Acute malnutrition (AM) is among the major health challenges in Ethiopia. As part of the solution, the government of Ethiopia (GOE) through the Federal Ministry of Health (FMOH) piloted the community management of acute malnutrition (CMAM) in 2000, adopted it in 2003, and decided to scale it up countrywide in 2008. Currently, over 14,000 facilities are providing CMAM services, and over 300,000 SAM children are treated yearly. This rapid expansion has been made possible by task-shifting the management of uncomplicated cases of severe acute malnutrition (SAM) and cases of moderate acute malnutrition (MAM) at health post (HP) levels where the mid-upper arm circumference (MUAC) only programming approach is preferably used. Ethiopia still uses the MUAC definitions adopted at the onset of CMAM and at present defines SAM and MAM in the National guidelines as MUAC <11cm and ≥ 11 cm and <12 cm respectively. On the other hand, the GOE has been hesitant in making the decision to shift to the new global MUAC-based definition given the 2—4 times potential increase in caseload reported by several cross-sectional surveys. This study was conducted with the general objective of providing practical evidence on the program and cost/cost-effectiveness implications for Ethiopia of aligning with the new global WHO and UNICEF cutoff points for identification of acute malnutrition (AM) and graduation from a CMAM program.
The study was conducted in two regions of Ethiopia -Oromia, and Amhara- with each region providing two woredas for the study. The surveyed woredas were Legambo and Mekdella in the Amhara region and Fedis and Meta in the Oromia region. A total of 36 randomly selected HPs were used (8 non-contingent HPs in each Oromia woreda and 10 non-contingent HPs in each Amhara woreda). For the inpatient component of the study, the 17 stabilization centers (SCs) serving these HPs were included. This study used mixed methods including both quantitative and qualitative approaches. The quantitative component employed a cluster randomized control and parallel study design that used HPs or individuals as the unit of randomization depending on the particular specific outcomes. The qualitative component used focus group discussions and key informant interviews to gather information on the perceptions of the targeted CMAM stakeholders on CMAM and the proposed change in cut-offs. The 36 HPs were randomly allocated to either the control or intervention arm. The control arm HPs used the current national guidelines for the management of SAM and MAM while those in the intervention arm used the new global WHO/UNICEF guidelines. Both arms used a more flexible criterion for exiting a child as a non-respondent. The study had an impact assessment sub-component and a cost-effectiveness sub-component.
The results of the study indicated that: 

1), The increase in caseload and workload resulting from shifting from the current national SAM and MAM admission and discharge criteria to the new global WHO/UNICEF criteria are likely to be on a smaller scale than is usually claimed and will be transient. The increase is unlikely to overwhelm the capacity of the Ethiopian government and its partners in the long term.

2), At the predicted increment of caseload, with the existing staffing norms at HPs, HEWs may need to dedicate during the maturation year up to 5% of their annual working time to OTP and SFP services. Staffing norms will need revision if the dedication of that amount of time causes any negative impact on other HEWs activities.

3), It would be wise to capitalize on the willingness of those caregivers who keep their children in care until they are discharged as non-respondent to improve program performance. This can be achieved by adopting the treatment-to-goal approach and by allowing a longer stay in the program than is currently the case. The maximum duration before declaring a child non-respondent should be increased to at least 12 weeks.

4), It is encouraging that the HEWs and their kebele and woreda level supervisors, the community leaders, and the beneficiaries of the CMAM program perceived it as a relevant and effective intervention and viewed the shift as a positive move to improve the survival of children in their communities by allowing access to treatment to those in most need and enabling early access to treatment.

5), The budget increment that is likely to be transient should be balanced against the improved cost efficiency and the nutrition and health benefits when making a decision on the need to change the current policy or not. As pointed out by some stakeholders interviewed, availability of supplies, especially RUTF, is the most significant challenge we can envisage but based on our findings we believe this challenge can be overcome.

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Asfaw Yosef Beyene, BAHWERE PALUKU(2017), program and cost implications of WHO 2006 recommended MUAC cut-off points for Acute Malnutrition management in selected woredas of Amhara and Oromia Region, Ethiopia. Pan African Clinical Trials Registry: URL: https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=2454

The study was conducted in two regions of Ethiopia -Oromia, and Amhara- with each region providing two woredas for the study. The surveyed woredas were Legambo and Mekdella in the Amhara region and Fedis and Meta in the Oromia region. A total of 36 randomly selected HPs were used (8 non-contingent HPs in each Oromia woreda and 10 non-contingent HPs in each Amhara woreda). For the inpatient component of the study, the 17 stabilization centers (SCs) serving these HPs were included. This study used mixed methods including both quantitative and qualitative approaches. The quantitative component employed a cluster randomized control and parallel study design that used HPs or individuals as the unit of randomization depending on the particular specific outcomes. The qualitative component used focus group discussions and key informant interviews to gather information on the perceptions of the targeted CMAM stakeholders on CMAM and the proposed change in cut-offs. The 36 HPs were randomly allocated to either the control or intervention arm. The control arm HPs used the current national guidelines for the management of SAM and MAM while those in the intervention arm used the new global WHO/UNICEF guidelines. Both arms used a more flexible criterion for exiting a child as a non-respondent. The study had an impact assessment sub-component and a cost-effectiveness sub-component.

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