From the editor

Queing for cash transfer

Four of the six field articles in this issue of Field Exchange endeavour to demonstrate some form of intervention impact. The programmes are all very different; nutrition supplementation of HIV positive individuals in Zambia, community based nutrition programming in Bangladesh, a voucher scheme for fresh fruit and vegetables in a Dadaab refugee camp in Kenya and a joint cash and food programme in drought affected Swaziland. The programmes are either novel, i.e. the voucher scheme in Dadaab, are pilots contributing to a growing body of evidence, i.e. Zambia and Swaziland, or follow an approach for which there is a weak evidence base, i.e. the community-based nutrition programme in Bangladesh. All programmes therefore have a need to generate robust evidence of impact. The need for more evidence based programming is increasingly being emphasised in the nutrition sector. The recently published Lancet series on nutrition highlighted the lack of evidence for much of what is done in the name of nutrition programming. The ENN has also raised this issue on numerous occasions and published studies showing the lack of robust evidence for emergency nutrition programming (Duffield et al, 2004¹). The efforts to demonstrate impact in the programmes included in this issue of Field Exchange are therefore to be welcomed. However, it is important to examine closely the quality of the evidence for impact cited in these articles and the way in which impact assessments were carried out.

The ENN has argued for several years now that lack of an evidence base for certain types of intervention has allowed the same interventions to be rolled out uncritically and that, in some cases, this may lead to ineffective programming. The recent experience of piloting CTC/CMAM² and the systematic effort to generate a robust evidence base demonstrates how important it is to take this approach. CTC/CMAM is now being rolled out and scaled up in numerous countries with great confidence and secure funding (see article in this issue on decentralising outpatient treatment of severe acute malnutrition (SAM) in Ethiopia). Yet, the CTC/CMAM story is fairly unique in our sector. Other new and promising intervention designs, while continuing to be piloted, rarely, if ever, seem to attract the same level of support from donors because of the absence of robust evidence of impact. New and potentially improved approaches and advances therefore arguably take longer to establish.

The four programmes described in articles in this issue all take different approaches to impact assessment. The most rigorous is the nutrition supplementation study in Zambia where patients were separated into an intervention group receiving a nutritional supplement, a group receiving Home Based Care rations and a control group who received no food support. Outcomes were measured and compared for food consumption, coping strategies, functional ability and anthropometry. In contrast, the nutritional statuses of the population groups targeted under the community nutrition programme in Bangladesh were not rigorously compared with control groups. Comparisons were made with national data and between discrete time periods. The findings were therefore not statistically meaningful. The refugee voucher programme in Dadaab refugee camp assessed impact in terms of dietary diversity and selective feeding programme coverage (the voucher acting as an incentive for mothers to bring children to the selective feeding programme). Programme impact on nutrition status and infant and young child feeding indicators were not therefore measured. The food and cash transfer programme in Swaziland assessed impact on the basis of a number of criteria including dietary diversity, expenditure patterns, coping strategies and empowerment of women. Again, impact on nutritional status was not measured.

It is not our intention to criticise the lack of robust impact assessment carried out by agencies implementing the type of nutrition interventions outlined in these field articles but rather to highlight the difficulty agencies face in generating a solid evidence base for what they do. Most agencies are hard pushed enough just to implement a programme, let alone pilot an innovative approach. Conducting rigorous research to demonstrate impact as part of programme implementation is just a step too far for most agencies. Although donors require monitoring and evaluation of programmes, most donors do not insist on robust evidence of impact. They tend to be happy with evidence of process, i.e. that the programme delivered the outputs set out in the proposal. As a rule, agencies would love to be able to generate harder scientific evidence of impact. However, to do this they would need funding (research is not cheap) and expert support from research groups (most agencies do not have in-house expertise to design rigorous studies). For their part, research groups in the academic sector need a form of flexible funding. Even where research groups have strong working relationships with implementing UN agencies or non-governmental organisations, they can never be sure when an emergency programme is going to be implemented and for how long. The challenge for them is therefore how to secure funding for research that is flexible, i.e. can be mobilised when a research opportunity materialises. Typical donors for this type of operational research tend to require proposals with a long lead time and that expenditure of the grant takes place within discrete periods (although no-cost extensions are often permissible).

Overall, therefore, there are weak mechanisms in place to facilitate operational research and rigorous impact assessment involving randomised case control studies - the gold standard of research. It has been argued that ethical issues would, in any case, prevent this type of research or that it would be difficult to find control groups. However, step-wedged design is often feasible and a means of getting around this problem.

It is clear that donors need more technical expertise within their organisations and more flexible funding mechanisms that allow operational research. At the same time, implementing agencies must be more honest about whether there is an adequate evidence base for the type of intervention they are implementing and should endeavour to build up a body of evidence for effectiveness and impact at every opportunity. Without this, new and promising approaches will take many years to be adopted and rolled out, while more questionable programme approaches will continue to be implemented as a default position and because there is a track record of funding. The emergency nutrition sector is awash with the creative energy and drive to improve practice. All we need now is a better system which expedites the critical research needed to underpin this.

There are many other articles of interest in this issue of Field Exchange. The research summaries cover a broad range of topics. These include the relationship between protein energy malnutrition and genetic mutation, the impact of introducing new breeds of livestock as part of emergency restocking programmes on local genetic stocks in Boznia-Herzegovina, and an Action Contre la Faim (ACF) study on the impact of the current food price crisis on rates of malnutrition in four African countries.

Finally, we hope you enjoy your 'free gift' with this issue. Funded by the Global Nutrition Cluster, the entire archive of Field Exchange (35 issues produced since 1996) has been catalogued into an online search database that is replicated on the CD enclosed. Feel free to copy the CD to share with others, or make your own from the link on the ENN website.

Enjoy!

Jeremy Shoham
Editor

Any contributions, ideas or topics for future issues of Field Exchange? Contact the editorial team on email: office@ennonline.net

¹Duffield A, Reid G, Walker D, Shoham J (2004). Review of the published literature for the impact and cost-effectiveness of six nutrition related emergency interventions. Report for the Emergency Nutrition Network. December 2004.

²Community Therapeutic Care/Community management of acute malnutrition