Thank you for your question. Very pertinent indeed. You are absolutely right: many of the organisations that have been carrying out coverage assessments over the past few years, and who make their results available to the public, are showing coverage results <50%. I think it’s safe to assume that this is the case for many other programmes without such information. You also mention that this is lower than earlier programmes. Many early CTC programmes delivered coverage >70%. This happened consistently enough for us to know that such performance is possible. But what recent results have shown is that such levels of coverage do not come naturally, or are not intrinsic, to CMAM programmes. Rather, coverage above 50 or 70% is possible only when programmes prioritise specific actions. The assertion that barriers such as RUTF stock-outs have been removed is problematic. Whilst it is true that RUTF is more widely available than ever before – at a global and even country level – the real question is the availability of RUTF at the level of the service delivery unit (e.g. health centre). What we are seeing more and more with the scaling up of CMAM programme is irregular availability of RUTF in many health facilities, which leads to an erosion of trust and defaulting amongst beneficiaries. This is partly responsible for the low levels of coverage being reported by many CMAM programmes, but it is not the only one. Most of the available research on non-attendance suggests that awareness continues to be the single most important reason why cases that should be enrolled in a nutrition programme are not. This covers both awareness about the service (where it is, what it does, who its for, etc.) as well as the way in which people link the condition that they see in their children with the services that they hear about. This is commonly seen as a population-level problem (i.e. a problem of community awareness) but it is perhaps best seen as a service delivery problem. And that is the point: one of the main reasons why CMAM programmes are failing to perform like they did before is because the first “C” (Community) is dealt with last. Community sensitisation, when it happens, is mostly a one off, top-down affair. Real, consistent and meaningful community engagement (that understands community perceptions first, and then works on influencing awareness) remains limited. To be fair, there are some positive examples out there of CMAM programmes doing robust community work, and more often than not this manifests in higher programme coverage. These are not the only issues: distance continues to be an issue in many areas, as is insecurity and the way in which “rejected” cases are handled at facilities. But what coverage assessments such as SQUEAC have done is helped programmes understand what is happening around them. Their most important contribution is not what it says about coverage estimations, but rather, its ability to tell programmes why it is what it is. There are a number of emerging lessons out there, and what we need is exactly what you called for: for field practitioners to share their experiences, for good (and poor) performing programmes to share their lessons, and for the sector to start reviewing the programming and policy implications of these lessons on the way we run these programmes.

Thank you to Saul for his comprehensive reply. I totally agree with him. RUTF is only one (even if a big one) barrier to coverage and indeed, as he pointed out, there is often enough RUTF in the country but the situation in the field is sometime very different and related to challenges with logistics/distribution of supplies and it doesn't take very long for mothers to get discouraged and refuse to attend the programme, this is even more evident when other barriers like distance, long waiting time to be served, quality of the service, etc. are involved (this without mentioning that during this period the SAM child will not receive his treatment). I cannot agree more when Saul mentions that the "C " is now more a very little "c", which means that the component that can ensure high coverage becomes a secondary component of the service. Majority of barriers found in coverage survey are related to a failure in addressing the community component, including, as mentioned, knowledge of the service, management of rejections, involvement of all key community stakeholders, etc. It is sensible to expect that coverage may be lower, at the beginning, with the integration of the service within MoH run clinics and this considering the limited capacity (in terms of resources) for the MoH to develop the community component; however this is an aspect where NGOs/local organizations can be very helpful and support the MoH; maybe NGOs/local organisations closely working with MoH should reconsider their role, which is still largely related to the clinical part, and provide support to the community component which will actually ensure a better coverage. Just few thoughts.

I agree with everything written above. I would also like to point out that the early CTC programs were "activist" efforts. We had a lot to prove about the safety and efficacy of the CTC protocol and to show that CTC could deliver an order of magnitude increase in coverage (and effectiveness) over the TFC model that was prevalent at the time. This meant that we did everything we could to achieve program coverage. This led us to recruit a large number of community-based volunteers for case-finding and referral, a de-facto abandoning of the use of weight-for-height, concentration on activities to inform the population about the program, who it was for, what it was for, where it was delivered, harmonising modern and folk aetiologies, use local terms, and so-on. This all comes under the term "community mobilisation". We made efforts to do this well and to make the programs fit the local contexts as much as we could. The current CMAM efforts tend to have a "if we build it they will come attitude" or mistake the enabling technology (RUTF) for the intervention that it made possible (there may be something of this in the original question). I often see weak community mobilisation, use of health extension services rather than community-based volunteers, a reluctance to engage with (e.g.) traditional healers / traditional birth attendants / local opinion formers, confusing and over-elaborate admission criteria (the W/H mess), and attempts to "integrate" with poorly executed programs such as SFP. I have seen some good recent CMAM programs. These have usually been supported by "development" NGOs with experience of community-based / participatory methods. I have been surprised by the NGOs that "get it" and those that really don't "get it". Some reputable INGOs have failed to get it. Some of these have realised that they do not "get it" and have started learning exercises (some based around the SQUEAC method). Others are in denial and continue to deliver weak programming or stick with vertical programs that achieve modest coverage (i.e. c. 20%) at delivering the CTC protocol simply because it fits with the general structure of their programming or their volunteer model. Some statutory sector programming is little more than RUTF in a handful of centres. We know that, done right, the CTC / CMAM model can deliver high coverage (SC-US achieved almost 90% coverage in one program but 70% - 80% was routinely achieved by CTC) and high cure-rates. If we are not seeing this it is because we are doing it wrong. The odd thing is that we do know how to do it right and we have proof of what is needed. The problem appears to be in convincing people that they have to emphasis the "C for community" over the "C for clinical". That has proved hard to do. Even when we have convinced donors and partners the emphasis has tended to be on parallel extension services implemented by a NGO rather than bringing the community and the program together. In dark moments I sometimes think (and say) that CMAM is an intervention that has failed to live up to its early promise. We all need to work a lot harder at getting this to work. Just my tuppence.

Hello there, I totally agree with Mark on the fact that we are not tapping in to the potentials of CMAM/CTC to solve nutritional problems of communities(for the short and long run). I also share your feeling and am saddened by the situation. I have been part of programs that had very high coverage and quality by any standard earlier. I remember the level of investment we put to build our teams' capacity and commitment for continuous community mobilization and engagement. That has helped us to dramatically improve coverage, ensure defaulter tracing and strengthen referral network for beneficiaries. I also witnessed that CM can be brought at the core of quality health and social services delivery in my other projects. Now it seems CMAM partners by and large are neglecting the issue. So, it would be helpful if Valid or other organizations could work on a capacity development package that is targeted at donors that would go empty handed with low quality low coverage programs, at INGOs and their field staffs. I think we should take stock of our experiences so far and design the package- will be glad to contribute to such efforts. thanks anonymous to raise the question,