Editorial
Dear Field Exchange readers,
Welcome to the 64th edition of Field Exchange. We are delighted to kick start 2021 featuring a special section on learning around CMAM Surge, nicely coinciding with the 20th anniversary of community-based management of acute malnutrition (CMAM), an approach that originated as community therapeutic care (CTC).1 Concern Worldwide (Concern) were closely involved in the first CTC programmes undertaken by VALID International in partnership with Concern and Oxfam in Ethiopia and have remained committed to community-based care since, learning from and evolving their approach along the way in open and close collaboration with many partners and increasingly government. CMAM Surge is an approach that works to support government health systems to prepare for and manage spikes in caseloads of wasting that are typical in many contexts. CoPncern first piloted CMAM Surge at county level in Kenya in 2012. It has since been implemented in 12 countries (seven supported by Concern) and momentum is growing for it to be applied more broadly to co-morbidities, such as diarrhoea and malaria (Health Surge) in multiple contexts. This special section includes seven articles that tell the story of the evolution of the approach, reflecting on the strengths, weaknesses, lessons learned and ways forward. A few things struck us as we reflected on the experiences shared and on several related articles in the edition.
Essentially, CMAM Surge is a health systems strengthening (HSS) approach that has demonstrated good traction at health facility and district levels. Government authorities have engaged with CMAM Surge to different degrees in different contexts. The critical importance of government leadership is reflected in an article by Ngetich et al that explores the testing and scale up of Integrated Management of Acute Malnutrition (IMAM) Surge (CMAM Surge) in 10 priority counties in the Arid and Semi-arid Lands (ASAL) to improve the shock-responsiveness of the health system. Success factors include early and sustained government leadership and the involvement of decision-makers at sub-national level. Long term, flexible financing from governments and donors was also critical. A related article on HSS in Kenya by Hailey et al under the MQSUN+ Consortium describes the transition of external humanitarian support for nutrition services towards government-led, managed and financed nutrition services in the ASAL regions over the last 14 years. Donor openness to innovation has also helped move CMAM Surge forwards. In West and Central Africa, European Civil Protection and Humanitarian Aid Operations (ECHO) prioritised CMAM Surge which helped drive uptake by partners in the region. Important lessons include the need to ensure that partners are well capacitated - Save the Children International and Concern were engaged to provide technical support to partners to deliver due to some early shortcomings - and to make sure that the haste of non-governmental organisations (NGOs) to support implementation does not deprioritise government engagement and fuel perceptions that CMAM Surge is an externally led and resourced activity.
In making the case for CMAM Surge, cost is a question. An article on the cost-effectiveness of CMAM Surge reflects on the difficulties of demonstrating cost-effectiveness of HSS approaches, given that many of the positive outcomes (empowerment of health staff to make informed decisions for example) are difficult to quantify. The authors argue that, before cost-effectiveness can be demonstrated, we first need cost analysis tools more fit for purpose for HSS initiatives.
The emerging direction of travel by Concern and others into Health Surge is an interesting one. Staff on the ground began to apply the CMAM Surge approach used for wasting management to other morbidities as doing so made practical sense in their day-to-day management of caseloads. There is now a growing community of practice amongst the ‘CMAM Surge’ fraternity at global and regional level, led by Concern, who are developing the approach and supporting resources to continue rollout. Critical to this new initiative will be active engagement of the health sector at global, regional and national levels. One of the constraints to embedding CMAM in health systems is that it is an initiative that has been ‘housed’ and essentially owned by the nutrition sector; we need to make sure we don’t do the same for Health Surge.
How to support HSS in more acute emergency contexts and fragile settings needs more consideration. Some of the challenges associated with this are reflected in an evaluation of the Northeastern Nigeria emergency response by Donnelly et al, also under MQSUN+. While external support addressed urgent needs, it was not designed to encourage long-term sustainability and government ownership and recruitment of local staff ended up depleting the government work force. Figuring how to immediately meet urgent needs versus long term capacity support is a tough balancing act.
This special section of Field Exchange sets some of the scene nicely for a virtual conference for practioners that Concern is hosting between 22nd and 25th March this year in partnership with Irish Aid. CMAM 20 years on: going to scale in fragile contexts is an event designed to take a moment to share and reflect on operational learning and direction on CMAM programming. The conference will feature country and regional presentations and panel discussions from Democratic Republic of Congo, Niger, Kenya, Ethiopia, Somalia, South Sudan, South Asia and Pakistan. See the news item in this edition for more information and registration details. ENN is a member of the steering committee for this event and we look forward to updating you on it in our May edition.
A prevailing context that continues to trouble us the world over is the COVID-19 pandemic. But, as ever in the nutrition world, challenges are met with field innovation; necessity remains the mother of invention. Several articles show the formidable task that decision-makers and health workers have had all over the world to quickly adapt services across nations to ensure that nutrition services are continued and those in need can access them. An article by Action Against Hunger provides an overview of programmatic adaptations that have been made in wasting treatment services in multiple locations. Other articles zone in on adaptations made in Zimbabwe (use of RapidPro software to allow remote data collection); Zambia (reallocation of resources to support personal protective equipment and community-level screening); and Ethiopia (use of Family MUAC to enable screening of infants under six months of age for management in an established programme). A common theme across these contexts is the initial fall in service uptake followed by an increase again as adaptations were made; this reflects success that has enabled the continuation of services. However, interpretation of such trends is complicated; where screening criteria have been amended, such as higher mid-upper arm circumference (MUAC) thresholds, we are not comparing like with like. Where frequency of attendance to treatment facilities is reduced to minimise contacts, we don’t yet have clear data on outcomes. Predictions of the consequences of the COVID 19 pandemic for nutrition are grim; the challenge remains in evidencing this.
Several more articles reflect on the power of information. A key success of the CMAM Surge approach is its potential to empower health facility staff. By building health workers’ capacity to analyse their own data and make decisions, not only are better decisions made, but the workforce becomes more engaged and motivated. The desire of health workers to apply the approach to other childhood illnesses demonstrates their conviction that it works. At a higher-level, the Kenya experience shows that a well-functioning nutrition information system, owned by the government, has supported informed decision-making around nutrition services. Access to and use of information to inform decision-making can be supported by the use of technology with several examples in this edition, such as the use of CMAM Surge online dashboards; Zimbabwe RapidPro software for remote data collection; and use of earth observation data to detect cropland abandonment by World Food Programme (WFP) Mali that enabled early planning for food assistance three months ahead of the lean season.
When it comes to task shifting to community-level, several articles reflect how training and supervision are key to quality services. A strong theme throughout the issue is the shifting of tasks to Community Health Workers (CHWs) and shifting further still to caregivers for the screening of malnutrition across multiple contexts (Family MUAC) – both accelerated in the context of the COVID-19 pandemic and including infants under six months of age. A key theme is the critical need for quality training and supervision of CHWs (and training of caregivers including refresher training) to ensure quality programming is maintained. The Zimbabwe RapidPro article, which found a large discrepancy between the number of referrals and actual admissions, demonstrates this very clearly. The need for training of caregivers is echoed in a research summary by UNICEF West and Central Africa Regional Office (WCARO) that shares evidence and experience on the use of Family MUAC in the region. Not only are CHWs the unsung heroes of the pandemic response - adapting to and accommodating to demands that carry personal risk - they are the backbone of nutrition programming and the route to scale. Key challenges persist, including how to sustainably incentivise CHWs as well as ensure quality training and supervision.
As ever, we were spoilt for choice when it came to interesting research to summarise. A rich mixture includes a thought-provoking paper on sex differences and undernutrition by Thurstans et al. Although higher neonatal and infant morbidity/mortality for boys is well described, it is commonly assumed that girls are very often disadvantaged over boys. A systematic review and metanalysis of 44 studies showed consistently higher odds for boys being wasted, stunted or underweight than girls across multiple contexts. Possible reasons are now being examined by the authors with further papers to come but results are starting to show that this is not the result of gender bias, but due to multiple other biological and social factors. This has the potential to be an area of debate that is politically charged, with signs that this is already the case. Interestingly, the authors found that even where sex differences are reported in a paper, they are not always acknowledged or explored. This paper challenges the current notion that equal representation of boys and girls in wasting treatment programmes, for example, is a sign of equity, and that over-representation of boys is a sign of gender bias. In fact, such programmes may be reflecting the reality. The paper’s findings also raise the question of whether joint sex versions of growth charts and universal measurements such as MUAC consider these differences and fully account for the fact that boys have further to fall to meet these thresholds, and may therefore be in a more depleted state than their female counterparts. Critically, the message of this study is not that boys should be prioritised over girls, rather it seeks to support all at-risk children, through improved understanding of sex differences in undernutrition. To help, the authors call on nutrition actors to improve data collection in programmes, surveys and research through the full disaggregation and analysis of sex and age in order to identify which children are most vulnerable in specific contexts, and to allow comparison of programme data with population-level burdens. We welcome submission of such analyses to Field Exchange.
Adolescent nutrition is an area gaining increasing attention. We summarise the results of a global stakeholder survey of policies, research, interventions and data gaps on adolescent nutrition by ENN, along with several articles describing research in this age group. With evidence and programme experience in this area growing, we consider it a good time to produce a special edition of Field Exchange on Adolescent Nutrition (Issue 66) in collaboration with the Adolescent Nutrition Interest Group - an informal collective of interested researchers, academics and programmers established by ENN, the London School of Hygiene and Tropical Medicine (LSHTM) and Save the Children. We will soon launch a call for content for this issue, due out in November 2021 - watch our website for more details. Meanwhile, we encourage you to participate in (or catch up on) a virtual meeting on adolescent nutrition (9th and 10th Feb), convened by ENN, UNICEF and LSHTM to share information on some of the latest research and operational initiatives in adolescent nutrition and explore priorities for assessing and improving adolescent nutrition across policies and programming. Visit www.ennonline.net for registration details or to access a recording after the event.
The news section in this issue reflects a busy and critical year ahead for the nutrition world, from conferences (Nutrition For Growth, Food Systems Summit), to guideline development (World Health Organisation (WHO) wasting guidelines update) to revamped ways of working (e.g. relaunch of the Global Nutrition Cluster (GNC) Technical Alliance, formerly the Global Technical Assistance Mechanism for Nutrition (GTAM) and a revamped UNICEF-WFP partnership on wasting management). Watch out for updates and summaries in Field Exchange online and in future editions and please share with us what you are doing to prepare and contribute. We especially welcome national perspectives on these international fora and initiatives.
Finally, we’d like to highlight to you a letter to the editor from Mubarek Abera, Ethiopian lecturer and nutrition scientist, that reflects the value of giving researchers from the ‘Global South’ space in global platforms and opportunities to engage in international nutrition discourse. The stark Global North/South Gap in this regard is highlighted in an exposition of a sobering online exhibition of cartoons (illustrations of blog articles written by local researchers) by Congolese political cartoonist, Tembo Kash from Democratic Republic of Congo (DRC). Exploring power dynamics between researchers from the Global North and Global South, ‘(Silent) Voices: Bukavu Expo’ raises issues about donor methodologies, duty of care, cultural differences and gender discrimination as well as the difficulties of conducting research in conflict and post-conflict settings. We can all do more to give a voice and a platform to members of the Global South. Through 2021 we will continue to proactively pursue and support greater national authorship of the articles that we publish and track our success in this. We will summarise key Field Exchange articles into ‘digested’ reads for sharing online and with national and sub-national stakeholders and will examine how we can further distill the ‘so what’ of research findings for policy and programming to improve accessibility for all. We have editorial capacity to support article submissions in French and look forward to featuring more nationally authored Francophone learning through 2021. Please help us by encouraging and supporting your national colleagues – programmers, researchers, policy makers – to contribute to Field Exchange.
This edition again demonstrates the continued innovation and adaptation of nutrition actors to evolving contexts and challenges. The challenge remains to keep nutrition centre stage within all the various (and what can feel like competing) global priorities, including pandemics, food systems, and climate change, where there has never perhaps been greater urgency and opportunity to integrate nutrition. We look forward to capturing your experiences of doing so through 2021.
Chloe Angood (Sub-editor), Anne Bush (Surge Editor), Marie McGrath (Editor)
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