The efficacy of the CMAM protocol can be defined as how well the protocol works in ideal and controlled settings. It is measured by the cure rate:

which is usually estimated in a clinical trial.

For the CMAM protocol, the cure rate is close to 100% in uncomplicated incident cases (i.e., in cases with mid-upper arm circumference [MUAC] at or just below the admission criteria and cases with mild oedema). There is, therefore, little room for large improvements in the efficacy of the CMAM protocol. Although we cannot significantly change the efficacy of the CMAM protocol, we can change the effectiveness of the CMAM protocol.

The effectiveness of the CMAM protocol can be defined as the cure rate in a beneficiary cohort under program conditions. Effectiveness depends, to a large extent, on:

  • Severity of disease. Early treatment seeking and timely case-finding and recruitment of severe acute malnutrition (SAM) cases will result in a beneficiary cohort in which the majority of cases are uncomplicated incident cases. The cure rate of the CMAM protocol in such a cohort is close to 100%. Late treatment seeking and weak case-finding and recruitment will result in a cohort of more severe and more complicated cases. The cure rate in such a cohort may be much lower than 100%.

  • Compliance. Programs in which the beneficiary and the provider adhere strictly to the CMAM protocol have a better cure rate than programs in which adherence to the CMAM protocol is compromised. Poor compliance can be a problem with the beneficiary (e.g., sharing of ready-to-use therapeutic food [RUTF] within the household) or a problem with the provider (e.g., RUTF and drug stock-outs), and both have a negative impact on effectiveness.

  • Defaulting. This is the ultimate in poor compliance.

An effective program must, therefore, have:

  • Thorough case-finding and early treatment seeking. This ensures that the beneficiary cohort consists mainly of uncomplicated incident cases that can be cured quickly and cheaply.

  • A high level of compliance. This ensures that the beneficiary receives a treatment of proven efficacy.

  • Good retention from admission to cure (i.e., little or no defaulting). This also ensures that the beneficiary receives a treatment of proven efficacy.

Coverage is one factor (the other being effectiveness) in the capacity of a program to meet need. It can be expressed as:

Coverage depends directly on:

  • Thorough case-finding and early treatment seeking. This ensures that the majority of admissions are uncomplicated incident cases, which leads to good outcomes (i.e., close to 100% cure rate).

  • Good retention from admission to cure. This is the absence of defaulting.

Coverage also indirectly depends on compliance (see Figure 1).

Figure 1: Relations between factors influencing coverage and effectiveness image-center

Meeting need requires both high effectiveness and high coverage:

Coverage and effectiveness depend on the same things (see Figure 1) and are linked to each other:


Good coverage supports good effectiveness. Good effectiveness supports good coverage. Maximizing coverage maximises effectiveness and met need.

The implications of:

are illustrated in Figure 2 and Figure 3. Programs with low coverage fail to meet need.

Figure 2: Effect of coverage on met need in two programs image-center

Figure 3: Tanahashi coverage diagram illustrating the effect of different types of coverage barriers on service achievement (met need) image-center

This online toolkit describes the SQUEAC and SLEAC methods for investigating and improving the coverage, effectiveness, and met need of CMAM programs. It also includes 10 case studies, each of which presents useful insights into how SQUEAC and SLEAC can and should be applied; a set of technical guidance and tutorials, which provide greater detail about case-finding, survey sample sizes, calculations used in SQUEAC and SLEAC, and smoothing of time-series data; a brief tutorial on working with the formulas used in this toolkit; and a glossary of SQUEAC and SLEAC terms.