From the editor

Successful homestead gardening in Satkhira, Bangladesh

The year 2013 promises to be an important year for the nutrition aid community and those whom it serves. Since the launch of the Scaling up Nutrition (SUN) movement in 2010, the Hunger Summit in London 2012 and other events and initiatives, nutrition - or rather the problem of undernutrition - has (at last) been receiving unparalled national and global attention. This year is proving to be a very important year for governments, civil society, donor organisations, UN agencies, businesses and foundations to deliver on this momentum. Targets and resource pledges to enable actions at the national and local levels to reduce stunting, acute malnutrition and micronutrient malnutrition are evolving. By the end of 2013, there will have been numerous high level forums, meetings and conferences where advocates, decision makers and implementers will have gathered to demonstrate their commitment to what we should all consider to be the realisation of nutrition justice, i.e. the eradication of undernutrition in all its forms now and in the future. This editorial casts a spotlight on the achievements and challenges relating to treatment of acute malnutrition and what the ENN have learnt from a recently completed review about the financing and systems landscape currently in place and the adjustments that will be needed if greater scale up is to be achieved. The review was undertaken by the ENN as a follow up to the 2011 CMAM Conference in Ethiopia, and was funded by Irish Aid and CIDA. We believe that the findings from this review raises important issues and want to use this editorial to share these, in the hope that the lessons can be usefully learnt by the nutrition community and beyond.

The review involved country case studies from Kenya, Ethiopia, Malawi and Nigeria, in-person and telephone interviews with donors, UN agencies and foundations involved in CMAM financing, programming and research, grey literature review and donor feedback on initial findings.

The context for the review is that today, CMAM programmes are being implemented in over 65 countries, yet UNICEF estimates indicate that only 2 million of the estimated 20 million severe acute malnutrition (SAM) cases are currently being treated. Moderate acute malnutrition (MAM) treatment through supplementary feeding programmes (SFPs) is not monitored globally but does not appear to have kept pace with the scaling up of SAM treatment. Furthermore, coverage for in-patient care (IPC) for complicated acute malnutrition is also not monitored and therefore, global coverage is unknown. Many countries with very high caseloads of acutely malnourished children - such as Bangladesh, India, Nigeria and Indonesia - have very low CMAM coverage. Should CMAM be scaled up in these high burden countries, global coverage of treatment would substantially increase. Key findings from the review are as follows:

The current conceptual, terminological and programmatic demarcation between acute malnutrition and chronic malnutrition (the latter often referred to as stunting) undermines programming coherence and sustainability. Acute malnutrition is a condition that is endemic to many poor, emergency-prone and fragile country contexts, but is often viewed as an emergency problem. Furthermore, there is emerging evidence that acute malnutrition has a significant impact on stunting so that unless acute malnutrition is addressed in all contexts, efforts to reduce stunting in the critical 1000 day window will be undermined with concomitant impact on human and economic development. There is therefore a pressing need for longer term funding for acute malnutrition treatment and to broaden the conceptual understanding about the benefits of addressing both forms of undernutrition through common or inter-linked policies and treatment and prevention programmes. This will have implications for the current funding modalities for programme scale up.

As yet, there is no agreed vision for how the current level of CMAM programming and financing will be sustained and increased. Meeting the full costs of CMAM programming is generally beyond the reach of many governments of high burden countries. A large proportion of CMAM programming costs are due to the high cost of ready to use therapeutic food (RUTF). The efforts to increase local production of RUTF have not substantially lowered cost. It is widely agreed that effective new formulations are needed (some work is ongoing) to substantially lower costs. Until such time, however, countries with low budget allocations for nutrition will require considerable external donor funding. To avoid the risk of losing the hard won gains for effective treatment of acute malnutrition, a clearer vision and financial commitment to sustain and increase levels of CMAM programming is needed.

The SUN Secretariat is working with many governments to support national and aggregated global costings of scale-up for nutrition programming (often including CMAM). It is vital that donors and governments continue to work together to determine realistic financing strategies for implementing these plans. In most cases this will undoubtedly require ‘front-loading’ of donor and possibly private sector support. Over time, though, governments should be able to take increasing responsibility for financing CMAM, as programmes that prevent acute malnutrition have effect and reduce the acute malnutrition burden.

Historically, the majority of CMAM financing has been through humanitarian funding mechanisms. Recently, even though CMAM is increasingly being scaled up in non-emergency contexts, humanitarian resources continue to be deployed. This type of financing is not ideal for sustainable programming. In particular, it has led to ‘stop-start’ programming, poorly integrated programmes and undoubtedly has higher transaction costs for both government and their partners. Some donors are recognising the limitations of financing in this way and are employing alternative mechanisms in chronic emergency settings - such as multi-year humanitarian financing or pooled emergency and development funds. This type of financing should help build greater nutrition resilience in these settings.

In emergencies, as well as non-emergency contexts, financing for CMAM is typically channelled through the UN and non-governmental agencies. This review has found that by-passing government channels for CMAM financing can prevent government nutrition stakeholders from building up sufficient political capital within their treasury departments, with the result that budget allocations to nutrition are perpetually marginal. This review urges key stakeholders to not only improve tracking of CMAM financing to obtain a clearer picture of the proportions allocated through humanitarian and development mechanisms but also, the arrangements through which financing is channelled. Furthermore, consideration of financing mechanisms that pass directly to governments for scale-up of CMAM (and nutrition more generally) through pooled or matched finds is emphasised. Impediments such as lack of financial transparency and accountability can be obviated through a variety of mechanisms. Such funding arrangements are currently recommended in various international consensus statements, such as those concerning Aid Effectiveness.

Three UN agencies currently have global roles and responsibilities for acute malnutrition in non-refugee settings; UNICEF for the treatment of SAM, WFP for MAM and WHO for IPC. This tri-partite architecture is unique for a single health condition. A major challenge is the lack of geographic and programming convergence of the three agencies. In practice this can mean that children who have recovered from SAM and progressed to a state of MAM are either discharged without follow-up treatment or where resources permit, are kept for longer in SAM treatment until they recover fully. There is currently no mapping of the extent to which this happens but interviews conducted as part of this review indicate that this may be a widespread occurrence. There is also no mapping of IPC coverage. However, WHO are known to lack operational capacity and resources in many countries.

These findings raise questions about the accountability for programme coherence when different agencies are required to treat a sliding scale of severity of the same health condition, the transaction costs for this arrangement and, whether there would be cost and programmatic gains if one agency had oversight and responsibility for the management of acute malnutrition.

The summary and full reports of this review are available on the ENN website and ODI will be publishing an edited version as one of their HPN papers.

Now back to this issue of Field Exchange that contains its usual wide range of material. Given the themes emerging in global discussions, one field article is particularly topical, tackling a combination of resilience, chronic poverty, climate change and disasters in Bangladesh. Caitlin Macdonald, Peggy Pascal and Dany Egreteau from Solidarités International share the experiences of an agro-based community heavily reliant on the natural environment for income generation and livelihood options. The transition from rice production to largely externally controlled shrimp farming has moved land control and economic gains away from the local farmer, with these negative consequences potentiated by increased soil salinity due to farming methods and repeated disasters (flooding). In describing priority actions, the authors observe that the existing method of reactive, short-term aid delivery in this emergency prone region is insufficient in the current circumstances. The complexities of this situation require a long-term approach designed to strengthen community resilience, as well as recovery and adaptive capacity to the changing environment.

An article by Pankaj Kumar and colleagues at Concern Worldwide in Ethiopia describes the success of a short term intervention using fresh food vouchers to improve dietary diversity amongst children and pregnant and lactating women. Increased availability of fresh food on markets was enabled by the project which, coupled with the vouchers and health education sessions, enabled access to fresh foods. The challenge for the community is to sustain this improved pattern of consumption.

Coverage of CMAM programmes - a familiar topic to Field Exchange readers - is covered in a number of articles and research pieces. An article by Casie Tesfai at IMC is distinctive in describing high OTP coverage achieved by a Ministry of Health (MOH) led programme in Chad. This is attributed to good awareness of the community regarding CMAM, a strong, motivated community volunteer network, and active participation and CMAM leadership by MOH leaders at district level. Another research article from Chad by the same author and colleagues (Ruwan Ratnayake and Mark Myatt), describes a matched case-control study to undertake a causal analysis of SAM as part of a SQUEAC coverage assessment. This is an evolving area with the authors raising some challenges, e.g. limitations of using matched controls to detect differences that do not vary at community level, and around complications in assessing IYCF practices retrospectively. However, the approach appears to be a feasible addition to the SQUEAC coverage assessment method that can help identify risk factors which in turn inform programming priorities. Another field article describes the ‘Boosters, Barriers, Questions’ approach to organising and analysing SQUEAC data, collecting and triangulating qualitative and quantitative information to inform programming. You can look forward to further articles on the theme of coverage assessment in issues 46 and 47, planned by the Coverage Monitoring Network.

A number of other articles in this issue of Field Exchange pick up on the challenges of measuring programme impact or conducting operational research. This is well described in a summary of a published article by Bridget Fenn who led on an evaluation of a SCUK programme in Ethiopia. In this evaluation, the hygiene component of the WASH intervention appeared to have a strong impact on stunting but only cautious conclusions were possible due to many limitations in research design. One of the strong recommendations made is that quality operations evidence-based research needs integration at project design stage, adequate funding and academic partnerships. The ENN empathises with the challenges of operational research having, with OFDA funding and in partnership with SCUK, just completed research on MAM interventions in Niger and Chad. Even with considerable investment in research expertise from the outset, this has proved immensely challenging in terms of methodology and implementation but with interesting findings that we look forward to sharing with you soon.

As we went to press, we heard of the release of the report on mortality rates during the Somali famine of 2010-12, which casts a long shadow over the effectiveness of humanitarian response systems. We have included a summary along with the essence of an online blog written by Andy Seal and Rob Bailey on the subject that raises a critical political dimension to the famine, which has not been a significant part of the discourse since these events and warrants urgent further discussion in the context of future complex emergencies. We urge you to contribute to the conversation on their blogspot (see the article for the weblink). This last minute addition to our pages contrasts harshly with our cover picture of a young, laughing girl in Somalia, when you think that over half of the estimated quarter of a million deaths (or more) was amongst children under 5 years. We haven’t changed it, a reminder of the immense human loss the country has borne.

Finally, a reminder on the upcoming urban themed issue of Field Exchange due out in July 2013. All contributions or suggestions should be sent to marie@ennonline.net

Yours

Carmel Dolan, Marie McGrath and Jeremy Shoham

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