Editorial
This issue of Field Exchange speaks largely to the themes of scaling up and integration of nutrition programming, as well as multi-sector approaches to addressing undernutrition. If you add in ‘resilience,’ these are probably the most current pre-occupations of nutritionists and the broader development community.
Scaling up nutrition programming, whether under the umbrella of the Scaling Up Nutrition (SUN) Movement or not, is an obvious area where we urgently need to make progress. Coverage of nutrition-specific programmes, like treatment of acute malnutrition, are still woefully inadequate (see the articles on the No Wasted Lives Initiative and CORTASAM, that are concerned with addressing exactly this). We know less about the coverage of nutrition-sensitive programmes and it would perhaps be unwise to try to specifically quantify coverage until there is greater clarity around definitions of this type of programme. What we can say, however, is that coverage is low – especially in fragile and conflict-affected states. The need to ‘integrate’ nutrition programming or elements of nutrition programming into existing health and other programming infrastructure requires little justification other than the fact that integration is key to sustainability and national ownership. It is the justification, focus and resources devoted to multi-sector nutrition approaches where arguments and rationale perhaps become more equivocal. Although cited as critical to address the majority of the global burden of stunting in the LANCET 2008 series, Field Exchange 51 (special issue on nutrition-sensitive programming) argued that nutrition-sensitive and/or multi-sector programming (terms often used interchangeably) are poorly defined and even more poorly evidenced in terms of impact (Editors, 20161 ). In the 18 months since this edition, researchers and knowledge management actors have continued to examine how multi-sector nutrition programmes are being enabled (particularly in SUN countries) and evidence for nutrition impact and the process by which impact is mediated (theories of change). Overall, it has to be said that there is slow progress – both in terms of our understanding of how and whether nutrition programming is changing on the ground to become more sensitive and multi-sectoral, and the evidence for nutrition impact of this approach. It must be asked, therefore, whether our efforts in scaling up so called nutrition-sensitive and multi-sector programming are perhaps a little premature in that there is so much investment in enabling the approach before we have evidence of what works and in what contexts. We can only hope that the ‘leap of faith’ proves to be justified as the evidence from pilot programmes and research continues to emerge.
One other question that may be worth considering is why we often appear to separate out the processes of ‘scale up’, ‘multi-sector planning/programming’ and ‘programme integration’ in our writing and deliberations (see articles in this issue of Field Exchange). What drives the delineation? Is it the institutional architecture, e.g. nutrition-specific programme scale up is often undertaken in sectoral silos or without integration into existing programming (humanitarian and development divide) or is it a conceptual convenience and if so whom or what purpose does this serve? Why wouldn’t we always aim to scale up nutrition related programming in a way that ensures maximum synergy between sectors and as full integration within existing systems and infrastructure as possible? I’m afraid that these are simply reflections with no attempt to provide answers, although hopefully worthy of consideration.
So, onto the articles in this issue. A piece from Sudan written by the UNICEF team and the Federal Ministry of Health tells the story of scale up and integration of severe acute malnutrition (SAM) treatment into existing health services in what can only be described as a high burden low resource setting. The scale up led to a five-fold increase in cases treated, transitioning from a parallel humanitarian programme to a government-led integrated intervention. An interesting facet was that local production of Ready to Use Therapeutic Food (RUTF) increased 400 percent. Furthermore, government and development partners took on increasing funding responsibility for the programme. The many enabling factors for this successful programme included early government engagement, leadership and ownership; evidence of effectiveness and cost-efficiency; strong technical support from UNICEF and other partners; the formation of a community-based management of acute malnutrition (CMAM) Technical Working Group; and robust mentoring and monitoring. Another scaled up SAM treatment programme, this time in Ethiopia, is described by Amal Tucker Brown and Eric Alain Ategbo, UNICEF. Here, in response to the 2015-16 El Nino drought, SAM treatment was integrated into routine health services whereby the national community-based nutrition programme was scaled up quickly and to a high standard. An article by the USAID-funded SPRING project describes the rapid scale up of community videos to promote improved handwashing and complementary feeding in Niger and Burkina Faso. Evaluation found improved uptake of recommended handwashing and complementary feeding behaviours, and qualitative data indicated greater involvement of men in household and child-rearing responsibilities. SPRING rapidly scaled up the approach to 248 villages in Niger and 90 villages in Burkina Faso through collaborations with local partners, concept testing to adapt the videos to local contexts, and capacity building of video production hubs. Actions to support sustainability included exploration of income-generating opportunities of hubs and handover to Ministry-led regional technical advisory groups. Finally, the SPRING teams in Nepal and Uganda have written about developing and piloting a methodology to analyse planned and actual spend on nutrition from a government perspective – contexts where national policies dictate the need for scaling up of nutrition programming. The article describes challenges around aggregated budgets, lack of budget expertise amongst nutritionists, lack of data on central transfers to districts and off budget data in both countries.
Several articles describe in more detail the integration of programmes, either into existing services or with each other. In Mali, ALIMA write about strengthening pre- and in-service training for treatment of complicated SAM at the URENI teaching hospital where 262 health professionals working in 41 health centres were trained. In Yemen, an article by the World Health Organisation (WHO) team describes the in-service training and systems support provided for inpatient care of SAM which led to a mortality rate reduction from 8.3% to 4.5% between 2010 and 2013. Interestingly, one quarter of admissions were infants under six months of age. Also catering for this age-group, the team at GOAL have written an article about the successful integration of care for malnourished infants under six months of age into CMAM and primary health care services in two refugee camps using the community-based management of acute malnutrition in infants under six months (C-MAMI) tool.
A number of articles describe successful multi-sector programming or initiatives to promote multi-sector programming. An article by Salome Yesudas describes a multi-sector programme by ‘Living Farms’ in India targeted to the most marginalised tribes. The programme involved supporting stronger governance and strengthening food security, biodiversity, health service access and infant and young child feeding (IYCF). Inter-sector collaboration was identified as the key to success. An article by Welthungerhilfe and Concern Worldwide describes an ECHO funded, short-term integrated multi-sector project in Sindh province, Pakistan, involving CMAM, IYCF, water, sanitation and hygiene (WASH), livelihood and cash elements. The interventions were targeted to households with malnourished children in so called ‘hot-spots’. The evaluation found significant improvements in IYCF, livestock milk production, and hygiene practices. However, only one third of households with malnourished children were reached with nutrition-sensitive components due to lack of resources and the level of waterborne disease and safe water access was not improved; the scale of intervention was beyond the capacity and timeframe of the programme. Lessons learned have been integrated into a follow-up project that includes an exit strategy transitioning SAM treatment to World Bank funded development programming. A piece written by Judith Kabore and Laure Serra, Action Against Hunger, describes work in West Africa to strengthen the capacity of civil society members to advocate for scaling up multi-sector programming over three years. Local civil society actors from 12 countries created a Nutrition Champions Network. Activities included regional workshops and training on budget analysis, and integration of nutrition elements into other sector programming (increasing nutrition sensitivity).
There are numerous other articles in Field Exchange 55 covering topics as diverse as social behaviour change around food preparation and hygiene, and an innovative university led ‘Feed and Read’ programme in Nigeria, that helps prepare marginalised highly vulnerable children for higher education and modern sector employment.
Once again this is a bumper issue and thank you to all the contributors. The process of pulling Field Exchange together has certainly changed since the early days, when editors had to speak to numerous potential authors to get buy-in to writing an article and then very often had to pursue (as politely as possible) potential authors for a first draft. Getting that first draft was often the critical point, as if an author (s) had invested time and energy to get it to draft stage, then they would usually want to see it through from there. We are now fortunate enough to have a consistent flow of ‘unsolicited’ ideas and material submitted to the team and long may this continue. As editors, we remain heavily engaged in the evolution of articles, providing feedback, suggestions and asking questions which we think will resonate most with you, the reader; in essence, a friendly peer review. As ever, we are very grateful to the busy individuals who take the time to document their experiences and accommodate our queries. Special thanks go to the French-speaking authors from ALIMA (Niger) and to APPEL (Madagascar), who handled our French/English conversations with endless patience. As a new principle, all field articles will be available in French online at: http://www.ennonline.net/fex. We have also translated into French a selection of articles from the last five editions of Field Exchange, that are being compiled into a special compilation edition for regional dissemination. This will be available online late September.
Finally, look out for our next issue of Field Exchange (56) which will be a special issue on the Nutrition Cluster with an editorial co-written by Josephine Ippe (Global Nutrition Cluster Coordinator) and Carmel Dolan (ENN Technical Director). It should be a good one!
Jeremy Shoham, Field Exchange Editor
1Editors (2016). Introduction to the special issue. Field Exchange 51, January 2016. p1. www.ennonline.net/fex/51/editintro