One UN for nutrition in Afghanistan - Translating global policy into action to tackle wasting

This is a summary of a Field Exchange field article that was included in issue 63 – a special edition on child wasting in South Asia. The original article was authored by Maureen L. Gallagher, Martin Ahimbisibwe, Dr. Muhebullah Latifi, Dr. Zakia Maroof, Dr. Said Shamsul Islam Shams and Mursal Manati.

Maureen L. Gallagher is Chief of Child Health and Nutrition for UNICEF in Mozambique.

Martin Ahimbisibwe is head of Nutrition at World Food Programme (WFP) Afghanistan.

Dr. Muhebullah Latifi is Food Security Policy Officer for the Food and Agriculture Organization (FAO) Afghanistan.

Dr. Zakia Maroof is a Nutrition Specialist for UNICEF in Afghanistan.

Dr. Said Shamsul Islam Shams coordinates the Technical Secretariat of the Afghanistan Food Security and Nutrition Agenda located at the Administrative Office of the President of the Government of Islamic Republic of Afghanistan.

Mursal Manati is Director of the Public Nutrition Directorate at the Ministry of Public Health Afghanistan.

Background

Undernutrition is an underlying cause of child mortality in Afghanistan. Approximately two million children under five years in Afghanistan require treatment for wasting, 780,000 of whom are severely wasted. While current Ministry of Public Health (MoPH) targets are to treat 600,000 wasted children, only 30,000 cases are currently reached.

Despite growing demands to address the problem of child wasting, the health system in Afghanistan is under-resourced and reliant on external aid to maintain service delivery. These issues are exacerbated by erratic climate conditions, widespread food insecurity and the hard-to-reach nature of many communities. More recently, the COVID-19 pandemic has led to increased food prices, the closure of borders, reduced mobility, loss of jobs and disrupted health services. This has led to a 50% reduction in inpatient admissions despite prevalent COVID-19 in the population.

Current interventions and inter-sectoral linkages

Integrated nutrition service delivery

In recent years, the MoPH and development partners have committed to integrating nutrition services into government systems. Nutrition-specific services in Afghanistan are delivered predominantly through non-governmental organisations (NGOs) contracted to deliver the Basic Package for Health Services (BPHS) and the Essential Package for Health Services (EPHS) through government health facilities. This includes the integrated management of acute malnutrition (IMAM).¹ Operational costs for these services are covered by the System Enhancement for Health Action in Transition Project for Afghanistan (SEHATMANDI). However, the cost of ready-to-use therapeutic food (RUTF) used in the management of medically uncomplicated cases of severe wasting in the community are not covered and must be sourced externally.

Admission and performance data are collected monthly from health facilities and collated in a national database managed by the Public Nutrition Directorate (PND) of the MoPH. Plans to make this information available via an online dashboard are being finalised. Screening data is collected by the Health Management Information System (HMIS) to enable the monitoring of nutrition trends.

Scale-up of wasting treatment services

The scale-up of treatment services has differed for moderate and severe wasting. For severe wasting, coverage was doubled between 2016 and 2018 to 60% at a cost of around USD20 million per year. In 2019, plans for further scale up were interrupted by a shortfall in RUTF supplies and overall funds. Moderate wasting programming is guided by the Humanitarian Response Plan (HRP). Under this plan, programming locations are prioritised by the Nutrition Cluster based on global acute malnutrition (GAM) rates and vulnerability to food insecurity. Treatment of moderate wasting is therefore implemented in around 45% of health facilities at a cost of USD28 million per year.

Further geographical scale-up of wasting treatment is limited by resource availability as well as by difficult terrain, weather and security issues. In some areas, the use of mobile health and nutrition teams, operated by the Directorate of Provincial Health (DoPH), have overcome accessibility challenges. This could potentially be expanded, particularly in the context of COVID-19, to minimise population movement. However, funding for this modality is limited.  

As the cost of RUTF is not covered under SEHATMANDI, procurement depends on off-budget and short-term emergency funding. This is led by the World Food Programme (WFP) and UNICEF with funding from various donors such as Food for Peace/United States Assistance of International Development (USAID) and pooled funding through the Afghanistan Humanitarian Fund (AHF). WFP and UNICEF also provide technical support and ad hoc training for wasting treatment. The World Health Organization (WHO) provides support for inpatient care of severely wasted children with medical complications. This includes training of health staff on the management of severe acute malnutrition (SAM), the supply of therapeutic milk preparation kits and medical resources and the rehabilitation of water and sanitation systems of inpatient units in hospitals.

Strengths and challenges of nutrition-specific programming in Afghanistan    

Much has been achieved in the strengthening and coordination of national nutrition programming. Led by the government, agencies collaborate to bring a quality continuum of care closer to women and children under the ‘One UN for Afghanistan’ strategy. Within this strategy, key collaborative initiatives between UN agencies, such as UNICEF, WFP and WHO, support the MoPH in technical coordination, development of strategies and guidelines, resource mobilisation, facilitation of technical working groups, capacity strengthening and programme delivery for nutrition programmes, including wasting treatment. These efforts have successfully increased admission into, and the performance of, wasting treatment programmes through the training of health workers, last mile delivery of supply, counselling on maternal, infant and young child nutrition (MIYCN), the rollout of community-based nutrition services and engagement of community volunteers and the use of home-based screening through Mothers’/Family mid-upper arm circumference (MUAC).²

However, the scale-up of treatment services is hindered by problems with the RUTF supply chain due to a reliance on off-budget funding. Integrating RUTF into the essential medicine supplies (EMS) list would increase the government’s procurement and supply chain capabilities; however, this is a challenge since RUTF is not currently integrated into the WHO global essential medicines list (EML). To mitigate these challenges, the MOPH is exploring the use of simplified protocols, using reduced RUTF dosages, for severe wasting treatment as well as local commercial production and home-based product formulations of RUTF.

Another important challenge is the lack of funding to sustain and scale up nutrition services.  Most donor support currently funds coordination activities or the procurement of treatment supplies for humanitarian actions. Other sources of longer-term bilateral funding are needed to support the government to sustain programming at full scale.

Putting prevention at the heart of wasting management – a vision for Afghanistan

Opportunities to enhance wasting treatment and prevention efforts

The burden of wasting in Afghanistan is overwhelming and increasing, driven by complex underlying causes such as household food insecurity, inadequate care and feeding practices, inadequate hygiene and sanitation and a lack of access to health services. Prevention must be central to wasting management in Afghanistan. This requires an integrated multi-sectoral package of nutrition, health, food security, social protection and water, sanitation and hygiene (WASH) interventions. Currently, the main preventive approaches focus on agricultural production, processing, storage, preservation and dietary diversification programmes as well as on social behaviour change. Synergy between wasting prevention and treatment programmes, including increased referrals and shared planning, must be improved to maximise their impact.

New way of working for UN agencies in Afghanistan

The policy and programming environment in Afghanistan shows promise for an integrated prevention and treatment approach to tackle child wasting. The government-led Afghanistan Food Security and Nutrition Agenda (AFSeN-A) provides an opportunity to bring all necessary services together in a multi-sectoral approach to tackling stunting and improving food security and nutrition overall. The AFSeN-A Strategic Plan 2019-2023 brings together key interventions and obligations under different government ministries and is led by a technical secretariat (the Administrative Office of the President (AOP)).  

Linked to the AFSeN-A Strategic Plan, UN agencies in Afghanistan have an opportunity to bring together an integrated package of services under the leadership of the government. While committed to working together under the One UN platform, there is no joint framework for action which limits impact. The recently developed Global Action Plan (GAP) on Child Wasting³ is a global framework for action to accelerate progress in preventing and managing child wasting and the achievement of the Sustainable Development Goals (SDGs). The AFSeN-A and agencies have also worked together on a complementary feeding framework with the same key areas of intervention as the GAP on Child Wasting (health systems, food systems, WASH and social protection). These, and the development of an operational roadmap for Afghanistan, provide an opportunity to consolidate efforts and bring the UN agencies together more concretely for enhanced outcomes. Based on the AFSeN-A Strategic Plan, the roadmap will identify provinces for convergence and indicators to measure joint progress. The AFSeN-A technical secretariat will lead this process to ensure that the result is in line with government priorities. A common project document and monitoring plan to prevent and manage wasting nationally, and in the selected priority provinces, will be produced by the end of 2020.

The government of Afghanistan is leading on the following next steps, with support from UN agencies:

• Mapping of current UN and non-UN interventions guided by the AFSeN-A Strategic Plan
• Identification of priority intervention areas, coordinated by AFSeN-A and MoPH/PND. This will be supported by UNICEF as Cluster Lead Agency and identified lead to coordinate the GAP on Child Wasting.
• Identification of funding gaps, as well as a costing exercise, to inform advocacy for funding and resource mobilisation by government and donors
• Identification of areas to expand the fiscal space for funding of the action plan with government and donors
• Advocacy for one focal donor to coordinate and advocate for funding for nutrition with other donors
• Collection of wasting data on a five-year basis (Demographic Health Survey)

Conclusion

Reducing wasting to acceptable levels in Afghanistan is within reach. However, stronger commitment from government and donors is needed to complement ongoing efforts. The GAP on child wasting offers an important opportunity to consolidate and build on the work done. UN agencies are committed to working together, driven by the government under AFSeN-A and coordinating with key ministries, to develop and operationalise a roadmap for Afghanistan. However, a broader funding strategy is urgently needed to support the development of longer-term solutions to prevent and treat child wasting.

For more information please contact Dr. Zakia Maroof.