge documents are available for download below.

It is strongly recommended that the tools are adapted to the local context, and align with pre-existing health and nutrition guidance. It is planned that these global guidance documents will be updated in 2022. Please refer to the learning documents for additional considerations and lessons learned in setting up CMAM Surge.  

Enhanced Responses to Nutrition Emergencies (ERNE)

The Enhanced Responses to Nutrition Emergencies (ERNE) programme, funded by ECHO and implemented through the novel Pilot Programmatic Partnership (PPP) is supporting coordination and learning on the CMAM Surge Approach.

Learning and evaluations

Since the first CMAM Surge pilot in Kenya in 2012, a wealth of experience and learning across a variety of contexts has been generated. Concern has supported several learning reviews and evaluations of the CMAM Surge approach in order to inform adaptations of the approach as well as investment in scale-up. Some key resources are available for download below. 

Roufai Mohamed, CMAM Surge Officer, Concern Worldwide delivers a coaching session on CMAM Surge in Koweit Health Facility, Tahoua. Photo: Apsatou Bagaya/Concern Worldwide
Roufai Mohamed, CMAM Surge Officer, Concern Worldwide delivers a coaching session on CMAM Surge in Koweit Health Facility, Tahoua. Photo: Apsatou Bagaya/Concern Worldwide

External resources

CMAM Surge Field Exchange Series 2021

In 2021, a series of articles were published on CMAM Surge in the Emergency Nutrition Network’s (ENN) Field Exchange journal. This seven article series summarises the key lessons learnt over the past eight years and the way forward for the Surge approach. The full articles can be found on ENNs website:

  1. CMAM Surge – Setting the Scene
  2. Implementing IMAM (CMAM) Surge approach – experience from Kenya
  3. The role of coordination in CMAM Surge scale-up in West and Central Francophone Africa 
  4. CMAM Surge – understanding costs and potential contribution to CMAM’s cost-effectiveness
  5. Expanding CMAM Surge beyond nutrition – towards a broader Health Surge approach
  6. CMAM Surge: lessons on the journey so far

In addition, Concern has provided technical support and collaborated with a number of key stakeholders in the production of other learning resources:

Coordination Mechanisms

Concern chairs the Global CMAM Surge Technical Working Group (Global TWG). The purpose of the Global CMAM Surge Technical Working Group is to ensure coordination of CMAM Surge activities to maximise quality, effectiveness, and learning. The membership includes a diverse group of CMAM / Health Surge stakeholders including Ministry of Health representatives, donors, and NGOs. The Global TWG was established in October 2020, and will remain operational until September 2022. 

Concern is co-lead of the West Africa Region CMAM Surge Taskforce with the French Red Cross (CRF). The role of coordination in the CMAM Surge scale-up in West and Central Francophone Africa is described in an article for Field Exchange. Since 2021, rather than routine coordination meetings, learning webinars have been organised. A summary of the 2021 webinars is available below.

National level CMAM Surge Taskforces have also been established in Mali and Niger. Led by Save the Children and Concern Worldwide respectively, in collaboration with Ministries of Health. 

Contact us

If you have any question related to CMAM Surge, please contact: cmamsurge@concern.net 

This publication covers aid activities implemented with the financial assistance of several donors, including the European Civil Protection and Humanitarian Aid Operations Department (ECHO), USAID, Irish Aid and others. The ideas, opinions and comments herein are entirely the responsibility of the author(s) and do not necessarily represent or reflect the policies of any donors.