Editorial
A number of the recommendations in the Grand Bargain reported on in the last issue of Field Exchange speak to the need to forge stronger links between humanitarian and development programming. Five of the field articles in this issue of Field Exchange relate, in one way or another, to this theme. An article by Alain Georges Tchamba describes the rapid scale up treatment of severe acute malnutrition (SAM) in the Democratic Republic of the Congo (DRC) led by COOPI in collaboration with UNICEF and government. This six month intervention, triggered on exceeding SAM prevalence thresholds, provided technical support, capacity development, Ready to Use Therapeutic Food (RUTF) and medicine supplies through the existing district health service system, achieved an estimated 71% coverage of SAM treatment in 21 districts. SPHERE targets were met throughout the programme. However, in spite of great efforts, the scale up and capacity achieved could only be sustained post-intervention in four out of the 21 districts. This was largely due to lack of supplies of RUTF and medicines, limited national capacity to sustain supervision, lack of development partners to assist transition, and reverting to paid treatment services. The clear inference is a question about the efficiency of a humanitarian system that invests so much to build capacity only to see it fall away within months of the intervention ending; it also raises questions about how development actors view acute malnutrition and whether this falls within their remit.
In contrast, two articles about the scale up of programming for treatment of SAM in Ethiopia following the El Nino related drought in 2015 demonstrates the impressive capacity building that has taken place within the Ethiopian health system in recent years. An article by GOAL describes how the agency provided support to the Ministry of Health (MoH), enabling scale up from 22 to 70 woredas over an eight month period. GOAL characterised this as a ‘light touch’ programme, building on existing capacity and supporting elements such as human resources, logistic coordination, and supply pipelines. The scale up was considerably helped by robust early warning data, flexible donor funding and experienced in-country NGOs. It is also of note that GOAL managed to secure concomitant funding so that WASH and emergency seed provision could be included in the SAM treatment programme to make it more ‘nutrition sensitive’. However, disappointingly, they could not secure funding for management of epidemics, scabies and diarrhoea. An article by Getinet Babu, Alexandra Rutishauser-Perera, and Claudine Prudhon from Save the Children UK compared the 2011 and 2016 humanitarian nutrition responses in Ethiopia and found significant improvements with respect to government leadership, programme coverage and quality. There was also evidence of greater commitment by humanitarian partners to government-led humanitarian coordination mechanisms, with responses reinforcing existing community systems rather than direct implementation. Unsurprisingly, there are still many challenges including capacity limitations, inadequate reporting and weak referral pathways between sectors. Also, of note was the difficulty in ensuring pipelines of corn soya blend (CSB) as part of the moderate acute malnutrition (MAM) treatment scale up. This reflected in part delays in information flow but also the separate programming and agency responsibility for SAM and MAM treatment and resulting difficulties of ensuring programme coherence.
An article by Linda Shaker-Berbari, Pressila Derjany Khoueiry and Dima Ousta from IOCC describes how in Lebanon in 2015, IOCC transitioned from direct implementation of SAM treatment, described in issue 47 of Field Exchange, to support for SAM treatment integrated within primary health centres (PHC), a move led by the Ministry of Public Health and in collaboration with UNICEF. IOCC focus switched to resource review, training and mentoring. A main challenge appeared to be the extra demands placed on health workers and the need for ongoing staff training to allow for staff turnover. RUTF is provided by UNICEF to the PHC services with subsidised consultation costs met by the family. IOCC are aware that quality assurance of staff and services informed by data on caseloads and outcomes are critically needed to determine the success of this transition.
Another article that relates to the connectivity of humanitarian and development programming describes a non-communicable disease (NCD) intervention amongst Syrian refugees and refugee impacted populations in Jordan. The 2014 Field Exchange special issue on the response to the Syrian refugee crisis highlighted the enormous problem of NCDs amongst Syrian refugees in Lebanon, Jordan and Turkey, and the lack of attention of nutrition and food security actors to it. ENN argued that a disproportionate concern with acute malnutrition and infant and young child feeding (IYCF) detracted from areas like NCD management, typically viewed as a less urgent and more ‘development’ type problem. The IOCC programming in Jordan suggests a gradual shift in focus is beginning to occur; IOCC have been conducting community awareness sessions and risk factor screening for Syrian refugees and Syrian impacted Jordanian communities, leading to improved access to health care. Greater coordination around NCDs in Jordan is planned for 2017.
What all these articles have in common is an implicit recognition of the fact that different forms of malnutrition cannot just be viewed as ‘humanitarian’ or ‘development’ phenomena. They exist in both emergency and stable contexts and it is the responsibility of humanitarian and development actors (national and international) to provide sustainable treatment and prevention programmes. Agencies such as GOAL and IOCC that have a long term presence in country appear to adopt a longer term ‘development’ perspective which is built upon strong relationships with ministries, which result in programming that supports government agendas and national nutrition plans, and the capacity to implement these. However, as in the case of DRC, short term dependence on humanitarian funding appears to largely preclude the potential for sustaining gains made during an emergency.
A second major theme in this issue relates to what is fashionably referred to as nutrition sensitive multi-sector programming, itself a topic of a recent special issue of Field Exchange (issue 51). A premise of the Lancet nutrition series (2008) was that even with scale up of nutrition specific interventions to 90% coverage, only 20% of stunting and 60% of wasting would be prevented. The residual caseload needed to be tackled by nutrition sensitive programming, i.e. interventions in sectors such as WASH (water, sanitation and hygiene), social protection, health and child protection, which have more explicit nutrition objectives and have adapted programme designs to enhance nutrition outcomes. The advent of the Scaling Up Nutrition (SUN) Movement (among others initiatives) has led to a marked focus on nutrition sensitive programming and global and country led efforts to scale up this type of intervention. Two articles in this issue focus on developments around this type of programming in Nepal and Uganda, implemented as part of national nutrition action plans.
The first, an article by Pradiumna Dahal, Anirudra Sharma and Stanley Chitekwe at UNICEF Nepal, describes the roll out of the Nepal 2012 multi-sector nutrition plan. This involved a restructuring of national, district and village level coordination structures, steering committees and technical working groups, and pilot programmes in selected districts with subsequent scale up being informed by lessons learned through these pilots. With an annual reduction rate of 3.3%, stunting has reduced from 57% in 2004 to 37% in 2014, although how much of this can be attributed to the MSNP 1 is debatable. A review of this roll out suggests that challenges remain with respect to capacity at district and lower levels. It may well be that this partly reflects the limited evidence base for what type of nutrition sensitive interventions work and in what context. The authors voice an urgent need to map interventions and resource allocations at district level to help identify gaps, while budget codes dedicated to nutrition are needed to help track spend. Development of MSNP 2 (2018-22) is underway, that will be greatly informed by a large government-led learning event in Nepal, supported by UNICEF, planned for May 2017 – we look forward to featuring it in the next edition.
The second article summarises work completed by the USAID SPRING project, documenting the common successes and challenges of implementing the National Nutrition Action Plans in Nepal and Uganda at national and subnational levels. It involved a two year, mixed method longitudinal study. A common driver of change in both countries was multi-sector coordination involving a strong nutrition secretariat. Barriers included vertical coordination that often took precedence, high staff turnover and poor engagement with academia and the private sector. Remaining challenges included the need for stronger integration of the NNAP into existing local and national policies and work plans, and improved budgetary processes and monitoring and evaluation frameworks. Although both countries demonstrated increased prioritisation of nutrition across sectors and funding allocations, there was no evidence of increased spending. This article complements well a number of research articles we summarise, again drawing on SPRING Project learning, published in the Food and Nutrition Bulletin on this same topic. The series includes detailed analysis of multi-sector nutrition plans, architecture, budgeting and spend in Nepal, Uganda and Ethiopia. Two outstanding conclusions from this work are that although enabling factors like coordination platforms, policies and prioritisation of nutrition are evident in all three countries, there is, as yet, no evidence of increased nutrition spend as a result of these changes and no evidence of new or adapted types of nutrition programming.
ENN is increasingly interested in how multi-sector platforms and policies are playing out on the ground and in particular, what types of programme are being implemented as part of multi-sector nutrition sensitive programming roll out. We welcome contributions on this subject from our readers.
This issue of Field Exchange features a special section that summarises some of the highlights of an ACF hosted conference that explored operational challenges and uptake of research on prevention and treatment of SAM. An editorial by Myriam Ait Aissa at ACF argues that there is limited space for sharing learning on process implementation and research uptake, and none dedicated to the presentation of scientific results on nutrition in humanitarian settings. The ACF team captured the entire meeting on video – we share all the links. In pulling this special section together, one of the frustrations for all was the need to limit sharing results in print for research destined for peer review publication. Whilst some journals have sped up the submission to publication time, others have not; this need to hold back doesn’t sit comfortably with the need to ‘fast track’ learning and sharing.
One longstanding gap area in nutrition is how to assess and treat acute malnutrition outside the 6-59 month age group. The ongoing humanitarian situation in Syria, where there are conflict affected enclaves with poor access for humanitarian actors, has highlighted again the fact that in extreme cases, undernutrition can affect all age groups. As a result, UNICEF engaged Valid International to develop contextualised mid-upper arm circumference (MUAC) cut-off points for older children, adolescents and adults to meet critical assessment needs in Syria. This is part of a larger package of work that includes development of contextualised treatment protocols. We share the extensive review of relevant published work and grey literature that was undertaken and the cut-offs proposed. The process and considerations in arriving at the proposed criteria are transparent; preliminary discussions are underway for a follow-up study to test the criteria.
Finally, as we go to print, you should soon be able to enjoy some more ‘live’ Field Exchange contributions in the form of podcasts on our newly launched MediaHub, where our regional knowledge management coordinators have interviewed authors featured in this edition (Stanley Chitekwe from Nepal and Alain Georges Tchamba from DRC); thanks to them both for taking this extra time to talk with us. When Field Exchange first began, the use of images was – and remains – a defining characteristic, to bring experiences to life. As technology has leapt ahead, so have we (albeit rather tardily); aided and abetted by the ENN SUN project team, we now have the capacity to bring a whole new dimension to our experience capture and learning. Critically, interviews and podcasts allow us to examine, listen, hear and interpret experiences in a different way to the written word; we welcome your feedback on these new media developments. If you have ever wondered what Field Exchange editors actually look and sound like, then please visit our media hub where you can now hear us discussing key elements of this issue of Field Exchange. More will undoubtedly follow; visit www.ennonline.net/mediahub so listen in.
Listen to the FEX54 "Editors Speak" podcast here
Jeremy Shoham and Marie McGrath, Co-Editors