Programme implications for WHO Growth Standards rollout

Summary of research¹

A recent study has looked again at the possible implications of switching over to the 2006 WHO growth standards on the premise that there has been no documentation of which case definition countries are using, and therefore of the size of the expected change in prevalence estimates for severe acute malnutrition (SAM). The study looked at 22 countries where SAM is prevalent and found that most countries currently use % of the median. Changing from <70% median (NCHS) to <-3 Z scores (WHO) results in particularly dramatic increases in the prevalence of SAM (eight times in one study). This finding contrasts with 1.5-3 fold increases when switching from <-3 Z scores (NCHS) to <-3 Z scores (WHO). The authors highlight the fact that widespread use of % of median has not previously been appreciated and that this raises important concerns.

First, treatment supply for SAM is already insufficient for current demand (Action Contre la Faim and Medecins Sans Frontieres estimate that only 9% of children with SAM currently receive treatment). Secondly, substantial financial investments are needed to create and sustain programme expansion. Availability of specially formulated ready-to-use therapeutic food is often the largest cost component for care in feeding programmes, while far greater investment will be needed to support the health systems and staff directly delivering treatment. Thirdly, if admissions for SAM increase too rapidly due to the combined effects of food shortages and new case definitions, treatment capacity risks being overwhelmed. In this situation, limited resources might not necessarily go to the most vulnerable children.

The authors conclude that the 2006 WHO growth standards may translate into the fact that more children can be treated at an earlier stage of the disease and greater public health impact achieved. However, for this to happen, policy makers must be fully aware of the varied effects, and possible side-effects of change. They must ensure adequate resources to increase supply of treatment for SAM. Strategies and practicalities for feeding programmes and roll-out of the WHO growth standards must be harmonised. Immediate efforts should prioritise roll-out of effective evidencebased community programmes. Horizontal health systems approaches, with extensive local by-in and integration with existing services, take extra time initially but often pay off longer term. Once treatment supply increases, coping with extra demand will be easier.

¹Kerac. M et al (2009). New growth standards: roll-out needs more resources. Vol 374, July 11th, 2009 www.thelancet.com