Below is an initial response from Peter Hailey: We have been trying to use a capacity based assessment to guide external resource inputs in Ethiopia. Karamoja, Kenya, Madgascar and a long time ago in Malawi. From a technical point of view there are difficulties and still a lot more work to be done to demonstrate how it might work. However, one of the major bottlenecks is from a conceptual point of view. On the one hand from the resource controlling and priority setting decision makers including in the NGOs and UN and on the other side from the technical "emergency" nutritionists. The decision makers tend to be linear in their view of emergency and development, or to say it in another way, in their view of life saving and capacity building objectives. Since the advent of very large scale CMAM programmes the technicians are torn between priorities that are defined in approaches like SPHERE and on the other hand by the inability to run a programme with this perspective at the scale of the Ethiopian CMAM programme with 7,000 OTPs. To add to all this confusion are the prevalence thresholds. The prevalence thresholds are a simple tool that has been distorted to such an extent that we no longer even recognise or adequately articulate what they can tell us and what they can't. You know that in most emergencies that single figure often decides the fate of several 100's of millions of USD. We are hoping that the paper can open up the debate on the conceptual approach to allow more space to work on the technical approach. To your question 3, challenging the CMAM model, in terms of its complexity: Yes for very large scale CMAM programmes predominantly run by Governments or local authorities, with some outside support, the CMAM model in the guidelines is too complicated. De facto OTPs in countries like Ethiopia are implementing a much simplified guideline. It is the ultimate step in the progression from ACF's guideline that you should have one nurse for every 10 children in a TFC, through CMAM refocusing us on communities and coverage. Can the CMAM programme be robust enough i.e. still save lives and reduce damage from SAM at the scale of a country and with very few technical inputs. It is only these approaches that make it into the lists of essential interventions in papers like those in the Lancet. The focus of programming for those interventions that do make it on the list are health system issues not often technical guideline issues. Assuming that as nutritionists committed to finding the best way to deal with SAM we imagine an intervention that is robust enough to operate at this scale. We have, i.e. very low tech centres, many children with SAM and a high risk of mortality and a product that can manage that condition. We also have a small window of opportunity whereby countries, donors etc are willing to scale up on a very large scale. I believe that the programme is robust but with some very simple improvements we can improve on number of lives saved for the resources we are investing. Most of the areas for improvement are not technical in the perspective of guidelines. They are things like improved outreach and community based work, improving work on barriers to access, and improved supply chain management. Don't forget that the revolution of CMAM was not the RUTF but the ability to focus on coverage or a "public health approach". In the end we save more lives by reaching more children even if the quality is not as good as we would want it to be. We are better to spend a higher proportion of our resources on ensuring that capacity in these simple areas is improved. I am not advocating for dropping quality work, if only because it has an effect on utilization of services. In 2005 in Ethiopia the combined CMAM programme was reaching in the low tens of thousands of children, in 2009 the programme reached over 200,000. The quality (SPHERE quality indicators) in terms of defaulters and distribution to non SAM cases has worsened but probably not the mortality rate in the centres. The technical resources (I mean HR in NGOs and UN) and their costs did not increase; the main resource increase has been the RUTF bill. Unfortunately we do not have the data on how many more lives we have saved and how much more efficient we have been but it is impossible that we have not improved. If we had this data we would be able to argue with donors that quality and prevalence is important but simple coverage is better. As a nutritionist and an NGO coming out of emergencies we tend to concentrate on quality and a temporary approach but CMAM is becoming a programme that should be in place all the time and adapted during an emergency. Essentially an emergency causes an increase in the numbers of SAM children. The phasing up approach based on capacity allows us to describe what it is we would do to change the routine programme to deal with this increase in children until the numbers go down again.

First of all i would like to apperciate for Peter Hailey and Daniel Tewoldeberha for their hard work in intiating the dialogue/debate. My point is regarding the definng of capacity building and caseload. My question is related to the Ethiopia context as your article is mainly based on Ethiopia situation. Now days, the OTP/CMAM implementation is decentralized to the health post level with catchment population roughly about 5000. it is known that the number of MoH staff per health post is maximum two health extension workers. It is known that there is one nutrition officer or nutrition contact person per district. whether or not there is emergency, this structure (two health extension workers) plus contact person at Woreda level is always there. given this situation, what capacity assessment are you looking for? With regard to definition of caseload, as it more decentralized to HP level, how is going to decide the treshold? for example, in one of the Woreda in North Ethiopia has more than 45 HP and if there is lets say 25 cases per HP there will be 1000 cases. there, are you referring caseload by woreda or by HP?

First of all i would like to apperciate for Peter Hailey and Daniel Tewoldeberha for your hard work in intiating the dialogue/debate. The point i want to raise is regarding assessing and definng of the existing capacity of health system and deciding the treshold for action. My question is related to the Ethiopia context as your article is mainly based on the Ethiopia situation. Now days, the OTP/CMAM implementation is decentralized to the health post level with catchment population of roughly about 5000. It is well known the number of Staff per health post is maximum two health extension workers. this is the governemt policy. Given this situation, what capacity assessment are you looking for? this is already known. The other point is regard the definition of caseload or treshold of action. The service is decentralized to HP level. even if the prevalence of SAM is about ten percent you can't get the treshold for action/caseload as the population of the catchment for HP is low. so, How is going to decide the treshold? Thanks

I must admit to being a little confused by the original question. I don't think that CMAM is either expensive or complicated. CMAM programs have been shown to deliver at well below US$50 per DALY averted in programs with considerable management overheads. This is very cheap (e.g. less than half the cost of DOTS for TB) and means that integration should be possible just about anywhere in the world (WB / UNICEF / WHO / &c. have US$100 - US$150 per DALY averted as the upper limit of cost for inclusion in a basic national health package in the poorest countries). CMAM is also a simple intervention. SC-US (e.g.) has a 90% coverage program with excellent recovery rates delivered by community-health workers (this came in at about US$26 per DALY averted) with management provided by local MoH and a local NGO. Getting CTC / CMAM to work well does require skill, effort, and patience. We are usually working in dysfunctional systems that need considerable support.

This is very interesting topic and I do agree with most reactions but I might say I am confused and would like some guidance in how to effectively reach those "thin children" in need of peanut butter as said above when you work in an environment where your partner does not see beyond delivery of supplies. We know very well that the delivery of the minimum health package in not always adequate in all settings. I think it is challenging and difficult to judge when quality of services should come first in our programming when you know the limitation of most ministries of health in developing countries where we are all working. I admit all but again I believe we need to continue working on advocating these governments, make sure they are involved in everything we do .... My question (not really a question but a concern) to the recent post from Mark Myatt, if possible how patient can we be when we know that the setting we are working in there is no appropriate skill (or no decentralization) and less effort (most time no effort at all) is being made by the direct partner?

On the CMAM framework with the issues of health systems as in South Sudan, mentioned above, I am certain that it can be implemented very well despite challenges here and there. The word community based explains better for CMAM. The only challenges faced is the resource control otherwise, it has been implemented by other organizations for example Concern worldwide, and Tearfund in Northern Bahel El Ghazal previously. around 2002- 2004 with capacity from Valid international the founder for this strategy in managing the malnutrition. And on the side of resources, it can also be done. Since i is community based, involve the community leaders in their specific community areas and you will see how these leadership cadre wonderfully do it. Involve the head head of the county and states at different levels during every level of programming for a wide range of accountability responsibilities, do not forget to involve the beneficiaries on engagement participation and feedback mechanism for accountability of everything in the programme. Most times we think of policy makers and higher officials in systems to do better. Their engagement level differs very much in every context. The health system in Sudan is great on the side of community health workers doing variety of tasks and this places the CMAM even to be better. I have been in South SUdan and the communities are very much responsive on interventions plus their community leaders. Given the many responsibilities and urgent issues the health system is struggling to address, their backup and authority for a go a head is enough and you deal with the community, payams, with scheduled joint events.activities with counties and state. Capacity building for the county health need to be among the priorities on health system strengthening. Providing resources when they are not able to use them is not a great work for development. It is like providing a computer and an office to a staff who do not know how to use the computer and mange an office. Capacity building is not the sending of the staff to training alone, but use of equipments, managing an office, managing resources, training on the national and international standards. Not forgetting, training on health issues and like CMAM, what it is and the support needed from the health system and their involvement. I feel most people approach the health system when there is need for recruitment for CMAM and when challenges are faced. I have the community engagement experience from various NGOs if I may mention them, International Rescue Committee, Save The Children and Merlin. With this, CMAM will work very well in weak health system. Weak systems I feel it is due to many reasons but change in frameworks components can lead to the beneficiaries continuing to get the services. My experience is that: Challenges are always there, even in places with stronger health systems like in Kenya, there are challenges in implementing the CMAM in some locations. May be at times people have to conceal some challenges by addressing it underground to avoid shame to a strong system. I came to understand the word 'strong' in any part of the world is not only the higher general system at the national level alone. The system on the ground matters a lot- those supporting the interventions on ground at the beneficiary level. talk of the. state, county, payam, community/village and the community themselves. This is why some states, counties, payams, communities can do better than others but all in all under one national health system. On the side of human resources for health/nutrition- you will find the framework specifying who to perform what task but based on different counties, this may change with starting from very low level and intensive capacity building on job and workshops. The followed with long term sponsorship for others after higher education to increase he number of higher calibre. I find CMAM the best intervention for community, the only challenge faced always is the accountability of food items at some few places.