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Over the years the scope of ENN’s work has expanded beyond a focus on humanitarian contexts to encompass a broader set of issues around drivers of wasting and stunting in both high burden and emergency contexts. We are also increasingly interested in the evolving policy and programming environment around malnutrition treatment and prevention. ENN is currently engaged in exploring the relationship between wasting and stunting (see the recent blog piece by Carmel Dolan here), stunting in emergencies, and on how stunting or wasting focused initiatives interact in practice.

While my work with ENN is focused on the scaling up of programs to reduce stunting (looking at SUN countries within the Asia region), the evolution of the scaling up of acute malnutrition and treatment and prevention programs is also of interest. To this end, in mid-May I attended the regional conference Stop Stunting | No time to waste - Scaling Up Care for children with Severe Wasting in South Asia in Kathmandu. It was organised by SAARC and UNICEF ROSA and brought together country teams from 7 SAARC countries (India was absent at the conference).

The 2016 Joint Child Malnutrition Estimates revealed that 52% of the 52 million wasted children worldwide live in South Asia of which 9 million are severely wasted. While prevalence of stunting is declining at a slow pace, there are still 61.2 million stunted children in this region.  

In South Asia, the gap between children needing specific treatment for severe acute malnutrition and those receiving it is very wide. Facility based treatment which is critical for wasted children with complications, is very limited in reach. Community Based Management of Malnutrition (CMAM) is currently being implemented in only 3 countries in South Asia (Afghanistan, Pakistan and Nepal) with limited coverage. This leaves most children with no access to specific treatment. It also appears that recovery after treatment, be it facility or community based, is not sustained, which is possible only when children and carers have access to food, a clean environment and primary health care services.

The meeting held in Kathmandu took into consideration these complex and diverse settings. I present a few points which from my perspective made this meeting different from others that I have attended on acute malnutrition in the region:

• Severe wasting was not looked at in isolation - Evidence shared from the region revealed that wasting and stunting share 4 main drivers - low maternal BMI, poor child diets and feeding practices, low levels of women’s education, and household poverty. The view articulated was that efforts to prevent wasting need to be linked to efforts to prevent stunting and combined with services and programmes for early detection and treatment of children with severe wasting.
• Child mortality risk - The oft repeated evidence based argument of increased mortality risk (9 times more than a normal child) of severely wasted children did not find mention. This is perhaps because there has been some recent evidence from mortality surveys from the region not consonant with this global evidence. I referred to this discordance in an earlier blog post. This sharply contrasts with severe wasting in the African context. 
• Situation of adolescents - Recognition that adolescents are anaemic and undernourished, drop out of education, are married and bear children early, are significant contributors to stunting and wasting in the region.  Addressing the health and nutrition needs of young women is critical.  
• The continuum of care - this was given a lot of emphasis and there was a concerted effort to replace the terms "management" and "treatment" with "care" for children severely wasted children. This goes beyond semantics - it brings to attention social determinants which need to be addressed beyond medical treatment of the child and the need for appropriate care at various levels (in the facility-linked to services in the community and in the family).
• Multisectoral approaches and programmes always feature in discussions on stunting reduction. In Afghanistan and Pakistan, Multi-Sectoral Plans and CMAM are implemented in parallel. A refreshing contrast is seen in Nepal where CMAM is built into the Multi-Sectoral Nutrition Plan (MSNP).
• Integration of CMAM into health systems was recognised as a difficult ask. High caseloads present a formidable challenge in this region. It was made clear that positioning severe wasting care squarely within primary health care makes it comprehensive integrated child centred health care. Nepal and Bangladesh have ongoing efforts to integrate CMAM into the health system.
• Integrated Management of Childhood Illnesses (IMCI) - The forgotten element of IMCI made a comeback. One of the components of the IMCI package has been services for acute malnutrition. A recent review of IMCI implementation showed that only 28 out of 90 countries provided services for acute malnutrition.
• Ready to Use Therapeutic Food (RUTF) was discussed but was not the focus of discussion. It was clearly stated that RUTF is a necessity only when prevention fails. At this point in time it has failed 9 million children in the region.  A good quality product is an essential part of a programme but is neither the only nor the most important component of a community based programme to combat severe wasting. By the end of the year it is expected that Bangladesh will start effectiveness trials using the RUTF made locally by icddr,B. Efficacy trials have shown that both varieties of the local product (Type 1 with rice and lentils and Type 2 with chickpeas) are as efficacious as the standard RUTF.

The discussions raised several issues, most important of which are the lack of consensus on screening methods, the lack of reliable coverage data, food insecurity, and seasonality and frequent natural disasters and their implications for wasting prevalence.

A thought on what is hindering scale up of CMAM in the region. Some stakeholders in India and South Asia perceive RUTF as a quick fix and a magic formula which does not provide sustainable impact and therefore resist efforts to roll out product based programmes. However, those who advocate for the use of RUTF see it neither as a magic formula nor as a product to be used in isolation; but as one of many components of Community Based Management of Acute Malnutrition.  

To overcome the impasse, a meeting of technical experts from the region is needed to draw up clear evidence based guidelines which is sensitive to the varied contexts in the region. One sincerely hopes that this will also bring Indian policy makers, technicians and implementers to the table. To address stunting, in addition to scaling up of nutrition sensitive interventions the importance of scaling up specific treatment for wasting must not be forgotten. There is no time to waste.