From the Editor
There is no single theme for this issue of Field Exchange but lots of interesting and wide ranging material. A good place to start this editorial is to note the short research piece on the World Bank/UNICEF/WHO joint database on child malnutrition, which has just been updated to include statistics on wasting. The latest report provides the current context in which we all work. In 2012, amongst children under five years globally, 162 million were stunted, 99 million underweight, 51 million wasted, 17 million severely wasted and 44 million overweight. Between 2000 and 2012, the prevalence of stunting, underweight, wasting and severe wasting fell while overweight increased. There is a higher proportion of stunting, underweight, wasting or severe wasting in children under five years in Asia.
Field articles in this issue cover a range of programming areas. An article by Cyrus Shahpar and Leisel Talley at CDC describes an impact study on a Blanket Supplementary Feeding Programme (BSFP) in northern Kenya. BSFPs are increasingly becoming standard practice to address seasonal peaks in wasting in high burden vulnerable countries. However, the evidence base for these programmes and their effectiveness is still weak. The Kenya study involved a prospective evaluation of a BSFP in Turkana and Wajir and was conducted using a longitudinal cohort of non-malnourished children between 6-36 months of age. As a group, nutritional status improved, however, a subset of children became malnourished whilst in the programme. Children who had a lower weight for height z score (WHZ) or mid-upper arm circumference (MUAC) or lower dietary diversity upon enrolment were more likely to develop acute malnutrition. BSFP monthly rations were consumed in less than 14 days for more than half of beneficiaries. These findings echo those of a similar study conducted by ENN in Chad that will feature in a future edition of Field Exchange2.
On a different note, a field article written by Save the Children Somalia examines the multi-sectoral impact of cash programming. Multi-sector integrated programming has become a bit of a holy grail in the nutrition world and is seen as desirable - if not essential - by many, as nutritional problems are invariably multi-causal. However, multi-sectoral programming is easier said than done for a variety of institutional, funding and professional reasons. This article describes how cash programming enabled beneficiary led multi-sectoral integration involving education, food security and livelihoods impact. These findings have particular resonance given the phenomenal scale of cash programming in the current Syria regional response and the move from cash for food or shelter towards more multi-sectoral objectives.
It is a nice change to feature a contribution from a team of veterinary doctors working with Vétérinaires Sans Frontières Germany in this edition. They describe a goat supplementary feeding and voucher based community animal healthcare programme implemented amongst pastoralists in two drought affected districts of Ethiopia. One of the aims of the programme was to improve child access to animal milk, which they achieved. Child nutrition impact assessment was limited to focus group discussions where benefits were reported. How to strengthen the nutrition impact assessment of ‘nutrition-sensitive’ programmes is a key question emerging from this article and is the focus of a research piece by ACF mentioned further below.
An article by Concern Worldwide describes a model to provide surge support for community based management of acute malnutrition (CMAM), to meet peaks in demand for nutrition services provided through government health systems in Marsabit County, Kenya. It involves risk analysis, threshold setting, monitoring against thresholds, provision of surge support and scaling down of surge support at health centre level. Small scale surge support has been ‘triggered’ 11 times by health workers at pilot health facilities between January and September 2013. Surge support included provision of extra staff, relocation of supplies, and more supportive training and supervision.
Another field article to mention, written by Ruco Van Der Merwe at Samaritan’s Purse International Relief, describes a milling voucher scheme for a food aid dependent refugee population in south Sudan. The scheme aimed to reduce ration exchange for milling services and therefore increase the length of time that household rations lasted. Local markets and milling services successfully adjusted to the increase in programme demands. However, an unanticipated consequence was a fall in miller profits due to over-supply of millers.
Special mention must be made to one field article that sparked a lot of discussion before it even graced the pages of Field Exchange, on the topic of infant and young child feeding (IYCF) assessment in small sample surveys. Written by a collective of agency country staff coordinated by Mark Myatt, the work grew from an increasing demand to assess community IYCF practice to inform programming design and monitor impact. Measurement of WHO IYCF standard indicators was limited due to the sample sizes needed. The authors describe an approach piloted in Sierra Leone, Niger and Sudan that involves a composite IYCF indicator to classify IYCF practice as ‘good’ or ‘not good’ amongst 0-23 month old children. Sample sizes were small, less than 210 children. The approach has its limitations duly acknowledged by the authors. Some important technical limitations and concerns are identified in a postscript to the article by UNICEF and WHO to which the authors again respond. The UN comment does reflect some shortcomings in the accessibility of technical guidance and shared experience both with and within country programmes – for example, relevant experiences in IYCF indicator rollout in UNICEF are highlighted in the postscript but appear not to have been accessible to the UNICEF staff who co-authored this article. Meanwhile, problems with the WHO IYCF indicators at programming level seem to be partly because they are perceived as complicated, rather than this actually being the case. The “collective action” called upon in postscript is heartening and we hope encourages individual agency responsibility and practical action to support the field more in their work, e.g. the development of user friendly guides on existing IYCF indicators by WHO. This article has sparked a constructive dialogue long overdue and is another reminder of how much innovation in our sector comes from those working “on the ground”. All involved are keen that this exchange proves the start of a technical conversation in some shape or form to fill this gap. Where feasible, the ENN will continue to feature such innovations and facilitate constructive dialogue around contentious technical areas, linking policy makers and programmers.
The research summaries in this issue cover a multiplicity of subjects. Many of these address important operational questions and challenges. However, there are also a couple of articles which shine a slightly less favourable light on the ability of our sector to learn lessons and move forward. We start with the positives.
With nutrition sensitive programming becoming something of a buzz phrase at the moment, we are pleased to be able to summarise an important study on how to make agricultural programming more nutrition sensitive. Based on three country case studies in Burkina Faso, Kenya and Peru the study tries to answer a number of key questions: How do national agricultural policies integrate nutritional issues? What are the main constraints to agricultural policies improving efforts to end under-nutrition? How best could these constraints be alleviated?
On a completely different topic, this edition features a study by MSF which looks at what happens to low WHZ kids not admitted to a feeding programme in Bangladesh where only MUAC is used as a criterion of admission for treatment. Low WHZ children were not admitted but monitored in the community. Findings are interesting on a number of levels as only 6% of uncomplicated low WHZ kids deteriorated, while there were very high levels of ‘spontaneous recovery’ (58%), amongst these children. This particular finding also resonates with the ENN Chad study on a BSFP referenced earlier, where the rate of spontaneous recovery (recovery without targeted intervention) was even higher - approximately 80%.
Another topical study we summarise is work in India by Singh et al which examines the feeding, clinical profile and management strategies for severely malnourished infants under 6 months in an inpatient nutrition rehabilitation centre. They find good outcomes although non-responders are high (approx. 27%), largely due to default. This complements nicely two additional articles on the topic of malnutrition in infants under 6 months. Firstly, a small qualitative study in Malawi investigated expectations of treatment for this age group amongst mothers and families. Interestingly, inpatient treatment was a preferred option based on high expectations (rather than experience) of care. A strong informal community network was identified that could help shape future community-based interventions. The second article by Martha Mwangowe and Jay Berkeley summarises common challenges in measuring infants under 6 months amongst experienced health workers in Kenya. Strategies to overcome these are identified, revolving around building trust to manage caregivers’ anxiety, and greater attention to detail in measurement.
There is also an interesting and potentially important study comparing outcomes of Lot Quality Assurance Sampling (LQAS) surveys with 30 by 30 cluster surveys. While LQAS confidence intervals were wider, only findings for one indicator were statistically different to findings from the cluster survey, yet LQAS was obviously and significantly a lot cheaper.
The several studies cited above point to knowledge acquisition and progress in our sector. However, two other studies summarised in this issue engender a little less optimism. One study reviews the factors leading to the Somalia famine in 2011 which led to an estimated 275,000 deaths – mainly amongst children. This study suggests and highlights failure of the humanitarian system, with political agendas of donors and regional powers being particularly implicated. Another study describes a small but significant outbreak of angular stomatitis (Vitamin B2 deficiency) in Uganda amongst a food aid dependent population. Although the incidence was low, the article highlights the inadequacy of the assistance ration and harps back to the 80s and 90s when outbreaks of this type and other micronutrient deficiencies were more common amongst refugee populations in particular. As the old saying goes ‘two steps forward and one step back’.
Hope you enjoy the read.
Jeremy Shoham and Marie McGrath
Co-editors
1See the GNC tribute to Basra at http://www.unicef.org/nutritioncluster/files/GNC_Tribute_to_Basra.pdf
2See a briefing note regarding the ENN research in Chad at http://www.ennonline.net/pool/files/research/briefingjan2013final.pdf