Field Exchange No. 37 (November 2009)
While there are at least four distinct thematic areas addressed by articles in Field Exchange 37, there is arguably one cross-cutting issue - namely the tendency towards fragmentation and lack of coordination within the emergency nutrition sector. We will return to this later. This issue of Field Exchange carries a number of research summaries related to the role of data and indicators in emergencies. There are pieces on the evidence for impact of the global food crisis on the poor, a new method of statistical forecasting for famine, based on data sets produced in Kenya, and programmatic implications of the roll out of the 2006 World Health Organisation (WHO) growth standards. There is also an important review conducted by the Health and Nutrition Tracking Service in WHO on the primary indicators used in emergencies. This highlights the lack of standardisation and measurability of many of the indicators used for monitoring emergency programmes. Another study, conducted by Fiona Watson, analyses the role of contextual (nonanthropometric) data in nutrition surveys conducted in Ethiopia. Again this highlights the lack of standardisation of information collected, as well as the limited use made by decisionmakers of this information.
A second thematic area concerns the use of specialised foods used in feeding programmes. Research findings are summarised on the relative effectiveness of fortified spreads compared to corn soy blend (CSB) in Malawi supplementary feeding programmes and, again from Malawi, the morbidity and mortality outcomes of using probiotic and prebiotic fortified ready to use therapeutic foods (RUTFs) compared to 'normal' RUTFs. Another study reviews the value of using lipid based nutrient supplements in food rations. There is also an article on the roll out of RUTFs in a number of Indian states, which discusses whether such a strategy is appropriate given long-term use of local recipes for treatment of severe acute malnutrition (SAM). Finally, a field article written by Caroline Wilkinson and Sheila Isanaka, compares the use of diluted F100 and infant formula in the treatment of severely malnourished infants under 6 months old in inpatient therapeutic centres in the Democratic Republic of the Congo (DRC).
Another thematic area is programming in conflict situations. One research summary describes the experience of decentralising growth monitoring in conflict affected areas of DRC. There is also a field article written in collaboration with members of SAACID (an Australian based charity), giving a fascinating account of a food kitchen programme in Mogadishu that has been running for two years and has served over 33 million hot meals in that time. The programme has operated in one of the most insecure environments of the world and yet only had one major security incident directly affecting the kitchen sites. However, the widespread insecurity in the city has impacted programmes by making access difficult, while the surge in demand for the meals has meant that each meal has effectively been used to feed close to five people.
A final thematic area in this issue of Field Exchange concerns 'how nutrition is conceptualised' within the humanitarian sector. The utility of the UNICEF conceptual framework on malnutrition is explored in an article from Afghanistan where interviews with stakeholders at community and various government administrative levels demonstrated how it has helped foster collaboration between the agricultural and health sectors. A second piece by Action Contre la Faim (ACF) evaluates their approach to integrated nutrition programming and reflects that, although the UNICEF framework has been useful in conceptualising how to integrate programmes across sectors, the practical challenges of so doing are substantial.
As with so many past issues of Field Exchange, it is hard not to be struck by the richness and diversity of initiatives and programming approaches that are ongoing in the emergency nutrition sector. In many respects this is commendable and engenders a sense of optimism around the fact that there is so much energy, innovation and drive towards improvement in the sector.
However, the other side of the coin - and one which is of increasing concern - is that many of the initiatives are uncoordinated, disparate, not joined up and are agency specific. At best this leads to competition between initiatives and approaches, with the best ones rising to the surface and receiving deserved funding and uptake by agencies. At worst it leads to confusion, inaction, duplication, and in some cases, wasted resources.
Some elements of this 'worst case scenario' are already being played out in two of the thematic areas above.... A range of new specialised foods is currently being developed by a number of actors to improve the outcomes for children affected by, or at risk of developing, moderate or severe malnutrition. These foods have different specifications and are being piloted in a variety of contexts and populations. There is no overall coordination of the foods being developed and piloted and perhaps more importantly, no agreed validation process. The result is an increasing number of pilot studies purporting to demonstrate certain outcomes in relation to programme efficacy and impact. At the same time, a number of private companies and other organisations are developing new products, yet have no internationally agreed means for validating these products.
Agencies responsible for implementing feeding programmes and donor organisations funding these programmes are therefore increasingly being faced with an array of potential products and no mechanism to determine which are most cost-effective and which ones satisfy essential nutritional and medical standards. This proliferation of initiatives is a relatively new phenomenon in the emergency feeding sector and is giving rise to a range of additional challenges. For example,
- What are the moral and entrepreneurial frameworks within which public private partnerships should operate?
- How to monitor private enterprise activities and partnerships and ensure that the independence of public sector collaborators is not undermined or perceived to be so?
- The need for clarity on entry and exit strategies for using specialised foods in a variety of contexts, e.g. blanket feeding to prevent malnutrition, feeding in situations of chronic emergencies, etc.
There are currently no lead agencies helping to chart the way forward in this increasingly complex area.