Editorial

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In this issue of Field Exchange we are delighted to feature, for the second year running, a special section that shares key outputs of Action Against Hunger’s Research for Nutrition Conference held in November 2016. Introduced in an editorial note by Myriam Assefa and Stephanie Stern, we summarise eight research articles based on conference presentations. Topics include relapsing severe acute malnutrition (SAM), photo diagnosis of SAM and innovative approaches to MUAC assessment. The write-up includes capture of panel discussions on overcoming research data management challenges in crisis contexts and how to improve the engagement of communities in research. The attendance and engagement of this conference reflects the appetite for discourse between researchers and programmers – 130 people attended the conference, while the call for abstracts generated 57 submissions. 

This issue once again contains numerous articles on nutrition-sensitive and multi-sector programming. A field article by Anne-Marie Mayer, Rose Ndolo and Jane Keylock describes lessons from World Vision’s experiences of implementing the ENTERPRIZE project in Zimbabwe. This large, multi-sector, multi-partner project aims to improve food and nutrition security through coordinated activities primarily across agriculture, finance and health sectors. Findings to date reinforce the value of articulating a theory of change and establishing a monitoring framework based on this, with input from programme stakeholders, communities, government and the private sector. Unintended consequences also need to be captured; in this instance, it was determined that targeting farmers with the greatest capacity for increasing agricultural productivity could exclude the poorest and most vulnerable, making nutrition objectives elusive. The authors assert a need for practical guidance to help implement and assess multi-sector programmes under operational conditions and that further case studies would help inform such guidance.  

This issue also includes a summary of an updated review of the linkages and evidence of impact of programmes aimed at enhancing agriculture, women’s empowerment and nutrition. Markets and women’s empowerment were found to be the most important factors that modify the impacts of agriculture on nutrition outcomes. As with many reviews, the conclusion was a need for more research; in this case, into sustainability, scale-up and cost-effectiveness of nutrition-sensitive agriculture programmes. Another article describes an impact evaluation of UK Department for International Development (DFID)-funded integrated livelihoods and nutrition programmes in Bangladesh. Here, no significant impact on infant and young child feeding, dietary diversity or child nutritional status was found.

Another article summarises the findings of a synthesis paper based on three case studies of multi-sector nutrition programming in Nepal, Kenya and Senegal. These case studies were conducted by ENN as part of the DFID-funded Technical Assistance for Nutrition (TAN) programme for the Scaling Up Nutrition (SUN) Movement. The case studies focused on programme implementation and enabling factors at sub-national level. The synthesis describes the type of nutrition-sensitive and multi-sector activities taking place and the degree to which these are embedded in government systems and processes. These case studies are the first in a series that ENN will be conducting over the remaining two years of the TAN programme. The synthesis is therefore a working document, but early findings suggest limited modifications to programming, despite national-level policies and structures geared towards supporting multi-sector nutrition programming. There is also a distinct lack of monitoring and evaluation, which is a critical gap if multi-sector nutrition programming is to be rolled out further in SUN countries and beyond. 

Given the demand for more experiences on what works and what doesn’t, ongoing implementation challenges and the potential to learn from each other, ENN is launching a new thematic area on en-net in mid-April 2018 on multi-sector nutrition programming. We welcome questions (and responses) from those with experience and interest in multi-sector nutrition programming across a range of sectors. Questions might relate to programme design, coordination of sector activities, monitoring and evaluation, and evidence of impact. We are particularly interested in experiences from countries that might be described as fragile and conflict-affected.

Health system strengthening in fragile contexts is an ambitious and some may consider an ‘unattainable’ goal where programming delivery is heavily dependent on UN agencies, non-governmental organisations (NGOs) and external funding. An article by World Vision describes an innovative model of partnership for the delivery of health and nutrition services directly through the Ministry of Health (MoH) for Southwest State in Somalia. Governed by a partnership framework and overseen by task forces, it has focused on strengthening the key pillars of the health system, addressing not only technical capacity, but leadership and management, with annual performance review. The MoH has demonstrated significant progress through this support. A key outstanding challenge is dependence on short-term/emergency funding; the authors highlight the critical need for donors to provide multi-year funding streams for health systems strengthening in fragile contexts.

Progress on scale-up of acute malnutrition treatment is examined in two field articles in this issue. The Ministry of Public Health and UNICEF in Afghanistan chart the evolution of integrated management of acute malnutrition (IMAM) scale-up between 2003-2017 largely through a government lens. By 2017, the IMAM programme had been scaled up to all 34 provinces, with approximately 78 per cent of districts having at least one component of the programme. Barrier analysis continues to inform ongoing activities, such as integration of ready-to-use therapeutic food (RUTF) into existing supply mechanisms, capacity development of community health workers in screening, and securing provision for IMAM within longer-term projects and funding mechanisms. Current strategy and plans are ambitious: 2020 targets include increasing coverage of acute malnutrition treatment to 80 per cent of malnourished children under five years of age. Integration of treatment services in the Basic Package of Health Services (BPHS) and Essential Package of Hospital Services is considered the means to sustainable scale-up.

CMAM scale-up is also the theme of an article by UNICEF in the Yemen. Introduced in 2009 by government and partners, CMAM services have evolved to meet the increased caseload associated with chronic conflict and now include mobile teams and integration with vaccination and community health workers’ services, allowing for increased geographical coverage. Despite significant challenges due to ongoing conflict affecting programme quality and coverage, the authors document significant improvement in cure and defaulter rates. An estimated 201,096 deaths of children under five years of age have been averted over the last five years (2012-2017) through the treatment of acute malnutrition.

In both Afghanistan and Yemen, the main focus of treatment of acute malnutrition has been on SAM. MAM treatment has not kept pace in either context. In Yemen, geographical coverage for MAM treatment is 48 per cent compared to 72 per cent for SAM. In Afghanistan, 2016 targets for SAM treatment were 40 per cent of the SAM burden. These were exceeded (47.5 per cent), while a 30 per cent target for MAM was not met (26 per cent coverage achieved).

While supplementary feeding programmes (SFPs) have been the default MAM response for many years, new and potentially more effective approaches, such as combining protocols treating SAM and MAM within the same programme, are being researched and in some cases entering mainstream programming. Multiple actors are currently involved in MAM management, ranging from national government to UN agencies, with evolving mandates and approaches. Researchers are also focusing on different approaches, including behaviour change communication (BCC), new product formulations and nutrition-sensitive interventions. The discourse and practices around MAM treatment are intensifying and evolving and ENN is keen to help capture these developments. We plan to produce a special edition of Field Exchange on MAM prevention and treatment at the end of 2018 and are calling on our readers to write up programme experiences and research on this topic. More details are given below.

Older people remain under the radar in nutrition response, with few agencies programming specifically for this demographic. Given that Africa has one of the most rapidly increasing populations of older people, the need for nutrition-oriented programming for this cohort is growing. An article by Kidist Negash Weldeyohannis of Help Age International (HAI) describes an eight-month nutrition (CMAM), water, sanitation and hygiene and livelihoods intervention programme in Ethiopia to target older people in several districts.

This was prompted by district assessments that found global acute malnutrition prevalence of 10.5-15 per cent and a SAM rate of 1-1.1 per cent among older people. Programming was well intentioned but had limitations. Lack of RUTF supplies to treat this older caseload meant supplementary food rations had to be used instead through a parallel programme as WFP had no capacity to absorb an older caseload into its existing SFP.

In Ethiopia, there are no national guidelines on acute malnutrition management for this age group, data are not included in regular facility reporting and older people are not routinely included in needs assessments. Resource constraints generally limited integration with existing services. The authors appeal for greater advocacy, capacity development and resource allocation by donors to meet the humanitarian needs of this neglected group. Given the current shortfalls in overall humanitarian resourcing to address the burden of child undernutrition, this ‘call for support’ does beg the question: how this can be achieved? Absence of national guidelines is no surprise, given there is no international guidance on acute malnutrition in older people. Whose responsibility is this?

Finally, several research articles featured in this issue highlight gaps, lack of knowledge and blind spots in our sector. One paper presents an estimate of the prevalence and burden of children aged 6-59 months concurrently wasted and stunted for 84 countries. These children are at even greater mortality risk than those with SAM. Pooled prevalence was three per cent (0-8 per cent), corresponding to nearly six million children concurrently wasted and stunted – and is likely to be an underestimate since it is based on cross-sectional data that does not capture incidence.

An article by Myatt et al takes a fresh look at routine, cross-sectional survey data gathered by UNHCR over a number of years. It is argued that baseline and end line data comparisons fail to capture the dynamic nature of programming between these timepoints. Refugee populations in particular are notoriously “unstable”, with camps populations often in a state of dynamic flux. This can confound survey results; e.g. those leaving may be in a better nutritional state than those arriving. The authors propose a new procedure using single-survey data to try and account for this population flux; more work is needed to test and develop new approaches.

Another article raises concerns over inadequate thiamine provision to critically ill inpatient SAM cases using current treatment protocols which may be contributing to significant morbidity and mortality outcomes; refeeding in those with borderline thiamine reserves can precipitate acute thiamine deficiency, which impacts survival and has longer-term neurological consequences. The authors call for a reformulation of F75 and supplementation of breastfeeding mothers of complicated SAM infants under six months of age.

When it comes to acute malnutrition in infants less than six months old, low birth weight infants (LBW) are getting renewed attention. They feature in a recent systematic review that examined impact of nutrition-specific and nutrition-sensitive interventions to reduce LBW incidence. Six interventions were associated with a decreased risk of LBW: oral supplementation with vitamin A, low-dose calcium, zinc, multiple micronutrients; nutritional education; and provision of preventive antimalarial drugs. An important research need is to distinguish impact of such interventions in women who are undernourished; only three of the 23 identified studies did such sub-analysis.

LBW infants were also a key discussion point in a meeting of the Management of At risk Mothers and Infants (MAMI) Interest Group, summarised in this issue. Researchers are examining vulnerability of LBW infants and how this contributes to the burden of acute malnutrition and mortality in both young infants and older children. Emerging findings suggest that LBW infants are more likely to be identified as wasted and stunted at birth and at six months; that elevated risk of mortality persists beyond early infancy; and that being LBW carries mortality risk that cannot be wholly accounted for by low weight. In other words, being born small is even worse than just being small.   

Discussion at the MAMI Interest Group meeting highlighted the limitations, as much as the potential, of nutrition interventions for this age group. Anthropometric indicators remain poor proxies for nutrition risk and do not exclusively capture it. Even labelling these infants as ‘acutely malnourished’ carries the risk of inappropriate intervention and may discourage wider ownership (for example, by the health sector) if those identified as high risk are seen as a ‘nutrition’ problem. The evidence gap for case definition is stark, albeit improving.

As a nutrition sector, we took ownership and led the way on CMAM, making enormous progress in scaling up effective treatment. However, there has been a cost to locating CMAM within nutrition services rather than health as we struggle to integrate treatment of acute malnutrition within health systems and structures.

Furthermore, our focus on treatment has meant prevention has largely been ignored. Intervention approaches have been dominated by product delivery, especially when it comes to moderate acute malnutrition. MAMI offers – and needs – a fresh approach to identify and manage high-risk groups led by health, as well as nutrition, experts from the outset, with prevention as a guiding principle. The MAMI Group has a rich mix of nutrition, paediatric and mental health programmers and researchers who are aiming to do just this. A critical next step, reflected in the conclusions of the meeting, is a call for support to ‘up the game’ and develop a Global MAMI Network with country-level research – robust randomised control trials and implementation research – at the heart of a shared agenda that rapidly informs policy and practice.

I conclude with a reminder to get thinking and writing about MAM treatment and prevention programming and research.

Happy reading,

Marie McGrath, Co-editor Field Exchange