In July 2019, we produced a special edition of Field Exchange (issue 60) on continuum of acute malnutrition care. Our editorial1 identified areas of action we felt were needed to address significant shortcomings hampering this provision. These related to United Nations (UN) institutional arrangements and divisions of roles among agencies, supply-chain management of ready-to-use products, and the lack of normative guidance in areas such as treatment of moderate acute malnutrition. Since then, we have engaged with different stakeholders at multiple levels to highlight these issues and have tried, as many others are doing, to catalyse progress. A key moment for everyone was the eagerly anticipated Global Action Plan (GAP) on wasting developed by five UN agencies (United Nations Children’s Fund (UNICEF), World Food Programme (WFP), the World Health Organization (WHO), the Food and Agriculture Organization (FAO) and the United Nations High Commissioner for Refugees (UNHCR)). As we release this edition, the final GAP on wasting2 has been released and a more targeted Roadmap for Action will follow. Discussions to identify commitments and actions by governments and other key stakeholders will continue throughout 2020, with the aim of releasing the comprehensive global plan at the Tokyo Nutrition for Growth (N4G) Summit in December 2020.
Many, including the Emergency Nutrition Network, acted quickly to provide feedback on the draft GAP on wasting within a short public consultation period in February. Given that 2020 marks 20 years since the birth of community-based management of acute malnutrition (CMAM) (community- based therapeutic care), we felt it most fitting to share reflections on the GAP from Dr Steve Collins of Valid International/Valid Nutrition, who conceptualised and was instrumental in the development and rollout of the community-based approach that is at the heart of case management of wasting today. Never one to shy away from challenging the status quo, Steve’s reflections provide rich food for thought and debate – your responses are welcome in the form of letters to the editors.
The Lancet Double Burden series, summarised in this edition, challenges us to address all forms of malnutrition – underweight, micronutrient deficiencies and overweight – together. Balancing the immediate and longer-term risks of different forms of malnutrition and associated interventions is complex. This is reflected in a views article by Manary et al that challenges the caution promoted by the Lancet series on the use of high energy and nutrient-dense foods for wasting treatment, due to concerns this may fuel long-term health problems down the road. The heightened and overdue focus on the double burden should not come at the price of attention (and resourcing) to address the more immediate mortality risks of wasting. On that note, it will be interesting to see how far we have come (or not) in addressing undernutrition when a follow-up to the 2013 Lancet series on maternal and child undernutrition is launched in June.
The need for context-specific emergency preparedness is another theme of this issue. An article by UNICEF Latin America and Caribbean Regional Office (LACRO) describes a regional initiative that leverages an existing risk-assessment model to determine nutrition risk scores (a composite of nutrition vulnerability and capacity indicators) to inform emergency planning. Data from 33 countries reveals a large gap in capacity and high nutrition vulnerability across the region. Country and regional action has been sparked to begin to address shortfalls. Building on this theme of contextual preparedness, an article by Mutunga et al describes experiences of using an adapted global nutrition in emergencies (NiE) training package as part of a regional emergency preparedness and response capacity-building initiative in Southeast Asia. Strong government participation, drawing on real-time experiences and integrated within national and sub-national planning and training curricula, has catalysed sustained initiatives. The current global NiE training package only focuses on CMAM, infant and young child feeding (IYCF) and wasting treatment; adjustments are needed to cover other prevailing nutrition problems in this context, including stunting, anaemia and non-communicable diseases. This suggests that a review of the current NiE package is needed to ensure it is global in reach, relevance and application.
Unpredictable events challenge even the most sophisticated levels of preparedness.
UNICEF’s article describing experiences in responding to the influx of Rohingya people in Cox’s Bazar, Bangladesh, is a case in point. The authors document a hybrid nutrition sector coordination model that drew on the planning of existing government preparedness clusters and the Inter-Agency Standing Committee (IASC) cluster approach, but did not involve official IASC cluster activation. The lack of recognition of the new Rohingya influx as official refugees by the Government of Bangladesh complicated the typical UN division of labour and UNHCR assumed coordinating authority. The nutrition response was fragmented in the context of an overwhelming situation. Based on this experience, the author suggests that coordination models for atypical scenarios should be examined and appropriate global guidance/coordination mechanisms developed and embedded within national and sub-national systems, in close consultation with government.
The current COVID-19 pandemic is perhaps the most extreme example of unpredictability and is completely unchartered waters for a global response. The potential fallout from this outbreak for nutrition – from redirected financing to compromised treatment in stretched facilities to reduced access to preventive services like mass vitamin supplementation campaigns or vaccination uptake – could be immense. Most immediately, what needs to happen now to prepare for outbreaks of the virus in Africa and parts of Asia where there is currently no diagnostic capacity and health systems are weak? Two research snapshots in this issue share some initial thinking, while a technical brief has been prepared by the Global Technical Mechanism on Nutrition (GTAM). This provides links to a compilation of guidance documents and resources to support practitioners to integrate COVID-19 preparedness and response into humanitarian nutrition programmes. Regular updates of this brief are planned.
The challenges in determining nutrition impact of interventions are reflected in several articles, yet demonstrating impact is critical for scale-up. Evaluation of a social protection programme in Nigeria that targeted mothers and infants within the first 1,000 days failed to show impact on wasted or underweight prevalence (as intended), but saw positive impact on uptake of antenatal clinic (ANC) services, health indicators, IYCF practices and stunting prevalence. The question is, does this reflect a lack of nutrition impact, or simply the limitations of a blunt anthropometric tool that we overly equate to nutrition status? An article by Berhanu et al shares lessons from the rollout to date of the Growth through Nutrition in Ethiopia project, a five-year (2016-2021), multi-sector programme implemented in 110 districts in four regions of Ethiopia. Midline assessments found improvements in child minimum acceptable diet, iron and folic acid supplementation in pregnant women, ANC uptake, and household water, sanitation and hygiene practices, but mixed results on breastfeeding behaviours. Impact on child nutrition status remains to be seen; the challenge will be to unpack the pathways of any demonstrated impact. Two research articles from Tufts University demonstrate the pressing need to ensure rigorous research and quality evidence to improve policy and programming. A landscape review of current research on specialised nutritious foods (SNFs) used to impact nutrition found narrow scope in terms of context and nutrition outcomes. More research is needed in emergency contexts and urban settings and on prevention, cost-effectiveness of alternative programme approaches, and long-term health and nutrition impacts. A review of research methods used to study SNFs by the same team identified many limitations in research design that compromise the evidence base and so fail to influence policy and programming. The authors propose specific actions for global agencies, research funders, researchers and practitioners to build a higher-quality evidence base for impact.
While demonstration of impact and efficacy are critical for creating an enabling environment for scaling up nutrition programmes, these are not sufficient enablers on their own. We have seen this with CMAM, where evidence of impact and efficacy is incontrovertible, yet many countries struggle to achieve adequate programme coverage. Equally, if not more important, is the extent to which programmes are embedded within government systems and assured of longterm financing, either through government and/or long-term development funding. The cost and opportunity cost for government and health services are therefore critical factors that need to be considered when trialing nutrition interventions. These considerations are highly context-specific and depend on country economic prosperity, policies (pro-poor and equity-oriented) and the location of nutrition in government. It is not enough for nutritionists to simply focus on the technical merits and achievements of programmes. At the outset of design and implementation, programme planners must consider the likelihood and feasibility of national governments supporting programmes in the longer term. With this in mind, it is heartening to see that several articles in this issue demonstrate government leadership and true collaboration with development partners. Some insights on this front are shared in a qualitative study by Suaahara II (Manandhar et al) which explores factors affecting the allocation and utilisation of local budgets, particularly those affecting investments for nutrition, in four districts of Nepal.
While local government was sensitised to the need and rationale for this programme, many barriers remained, especially around local budgetary processes.
Nutrition has always been an inter-disciplinary subject yet, at times, practitioners may be guilty of an over-focus on the technical aspects of programming, while paying less attention to the all-important question of whether a proven intervention can feasibly be implemented at scale.
Marie McGrath, Jeremy Shoham and Chloe Angood, Field Exchange Editors