From the editor

This issue of Field Exchange gives extended coverage to a briefing paper just released by Oxfam and SC UK on the 2011 response to the Horn of Africa crisis. This paper argues that the response was late and led to the unnecessary deaths of between 50,000 to 100,000 people, at least half of whom were children under 5 years. According to the authors, there was sufficient early warning to trigger a response as early as November 2010 but the main response only unravelled in July 2011, following declaration of famine and concerted media coverage. The paper identifies the usual litany of reasons for this failure of response, i.e. only responding when media attention is overwhelming, politically influenced decision-making, time-lags between early warning and appeals, making appeals on the basis of capacity to deliver and access rather than need, inability to act on risk and forecasts and the divide between development and emergency programming and funding. These reasons are familiar to most of us and were largely applied to analyses of previous failures of response going back as far as the Sahelian famine of 1984. However there is a coherence and clarity in this paper, particularly in the way it trains its focus on the need for future response to be based more upon risk reduction and the institutional structural change needed to support such an approach.

The ENN fully supports the recommendations in this briefing paper and believes that this important document can provide a powerful advocacy tool for change. Some of the issues around the emergency/development divide raise uncomfortable questions for the ENN itself, which we will reflect upon in due course. There is however one important element of the analysis which we feel is not adequately addressed in the report. This relates to the relationship between early warning and donor response and the recommendation for use of earlier triggers and risk analysis. These recommendations are hardly new and have been made repeatedly over the past 25 years. The piece of the jigsaw that is still missing is the lack understanding and transparency about ‘how donors make decisions whether to respond’. The failure of donor response over many years in certain high profile emergencies suggests that there are complex political and institutional processes that hinder timely and effective response, including the type of risk taking advocated in the Oxfam/SC UK briefing paper. The nutrition community, perhaps not unsurprisingly, continues to focus on ‘technical’ solutions, yet until we have a better understanding of the constraints faced by donors and their ‘room for manoeuvre’ to effect change, our technical solutions will have little impact on response. We therefore strongly support any advocacy efforts that encourage donors to systematically analyse their decision-making processes during emerging crises and to make such findings publically available.

And now to the rest of this Field Exchange edition. Field articles in this issue of Field Exchange (no 42) can largely be divided into those related to the treatment of severe acute malnutrition (SAM) and those related to treatment and prevention of moderate acute malnutrition (MAM). Three of the SAM related articles describe the experience of conducting different types of coverage surveys for community based management of acute malnutrition (CMAM) programmes and feature in a special section of this issue on coverage assessment. An article by Ernest Guevarra, Saul Guerrero, and Mark Myatt describes the use of the SLEAC method to assess national level coverage of CMAM in Sierra Leone. The advantage of the approach is that relatively small sample sizes are required to make accurate and reliable classifications of coverage and to identify barriers to programme access. Assessments can therefore be completed relatively quickly. The authors conclude that the SLEAC method should be the method of choice when evaluating coverage of CMAM programmes at regional or national level. An article by Jose Luis Alvarez Moran, Brian Mac Domhnaill and Saul Guerrero at Action Contre la Faim (ACF) describes the experience of conducting remote SQUEAC investigations in Mali and Mauritania where certain areas are difficult to reach by external investigators. The approach does require greater reliance on field teams, as well as strengthening or modifying certain SQUEAC processes, e.g. separating the data collection and analysis processes, using new technologies and addressing supervision and motivation issues proactively. A third article on coverage assessment describes the use of the SQUEAC method to undertake a causal analysis of SAM in rural areas of eastern Sudan. The data collected were sufficient to identify risk factors and risk markers (i.e. diarrhoea, fever, early introduction of fluids other than breastmilk) that were associated with SAM. The authors suggest that it is possible to use the SQUEAC toolbox to collect causal data using staff trained as SQUEAC supervisors and trainers, although data analysis may require staff with a stronger background in data-analysis.

Moving on, an article by Bernardette Cichon describes ACF nutrition survey findings in the Philippines, where three consecutive surveys found large discrepancies in the prevalence of SAM using either a weight-for-height cut off below - 3 z-scores or a mid upper arm circumference (MUAC) less than 115 mm. The authors conclude that as long as the risk of mortality in children with a weight-for-height of less than -3 z-scores but a MUAC greater than 115mm isn’t properly understood, all children classified as malnourished according to both indicators should receive treatment (in this instance, admission to a CMAM programme). The authors recognise that using two indicators complicates programming. Whilst not the case in this example, this may also have significant programme capacity implications. Interestingly, a research summary in this issues research section based on an old data set from Senegal examines the risk of dying of children having either a low MUAC or a low weight-for-height (z score) or a combination of both in the absence of treatment. Analysis found that MUAC has a better ability than weight-for-height (z score) to assess risk of dying. Furthermore, using both indicators together did not improve the identification of high risk children.

Also related to CMAM programming, a field article by Jan Komrska of UNICEF’s Supply Division in Copenhagen describes how UNICEF has been keeping pace with the increased demand for Ready to Use Therapeutic Food (RUTF) as CMAM programming has been scaled up rapidly across many countries. The article describes various strategies employed, including increasing the number of global suppliers in Europe, identifying local producers in Africa and Asia, improving forecasting of demand and the pre-positioning of stocks. Staying with SAM management, a research summary of work by Tufts describes the success of a pilot CMAM programme in an Upzila in Bangladesh where community health workers were responsible for and supported in diagnosing and treating SAM children. Programme indicators like recovery and mortality exceeded SPHERE standards and an extraordinary coverage of 89% was recorded.

A further three field articles deal with the prevention and treatment of MAM in different contexts. An article by Naomi Cosgrove and colleagues working for ACF in Myanmar describes how reduced daily rations of RUTF (one sachet instead of two or three used for SAM treatment) were used to treat successfully uncomplicated cases of MAM managed within the CMAM programme. Fuelled by imported supply constraints and a rising caseload, ACF modified the treatment protocol and introduced a second phase of treatment, once the child had improved from a severe to a moderate (i.e. MAM) stage of malnutrition. A key conclusion from the article was that the programme success was partly due to the high quality ration but also the attention given to programme design, including well trained staff and good community mobilisation. Another article written by Dr Jean-Pierre Papart and Dr Abimbola Lagunju of Fondation Tdh covers MAM management and the important role of quality staff in service delivery in Guinea. Community and facility level screening and provision of RUTF (for SAM) coupled with cooking demonstrations, counselling, some food supply (for MAM) and defaulter follow up were undertaken by government staff. Urban community health workers played a key role in service delivery. The authors concluded that government health facilities can deliver good results with the appropriate technical, material and equipment support. On the job training and supervision, feedback on performance and regular higher level supervision of nutrition activities played an important role in service quality. A WFP pilot blanket supplementary feeding programme (BSFP) in Kassala State, Sudan is the subject of a third field article on MAM, written by Pushpa Acharya and Eric Kenefick of WFP. This article details how intensive community engagement and sensitisation were key components of the programme, as were certain key messages derived from a KAP (Knowledge, Attitudes and Practices) survey. All pregnant and lactating women and children under five years of age were targeted with the BSFP, providing approximately 500 kcals/day. The pilot found that 68% of malnourished children enrolled in the programme recovered within four weeks, although the cost of the programme was at least twice as high per child as the targeted SFP implemented by WFP. The authors concluded that when food availability and quality is enhanced through the provision of small quantities of highly fortified food combined with the intensive engagement of the community around harmful feeding practices, the impact of food aid is significantly increased. The size of the programme allowed intensive monitoring by the Ministry of Health and WFP. The challenge lies in taking the pilot to scale.

A final field article written by Catholic Relief Services (CRS) in Zambia considers a Food by Prescription (FBP) programme that targets moderately and severely malnourished HIV positive adults with medicalised doses of nutrition supplements through the home based care programme. Individual sachets of the supplement are distributed to reduce household sharing and strengthen the understanding that the food is a ‘medicine’. Data from the pilot programme showed that there was an increase in client Body Mass Index (BMI) between admission and discharge. Among adult clients, the average BMI on admission was 17.6 and the average BMI on discharge was 20.5. The overall average increase in BMI pre-FBP to post-FBP was 2.9. Most clients required three to six months of nutrition rehabilitation to qualify for discharge.

The research section of this issue also covers a wide range of subjects. There are two articles on cash transfer programmes. One is a summary of a study of the national ‘Bolsa Familia’ programme (BFP) in Brazil, which is the world’s largest conditional cash transfer programme. It reaches 5,564 municipalities in the 27 states of Brazil and about 11 million families (25% of the Brazilian population).Once a family enrols, it must comply with certain health and education conditions to remain in the programme. The study found that children from families exposed to the BFP were 26% more likely to have normal height-for-age than those from non-exposed families; this difference also applied to weight-for-age but not weight-for-height. Another study looks at a cash transfer programme in Niger using mobile phone technology and found that in comparison to physical cash transfer programmes, there was a significantly reduced cost to programme recipients, as well as reduced implementing agency’s variable costs associated with distributing cash. There is also a fascinating article on the political economy of crop diversification policies and the policy process at government level in Malawi. The article explains how the processes of discussing, negotiating, approving and implementing policies are as important as the scientific content of the policies themselves. The experience with crop diversification shows that dominant stakeholders almost always have their way and that in Malawi implementation of crop diversification has been constrained by a dominant narrative that equates food security with maize production.

Other research of note in this issue include a psychological study to understand how humanitarian workers remain effective in challenging environments, a study to assess the effect of performance based payment of health care providers on the use and quality of child and maternal care service in healthcare facilities in Rwanda and a position paper to guide country-level health clusters on how to apply IASC (Inter-Agency Standing Committee) civil military coordination principles to humanitarian health operations given the "shrinking of humanitarian space" in many complex crises.

Our opening 2012 issue is a reminder of the ongoing innovations and inevitable compromises that are sometimes necessary in humanitarian programming. You can have the best designed intervention, but national and sub-national capacity to deliver on the ground and supply chain difficulties can make or break a quality programme. The articles featured also reflect some of the ‘grey’ areas in the emergency nutrition sector. For example, whilst SAM management has rapidly developed and improved through CMAM programming over the past 10 years, there is a limited evidence base for optimal programming for the prevention and management of MAM. The jury is still out on how best to deal with high and fluctuating levels of MAM and field practice remains a bit of a ‘free for all’. A news piece by ACF, laying out the agency’s position on the role of products in the treatment and prevention of global acute malnutrition, sets out certain boundaries whilst highlighting some of the more contentious areas. Our prediction is that the role of products in the prevention and treatment of MAM will be one of the big issues in the coming year. And we hope the SCUK/Oxfam paper has just generated another - the 2011 Horn of Africa crisis highlights once again a clear failure of response at the highest level of the international aid community. Is it not incumbent upon donor governments to analyse why that occurred and to work with the rest of us to address the reasons for this failure as urgently as possible?

We hope you enjoy this diverse issue of Field Exchange and wish all our readers a healthy, happy and productive 2012.

Jeremy Shoham, Editor
Marie McGrath, Sub-editor

We would like to dedicate this issue of Field Exchange to Kari Noel Egge and Mr Abdikarim Hashi Kadiye, whose untimely and premature deaths saddened the whole humanitarian community. We have included short tributes to both of them in a new Field Exchange obituary section for humanitarian workers, which we sincerely hope remains unused in subsequent issues.

¹Simplified LQAS (Lot Quality Assurance Sampling) Evaluation of Access and Coverage

²Semi-quantitative Evaluation of Access and Coverage