The aim of the CMAM surge model is to strengthen the capacity of government health systems to effectively manage increased caseloads of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM), during predictable emergencies without undermining ongoing health and nutrition systems strengthening efforts. It is based on one of the fundamental principles of CMAM; that early detection of malnutrition leads to improved treatment outcomes and fewer cases of SAM, as children are treated before their malnutrition becomes severe. The pilot project was initiated by Concern in collaboration with the SCHMT as well as health facility staff in May 2012,

1. WHAT WORKS?
Credit: Gideon Mendel

2. INDEPENDENT
EVALUATION OF THE
PILOT CMAM SURGE
MODEL
CONCERN WORLDWIDE
M A R C H 2 0 1 5
P E T E R H A I L E Y
C E N T R E F O R H U M A N I TA R I A N C H A N G E

3. THE SURGE
MODEL
An innovation that enables
the health system to predict
and cope with surges in cases
of acute malnutrition through
the setting of caseload
thresholds and a set of phased
actions to respond flexibly to a
threshold being met.
a. Planning and Preparedness
b. Response

4. SURGE
MODEL
PILOT
SURGE MODEL PILOT
May 2012 – October 2014 (29
months)
14 Health Facilities
Moyale, Sololo and Chalbi.
EVALUATION AIMS
Examine if the model works in the
way that it had been conceived.
Share lessons learnt as others
implement the model.
BACKGROUND
AND
EVALUATION
AIMS

5. SURGE
MODEL
PILOT
i. To determine whether the model is effective
in setting realistic threshold levels and
whether the interventions proposed take
place and are appropriate when thresholds
are reached,
ii. To determine whether the model positively
or negatively influences other health
systems activities (facility and district level),
iii. To determine the acceptability of the model
to the various stakeholders,
iv. To determine whether the model is more
cost effective than previous standard
practice of external non-integrated support,
v. To determine the sustainability of the
model,
vi. To share lessons learned with involved
stakeholders.
EVALUATION
OBJECTIVES

6. SURGE
MODEL
PILOT
i. How can the Health Facility and SCHMT
surge model be improved?
ii. How should the governance and leadership
role of the SCHMT and the CHMT for the
Surge Model be developed?
iii. How should the Surge Model ensure more
community based health system inclusion in
the surge model approach?
iv. How can the Surge Model better link to on-
going Health and Nutrition Strengthening
programming?
v. How can the Surge Model link to and inform
the early warning and response systems for
Northern Kenya?
SYSTEMS
PERSPECTIVE

7. PRINCIPAL EVALUATION
QUESTION
Can the IMAM Surge Model strengthen the health
system to manage increased caseloads of acute
malnutrition during predictable emergencies without
undermining ongoing health systems strengthening
efforts?

8. SURGE
MODEL
PILOT
Can the IMAM Surge Model strengthen
the health system to manage increased
caseloads of acute malnutrition during
predictable emergencies without
undermining ongoing health systems
strengthening efforts?
Within the constraints of a pilot programme
the Surge Model was found to have:
1. Strengthened the Health Systems ability to
manage increased caseloads of acute
malnutrition.
2. There was no evidence of negative impacts
on ongoing health systems strengthening
efforts and to the contrary evidence was
found that the surge model approach
contributes to improved coverage and
improved use of data and communication
between the Health Facility and SCHMT.
OVERALL FINDINGS

9. OVERALL EVALUATION
FINDING.
Surge Model Pilot rated as VERY GOOD-
SATISFACTORY.
Therefore, the evaluation recommends further scale up within
the pilot sub-counties and at a wider scale in Kenya and
elsewhere.

10. SURGE
MODEL
PILOT
The present evaluation is very context specific. Both
geographically and partnership context are influential.
i. Ensure robust monitoring and evaluation plan is in place
at start of scale up. Context will have a considerable
influence of the success of the next phase.
ii. The model has not been tested during a extra-ordinary
emergency A plan for real time evaluation of its
performance during such a situation is required.
The Surge Model pilot focused on the Health Facility
/SCHMT pairing.
iii. Ensure a systems approach is taken to scale up.
Including development of leadership and governance
roles of CHMT and SCHMT. In Kenya the role and links to
the NDMA should be included.
iv. Ensure all health system building blocks are included in
the systems approach. With particular attention to
human resources, financing and supplies.
The pilot was situated in a Government Health System was
present and HSS activities were on-going.
v. Embedding the scale up of the surge model in a HSS
approach has many advantages. However, the surge
model approach could be replicated at health facility
level with HSS principals in the absence of Government
e.g. Somalia.
KEY ELEMENTS OF
SCALE UP

11. THE IMAM SURGE MODEL

12. SURGE
MODEL
PILOT
Mixed methods design.
Key informant interviews
Focus group discussions at Health
Facility, Sub-County, County and
National Level.
Visited 9 Health Facilities and 1
outreach, pilot and non-pilot.
Data and Information analysis.
EVALUATION
METHODOLOGY

13. PILOT SITES
District Weak performance Average performance Strong performance
Chalbi
(4 facilities out of 7)
Folore (level 2)
Kalacha (level 2)
Hurri Hills (level 2) Turbi (level 2)
Moyale
(5 facilities out of 12)
Bori (level 2) Godoma (level 3) Dabel (level 3)
Nana (level 2)
Butiye (level 2)
Sololo
(5 facilities out of 9)
Walda (level 3) Uran (level 3) Ramata (level 3)
Waye Godha (level 2)
Golole (level 2)

14. SURGE
MODEL
PILOT
a. Relatively small surges for malnutrition
and morbidity experienced throughout
the pilot period.
◦ Only 1% of months had more than 3 times increase (OTP
3 average/month to 15/average per month).
b. Surge Model built on and in Health
Systems Strengthening. Differences
between Pilot and Non-Pilot Centres
limited.
c. Pilot coincided with devolution process.
Difficult to separate effects of Surge
Model from those of devolution.
d. Many elements of the Surge Model and
the findings of this study are context
specific for the Health System in
Marsabit with support from Concern.
STUDY
LIMITATIONS

15. TRENDS IN ADMISSIONS
•No seasonal pattern
•Same for SFP and OTP
•OTP: 3 children average per month. SFP: 9 children average per month
•Spikes mostly related to local conflict

16. TRENDS IN ADMISSIONS
•Seasonal Pattern
•Same for Diarrhoea and Pneumonia
•Diarrhoea: 23 children average per month. SFP: 7 children average
per month

17. SURGE
MODEL
PILOT
Approach is effective in supporting Health
Facilities and SCHMT to manage increases in OTP
and SFP admissions without undermining ongoing
health and nutrition systems.
o Threshold review and adjustment process should be
reviewed. More adjustment according to changes in
capacity.
o Change thresholds by more and make bigger intervals
between thresholds
o Monitoring system for capacity development required
to measure progress towards exit strategy and inform
need for changing threshold levels.
o Periodic independent capacity assessment of Health
Facilities to add to threshold setting and amendment
process and to measure N/HSS progress.
o Due to lack of major surges in pilot period upper
thresholds and actions have not been tested. Need to
include a specific scenario based approach to setting
and review of upper thresholds. Now probably to low.
EFFECTIVENESS

18. SURGE
MODEL
PILOT
Approach is effective in supporting Health
Facilities and SCHMT to manage increases in
OTP and SFP admissions without undermining
ongoing health and nutrition systems.
oThe lack of seasonal pattern and demonstrated
impact of local conflict suggest the need for more
emphasis on scenario planning and preparedness
for the thresholds and the response activities.
Conflict 1-2 months surge. Drought several months.
oActivities matrix in MoU should be simplified
especially for lower thresholds. HF matrix should be
simplified and number of activities planned at lower
thresholds reduced.
oSimplification in data recording and analysis for the
Health System and the Surge Model process are
possible.
oData analysis process and use of wall charts should
focus more on forward planning and preparedness.
EFFECTIVENESS

19. SURGE
MODEL
PILOT
Surge Model plus N/HSS
significantly contributed to impact
through:
oIncreased coverage.
oUse of data at HF and SCHMT level
oPromoting effective communication
between SCHMT and HF.
oTest the use of “numbers in charge” rather than
new admissions to set threshold levels.
oTo Plan, prepare and manage Nutrition and
Health System “emergencies” use historic
programme data and scenario planning rather
than nutrition survey data projections except
for rare extra-ordinary emergencies.
IMPACT

20. SURGE
MODEL
PILOT
Weak evidence for reduced costs due to
use of Surge Model.
Due to financial data not being organised to
evaluate properly
Many aspects of Surge model at lower thresholds
are same as or similar to N/HSS activities. So at
lower thresholds costs low.
oUse a Value for Money based approach to
examine increased efficiency of system
implementing sustained Surge Model alongside
NHSS.
oCosting of surge model to be reviewed with
simplification at lower thresholds and more
attention to higher thresholds.
oActivities matrix too many activities and overly
comprehensive especially at lower thresholds.
EFFICIENCY

21. SURGE
MODEL
PILOT
The approach was found to be
acceptable to all stakeholders and very
relevant for Health Facility staff and the
SCHMT.
oDevelop a systematic satisfaction monitoring
system for clients and staff as part of
programme accountability agenda.
ACCEPTANCE
RELEVANCE

22. SURGE
MODEL
PILOT
The approach has established the
foundations of a sustainable approach.
oMore decentralization aspects of financial
management of surge model further down to
Health Facility.
oMore decentralization of supply aspects to of
surge model to health facilities as part of
ongoing strengthening of the nutrition supply
chain. (Push to Pull).
oDevelop Surge Model analysis, monitoring and
response approach for SCHMT and CHMT. Use
of dashboards.
oConsider including diarrhoea as a Surge Model
morbidity.
SUSTAINABILITY

23. SURGE
MODEL
PILOT
The approach has established the
foundations of a sustainable approach.
oClarify roles and responsibilities, SCHMT,
CHMT, for Human Resources secondment in
response to surges.
oIncorporate Surge Model approach into County
Health System yearly planning process. Historic
data, scenario planning and self assessment of
capacity.
oIncorporate Surge Model financial planning
process into CHMT yearly contingency planning
process.
oUse Surge Model approach to clarify the
relationship between Health System
contingency planning and response and the
NDMA crisis modifier funding.
SUSTAINABILITY

24. Facility Based Nutrition Surge
Model in Kenya

25. V. Large
Emergency
(<1%)
Serious to
Emergency
(~1%)
Alert to Serious (~4%)
Normal to Alert (95%)
PROGRAMME
DATA
NutritionSurveyand
EarlyWarningData
Data for Plan,
Prepare and
Response
MoHCONTINGENCY
BUDGET
NDMA
Surge Planning
and Financing

26. THANK YOU