Combined Protocol for SAM/MAM Treatment

October 2016 Issue 53

• Combined protocol for SAM/MAM treatment • Intergenerational malnutrition in Somalia • Programming during conflict in South Sudan • Micronutrient distribution in Burundi • Resilience to emergency programming in the Yemen • Mobile phone survey data collection in Kenya • WHO SAM medical kits in South Sudan • Sampling during insecurity in Afghanistan Contents......

11 Meta-analysis of associations between An investment framework for stunting and child development 40 1 Editorial nutrition: Reaching the global targets 11 Who should finance the World Health for stunting, anaemia, breastfeeding Field Articles Organization’s work on emergencies? and wasting 12 Tackling the double burden of 41 Advancing Early Childhood 2 Nutrition programming in conflict malnutrition in low and middle-income Development: From Science to Scale settings: Lessons from South countries: response of the international Role of nutrition in integrated early Sudan community 43 child development 5 Pilot micronutrient powder 14 Ethiopia’s Productive Safety Net distribution in Burundi: Acting on Programme: Power, Politics and Practice lessons learned 15 Admission profile and discharge News outcomes for infants aged less than six 44 Combined protocol for SAM/MAM 51 Grand Bargain: Reform or business as treatment: The ComPAS study months admitted to inpatient therapeutic care in ten countries usual? 47 Adapting a resilience 17 Chronic disease outcomes after SAM in 52 Call for experiences on mothers improvement programme in measuring MUAC conflict: Experiences from Yemen Malawian children (ChroSAM): A cohort study 53 AuthorAID: A global network for early Open Data Kit Software to 67 Adolescent nutrition in Mozambique: career researchers from low and conduct nutrition surveys: Field 19 putting policy into practice middle-income countries experiences from Northern Kenya Robust evidence for an evidence-based 54 Accelerating the scale-up of WHO emergency nutrition 21 69 approach to humanitarian action treatment for severe acute response in South Sudan malnutrition Evidence in humanitarian emergencies: Sampling in insecure 22 75 What does it look like? 55 Global School Feeding Sourcebook: environments: Field experiences Lessons from 14 countries from coverage assessments in 23 Recovery rate of children with moderate Afghanistan acute malnutrition treated with ready- 56 The missing ingredients: Are policy- to-use supplementary food (RUSF) or makers doing enough on water, Intergenerational cycle of acute 79 improved corn-soya blend (CSB+) sanitation and hygiene to end malnutrition among IDPs in malnutrition? Somalia 25 Impact of child support grant in South Africa on child nutrition 57 Nutrition funding: The missing piece of the puzzle 26 Public health nutrition capacity: The Research quality of workforce for scaling up 58 Biofortification: Helping meet 8 Research Snapshots nutrition programmes nutrition needs worldwide 8 Factors influencing pastoral and 28 Research priorities on the relationship 60 Minimum Standards for Age and agropastoral household between wasting and stunting Disability Inclusion in Humanitarian vulnerability to food insecurity in 29 Co-trimoxazole prophylaxis to prevent Action Kenya mortality in children with complicated 61 Regional humanitarian challenges in 8 Determinants and trends of severe acute malnutrition the Sahel socioeconomic inequality in 30 The impact of intensive counselling and 62 NOMA: A neglected disease! child malnutrition in a mass media campaign on Mozambique complementary feeding practices and 64 Improving care of people with NCDs in humanitarian settings 8 The migrant camp that doctors child growth in Bangladesh built 32 Direct procurement from family farms 64 eLearning module on improving 9 Trends in adult body-mass index for national school feeding programme nutrition through agriculture and in 200 countries from 1975 to in Brazil food systems 2014: A pooled analysis 33 Relationships between wasting and 65 FANTA’s Body Mass Index (BMI) Wheel 9 Effect of lipid-based nutrient stunting and their concurrent 65 Launch of BabyWASH Coalition supplements on morbidity in occurrence in Ghanaian pre-school rural Malawian children children 66 En-net update 9 Thailand eliminates mother-to- 34 Local spatial clustering of stunting and child transmission of HIV and wasting among children under the age syphilis of five years Views 10 Decline in the prevalence of 36 Carbohydrate malabsorption in acutely 73 South Sudan nutrition: Overcoming anaemia among children malnourished children and infants: A the challenges of nutrition through wheat flour fortification systematic review information systems in Jordan 37 Nutrition among men and household 10 Making progress towards food food security in an internally displaced security in rural Rwanda persons camp in Kenya Agency Profile 10 Global and regional health 38 How to engage across sectors: 72 Wateraid effects of future food production Lessons from agriculture and nutrition under climate change: A in the Brazilian School Feeding modelling study Programme Editorial ......

Dear readers integrated ECD, which makes the case for mul- partners over a period of years to inform hu- ti-sector programming that considers responsible manitarian programming, with government here are three themes running through parenting, learning stimulation, education, and health information systems. ere are also two this issue of Field Exchange. We have social protection, in addition to health and nu- articles related to chronic disease in the context four field articles which describe the trition. Another summary presents the findings of emergency programming, One is a summary very real practical challenges of having of a study on the impact of a cash support grant of a study looking at mortality and risk factors toT adapt programming in the face of conflict in South Africa on stunting. No impact is seen for chronic disease in children who had been and insecurity. An article by Mustafa Ghulam and this is explained by high levels of HIV and ‘successfully’ treated for SAM seven years earlier and Mohammed Alshama’a, Save the Children, unemployment, which may confound any effect. in Malawi. Functional deficits were found and describes adapting a resilience improvement ere is also a summary of a study in 13 countries most alarming, nearly one-third of discharged programme in conflict affected Yemen and how looking at the degree to which nutrition is ex- cases had died and another 15% were lost to a scaled up e-voucher scheme still managed to plicitly mentioned in water, sanitation and follow-up. ese findings really challenge our improve dietary diversity in spite of the high hygiene (WASH) policies and vice versa. Perhaps notion of ‘cure’ when it comes to SAM; a return level of insecurity. Meanwhile, an article by surprisingly for this day and age, there is limited to normal anthropometry is not matched with Mercy Laker and Joy Toose, World Vision, doc- incorporation of nutrition and WASH in the a return to pre-SAM risk level, with long term uments how a CMAM programme had to be respective policies of the other sector. Interestingly, morbidity and mortality implications. e adapted in South Sudan when conflict broke the report authors suggest that the nutrition second article summarises a meeting held by out but still managed to provide critical life- sector has more of a vested interest in incorpo- MSF recently which focused on improving care saving treatment to young children. Afghanistan rating WASH objectives since we depend on of people with non-communicable disease (NCD) is the setting of a field article by Action Contre WASH to achieve nutrition outcomes; typical in humanitarian settings. e strand linking all la Faim, which describes measures taken to WASH outcomes do not depend on nutrition these pieces, either explicitly or through impli- allow sampling during programme coverage as- and so there may be less incentive for integration. cation, is that there are inextricable links between sessments that both maintained data integrity ere are also two research summaries about so called emergency and development nutrition, while protecting the safety of enumeration staff. the national school feeding programme in Brazil yet the analytical frameworks and architecture Finally, an article written about WHO’s emergency which has managed to legislate for procurement which underpin responses do not reflect this nutrition response in South Sudan documents from local farmers who provide the food for the adequately. Availability of resources for nutrition the development of a specific medicines kit (and programme. One of the studies looks specifically is undoubtedly a common challenge for all; a associated training package) for the treatment at lessons learnt about engaging across sectors study by the World Bank provides a timely re- of complicated severe acute malnutrition (SAM), from more of a political economy perspective minder of what it will cost to achieve global which allowed programming to continue in the and what is required to maximise success. targets for stunting, anaemia, exclusive breastfeeding and SAM treatment – applicable to both A final theme, and one which effectively pro- humanitarian and stable contexts. e bill comes vides an overarching framework for the themes in at $70 billion over ten years! discussed above, is the relationship between development and humanitarian programming and Finally, we would like to draw attention to a how there are strong conceptual, epidemiological new section of Field Exchange which we are tri- and institutional rationales for closer integration. alling in this issue. We call this ‘snapshots of re- A critical online article by IRIN (an independent search’ where the ‘bare bones’ of studies are non-profit media venture) highlighted a number summarised. e reason for introducing this of recommendations from the Grand Bargain section is partly economic (to cut down on (a package of reforms to humanitarian funding, printing costs), partly appreciating our readers launched in May 2016 at the World Humanitarian may value a digested read, and partly expedience Summit). Commitments are packaged under (there is more and more research being published Diversity of beans in Rwanda 10 measures/areas for reform. One of these and given the common ground between emer-

Jean D'Amour, Harvest Plus, 2009 Harvest Plus, Jean D'Amour, measures is ‘Enhance engagement between hu- gencies and development, there is a broader manitarian and development actors’. is is spectrum of research relevant to our readership). face of a marked deterioration in security. What about working collaboratively across institutional e short articles in this ‘snapshot’ are hopefully all these articles have in common is adaptation boundaries on the basis of comparative advantage" all of interest and include studies on; the social and innovation based upon on an ‘on the ground’ and “the use of existing resources and capabilities inequality of child malnutrition in Mozambique, perspective about what is possible and how best better to shrink humanitarian needs over the climate change modelling on the effect on food to preserve programme equity and effectiveness long term, with the view of contributing to the production and global and regional health, in the face of overwhelming challenges for pro- outcomes of the Sustainable Development Goals trends in adult Body Mass Index (BMI) in 200 gramme staff and beneficiaries. You have to ask (SDGs)”. A summary of a research prioritisation countries, the impact on child anaemia of a if someone somewhere is going to pull all these exercise on the relationship between wasting wheat fortification programming in Jordan and programming approaches together to produce and stunting concluded that the highest priority the effect of Lipid Nutrient Supplements (LNS) some sort of guidance on ‘how to adapt nutri- is to find evidence from evaluations and studies on morbidity in rural Malawian children. Please tion-related programming in insecure areas’? on the optimal timing of treatment and preven- let us know if this new section works for you. A second theme emerging in Field Exchange 53 tion programmes to impact wasting and stunting is the role of multi-sector programming in ad- as part of the same programme. An ENN inter- We hope you enjoy this issue of Field Exchange. dressing undernutrition. ere are a number of view with Rebecca Alum Williamand Shishay As ever, articles, ideas and feedback always wel- relevant research summaries. Complementing Tsadik from the Ministry of Health (MoH) in come. the recently released Lancet series on early child- South Sudan highlights the challenges of inte- hood development (ECD), we have a summary grating an effective nutrition information system Jeremy Shoham & Marie McGrath of a series of articles on the role of nutrition in (NIS), developed largely by nutrition cluster Field Exchange Co-Editors ...... 菀 Field Articles ......

A young child enrolled in a treatment programme

World Vision, South Sudan Vision, World Location: South Sudan What we know: Violent conflict typically contributes to increased malnutrition levels and challenges humanitarian response. What this article adds: Challenges to CMAM implementation encountered by World Vision in conflict-affected South Sudan included stretched government capacity, underfunding, supply chain interruptions, destruction of health facilities, limited staff capacity and compromised access. Adaptations made include investment in cluster coordination, development of alternative CMAM sites, training community volunteers, and pre-positioning therapeutic food. A multi-sector rapid response mechanism (RRM) was piloted to access hard-to- reach locations. Experiences show that flexibility and responsiveness are crucial in conflict settings; close coordination between sectors, including logistics, is essential; and predictable, long-term funding is necessary to sustain life-saving programming.

rotracted hostilities in South Sudan Partnering with United Nations (UN) have caused widespread displace- agencies and other non-governmental organ- ment; high rates of death, disease isations (NGOs), World Vision’s response to and injury resulting in disrupted the malnutrition crisis in South Sudan is Plivelihoods; severe food insecurity and a multi-sectoral. e community-based man- major malnutrition crisis1. Even before the agement of acute malnutrition (CMAM) model current conflict began, the nutrition situation is used to treat severe and moderate acute Nutrition was chronic. Of 21 counties assessed during malnutrition (SAM/MAM), complemented the 2013 lean season, 17 had global acute by food assistance, agricultural initiatives to malnutrition (GAM) rates above the emer- increase food production and improved access programming in gency threshold of 15%. to safe water, sanitation and basic healthcare to children under five years of age and pregnant Between December 2013 and February women. is article documents how World conflict settings: 2015, the number of children suffering from Vision’s nutrition team worked with the nu- severe acute malnutrition (SAM) doubled to trition cluster through 2014 and 2015 to adapt more than 229,0002. In the worst-hit areas its CMAM programme to overcome the chal- Lessons from Greater Upper Nile, Warrup and Northern lenges faced in South Sudan. Bahr el Ghazal in 2015, nearly one in three children under five were malnourished. e Contextual challenges and South Sudan malnutrition situation was classified as critical programme adaptations By Mercy Laker and Joy Toose (GAM between 15 and 29 per cent) or very A combination of vast geographical area, critical (GAM above 30 per cent) in more poor infrastructure and an unpredictable se- Mercy Laker worked as than half the country. Since the beginning of curity situation makes South Sudan one of the Health and Nutrition the conflict in December 2013, more than the most challenging and costly operating Technical Lead for World 1.5 million people have been displaced in- environments4. Contextual challenges for 3 Vision South Sudan from ternally, including more than 800,000 children . conventional CMAM programming, and October 2014 to April People fleeing their homes are forced to aban- adaptations made by World Vision to respond 2016. She is currently the don their fields and livestock. Many have to them, include the following: Health and Nutrition sought refuge on UN peacekeeping bases or coordinator for Care South Sudan. other informal settlements and can no longer Gaps in coordination grow crops or tend livestock. In February 2014, a Level 3 Humanitarian Joy Toose is an e majority of South Sudanese families Emergency 1 rely on emergency food assistance to survive. UNOCHA; South Sudan Humanitarian Response Plan Communications 2015. reliefweb.int/report/south-sudan/south-sudan- ose not displaced by fighting have faced Specialist with World humanitarian-response-plan-2015 difficulties in sowing crops due to interruptions 2 Vision International. UNICEF; South Sudan on the edge of nutrition catastrophe in trade and supply corridors for seeds and if hostilities don’t end now. UNICEF Press Release 4 supplies. Deteriorating food security is com- February 2015. www.unicef.org/media/media_79711.html 3 UNICEF; South Sudan Humanitarian Situation Report 23 pounded by lack of access to clean water, April 2015. reliefweb.int/report/south-sudan/unicef-south- This article is based on a detailed case study by sanitation and basic healthcare, increased sudan-humanitarian-situation-report-57-10-23-april-2015 4 GHA; South Sudan: Donor response to the crisis, (2014) 4. the authors available at: www.wvi.org/disaster- prevalence of disease, and negative impact on feeding practices. www.globalhumanitarianassistance.org/report/south- management/publication/nutrition-programmi sudan-donor-response-to-the-crisis ...... ng-conflict-settings-south-sudan-case-study 菀 Field Article ......

System-Wide Emergency Response was declared in response to the crisis. is reflected the scale, Figure 1 Objectives of the multi-sector rapid response team complexity and urgency of the crisis and the inability to implement effective response without OBJECTIVES OF THE RRM TEAMS INCLUDE: system-wide mobilisation. Due to the fragility and stretched capacity of the South Sudan Gov- ernment and Ministry of Health (MoH), the bulk of leadership and service delivery was taken on by the UN and partner NGOs5. Where CHILD CMAM programming would usually seek to HEALTH HEALTH NUTRITION EDUCATION PROTECTION align with and complement an existing MoH strategy and operations, in South Sudan much To deliver critical To provide safe To provide essential To provide learning To identify, register life-saving health drinking water and emergency opportunities, and commence of the strategic planning and day-to-day coor- services to reduce emergency latrines nutrition services including the tracing of dination relies on support from UNOCHA excess mortality to vulnerable to reduce provision of life- unaccompanied, (United Nations Office for the Coordination of and morbidity. communities, and malnutrition- saving messages, separated and Humanitarian Affairs) through the humanitarian to promote good related mortality as a safe and missing girls and country team and the sector cluster groups. hygiene and in children under protective boys; set up child prevent the 5, pregnant and environment and friendly spaces for Gaps in multi-sector resources outbreak and lactating women, entry point for psychosocial spread of water- and other other programme support. e response in South Sudan has been consis- related disease. vulnerable groups. interventions. tently underfunded. In 2015, only 41 per cent of the required US$1.6 billion had been com- mitted6. Stretched resources le gaps in the system-wide response. operations and access to referred services for displacements. e fluidity can make it difficult children or pregnant women who require addi- to achieve the eight weeks of contact required Adaptation: In the context of these capacity tional medical support. Referred children and for CMAM treatment. and resource challenges, it is more important pregnant women oen have difficulty accessing than ever for humanitarian agencies to actively services or medication due to distance or cost. Adaptation: e CMAM project model offers participate in the cluster system. is demands some measures which mitigate these impacts: agency commitment to attend the bi-weekly Adaptation: In areas without a functioning • Increasing the ration of RUTF to malnour- cluster meetings and ad hoc sessions addressing health facility, World Vision invested in a network ished children – providing two or more specific operational issues, improve focus on of community nutrition volunteers and secured rations, rather than one week’s supply, HRP targets, and leverage limited resources. alternative sites such as places of worship for when fighting is predicted. World Vision’s nutrition team also prioritised CMAM activities, oen transporting equipment • Training community volunteers to monitor cluster reporting that ensures better coordination and RUTF supplies in and out on an ongoing the children receiving treatment and help of programmes and helps identify and address basis; a challenge that is exacerbated by hu- ensure that children receive additional gaps or target areas. manitarian access issues (see below.) rations if access is impossible. • Where health facilities are being used, posi- is situation also interferes with capacity- Breakdown in ready-to-use- tioning supplies during the dry season be- building of local health staff, essential for the therapeutic food (RUTF) supply fore roads become flooded and inaccessible. chain sustainability of the programme, which should Supplies for targeted supplementary feeding ultimately transition to local health services. Rapid response mechanism programmes (TSFP) were provided by WFP, and Adaptation: With capacity-building of local (RRM) supplies for outpatient therapeutic programmes health services out of reach in many areas of In partnership with other humanitarian actors (OTP) and stabilisation centres (SCs) were pro- operation, the focus is on building community in South Sudan and with funding from the cured through UNICEF. Stretched resources, capacity through volunteers who actively par- Common Humanitarian Fund (CHF), World poor road access and on occasion insecurity ticipate in case-finding, referrals and follow-up. Vision trialled a multi-sector RRM to meet the oen resulted in breakdown of the supply. critical needs of displaced populations in hard However, this community capacity-building to-reach areas of the most affected states. RRM Adaptation: World Vision secured alternative does not allow for transition of CMAM respon- missions deploy mobile teams of nutrition water, supplies from Canadian and US offices as gis- sibilities to government. World Vision acknowl- sanitation and hygiene (WASH); health; child in-kind, creating a successful buffer to protect edges the need and has continued to resource protection; and education technical specialists. programming. and respond with CMAM interventions in some (see Figure 1). Poor local health infrastructure of the most hard-to-reach locations in South rough RRM, between July 2014 and March e impact of the current conflict on health in- Sudan. 2015 World Vision established 14 OTP sites frastructure in South Sudan surpasses that of Access and population movement across Unity and Upper Nile States (exceeding the two-decade civil war that ended in Sudan’s Humanitarian access to populations is hindered the projected 13). It screened 25,729 children independence. Where fighting has spread, health by lack of infrastructure in South Sudan and for malnutrition, treated 825 children for MAM facilities have been destroyed. Before the crisis, by ongoing conflict as fighting prevents staff (through supplementary feeding programmes), there were more than 300 outpatient treatment from travelling to affected communities. Poor and 301 children for SAM through OTPs. It centres across the country; by mid-2014, the road access and flooding during the rainy season, trained 142 community nutrition volunteers in number had dropped to 183. Access to other combined with the lack of secure storage for CMAM and infant and young child feeding in programmes addressing acute malnutrition has RUTF, can mean that supplies must travel long emergencies; 36 health workers in CMAM; and also declined drastically. Where health facilities distances by boat and by foot – increasing the 180 mother-to-mother support group leaders. still operate, they face significant challenges, time, cost and risk of programming. is can including lack of resources for training, low result in programme activities being delayed or and irregularly paid wages, a lack of supervision suspended. In addition, the nomadic lifestyle of 5 WHO; WHO responds to health crises facing war-wracked at all levels, and high staff turnover. South Sudanese means high mobility even in South Sudan, (September 2014); Ministry of Health, Health sector development plan 2011–2015, Government of As a result, humanitarian agencies oen the relatively stable locations, while the onset of South Sudan, (2011). struggle to find an appropriate base for CMAM conflict resulted in recurrent massive population 6 GHA; South Sudan: Donor response to the crisis, (2014) 4...... 菀 Field Article ......

ices during peak seasons can result in more effective responses in future. Inter-cluster collaboration is needed to jointly develop an RRM roster to regulate activities. is will enable better coordination among the partners’ various rapid response teams. Mapping of capacity gaps among partners prior to RRM design would help identify specific areas of intervention, avoiding conflict and duplication of activities. Finalising the ToR for the RRM and ensuring it is widely disseminated Transporting RUTF to all partners will enable common understanding World Vision, South Sudan Vision, World of the mutual benefit the model brings. What we learned Health Department (CHD) reported otherwise. CMAM for child survival amid In some locations, RRM provided beneficial is affected operations. conflict: Results complementarity surge capacity for existing e project design underestimated logistical In 2014, World Vision successfully treated 8,964 CMAM programmes. In Bol and Otego districts challenges around accessing hard-to-reach lo- children; 3,537 for SAM and 5,437 for MAM in Fashoda, for instance, the RRM greatly in- cations. Some proposed locations were completely through CMAM. World Vision operated three creased the coverage of existing CMAM pro- inaccessible in the rainy season, and the logistics SCs and 33 OTPs in Warrap and Upper Nile grammes through mass MUAC (mid-upper arm cluster was sometimes overstretched with nu- states. Food security interventions and WASH circumference) screening and referral of identified merous priority locations and limited air equip- projects reached 190,152 people during the same children to the existing OTPs for follow-up. ment. Consequently, several planned activities period. is response continued in 2015. Despite e RRM was quick to fill gaps when a were not executed. disruption of services due to eruptions of violence, partner was phasing out; for instance, when World Vison managed to reach more than During design, it was difficult to make accurate 235,000 people with food assistance; 97,000 Médecins Sans Frontières pulled out of Fashoda, caseload projections due to ongoing displace- the RRM took over the OTP sites in Lul people with WASH interventions; and 26,000 ments, hence lack of accurate population num- children and pregnant or lactating mothers with and Kodok. In Koch, the RRM made an impact bers, while lack of prevalence and incidence on the hard-to-reach districts of Nobor treatment for malnutrition. In the 2015 calendar data resulted in overestimations. For instance, year, humanitarian actors have reached 757,435 and Gany, where the existing partner could not although the project exceeded its target number reach. In addition, World Vision’s mobile RRM people with nutrition interventions. Without of children screened, the proportion admitted interventions across these key areas, the current team took part in inter-agency needs assessments, to OTPs was significantly lower than expected. including Kaldak and Canal, and pre-positioned level of food security and nutrition in South non-food items (NFI) and food items in Rumbek Low RRM coverage in some locations was Sudan would be far worse. to support activities in Canal and Khorfulus. due to changing contexts, with unanticipated Lessons learned drops in the incidence and prevalence of acute ree higher-level themes emerged in South In locations where the RRM team trained malnutrition in targeted areas. It is also possible Sudan that may be relevant to nutrition pro- community nutrition volunteers and mother- that some malnourished children were not gramming in other conflict-affected contexts: to-mother support groups, the number of children reached due to insecurity and population move- • Flexibility and responsiveness is crucial in screened and enrolled tended to be higher and ments. For instance, operations in Canal County the context of protracted conflict, with there was better follow-up of children even aer were suspended due to recurrent insecurity. provision of the RUTF. In Melut and Manyo, teams empowered to respond to rapidly for instance, volunteers and health workers con- Some proposed interventions were not ap- changing conditions. On-the-ground nutri- tinued to monitor and provide food to registered propriate for the RRM model. For example, tion teams must also have support to design children, even aer the project phase-out. constructing semi-permanent OTP sites was and test new initiatives to overcome chal- not possible due to difficulties finding skilled lenges. ey should also be accountable for In remote RRM sites where the caseload was contractors and transporting materials to the capturing and sharing the results and learn- very high with limited partner capacity, World hard-to-reach locations and insecurity. ings of these initiatives. Vision sought additional funding from other • Close coordination within and between donors to establish a longer-term presence, such Inability to access commodities sometimes NGOs, the UN and humanitarian clusters is as the mission in Koch, Unity State, which was prevented the implementation of certain compo- essential given weakened national infra later funded by Irish Aid for one year before nents of CMAM; better early integration with the structure. Ongoing insecurity and humani- being transitioned back to World Relief aer mobile food aid team could have mitigated this. tarian access issues mean significant support the caseload was contained and capacity built. Recommendations from UNOCHA and the logistics cluster is Development of terms of reference (ToR) for required to assist with access negotiations Flexibility and sensitivity to a changing op- the RRM prior to implementation and popu- and to deliver nutrition programmes. erational context were key to achieving some larising it among partners would have resulted • In the absence of transitioning capacity to targets, such as establishment of 14 temporary in more success; the RRM technical working local actors, predictable and long-term OTP sites using tents rather than semi-permanent group later developed a ToR. More flexibility funding is essential to sustain critical pro- structures as stipulated in the proposal. Com- would enable partners to implement the RRM, gramme delivery and expert staff retention. plementarity with other existing programmes allowing it to happen where there are no field- was critical in achieving project objectives. World Vision’s experience in South Sudan shows level agreements or partnership corporate agree- that CMAM remains a critical tool for addressing Challenges ments in place. Further integration of food-aid emergency levels of GAM in a conflict-affected Although the RRM was meant to support existing mobile teams and nutrition RRM teams would context. Direct treatment of malnutrition is nutrition programmes, it was sometimes mis- enable partners to implement the full continuum crucial to protect children from death and give understood as replacing, rather than comple- of CMAM, including interventions to prevent them (and ultimately their country) the best menting, static programmes. In some instances, malnutrition. e logistics cluster must prioritise chance of a secure future. this resulted in territorial tendencies, with its support; hard-to-reach locations present partners on the ground claiming universal cov- major logistical bottlenecks which partners For more information, contact: Joy Toose, email: erage even when communities and the County cannot always overcome alone. Outsourcing serv- [email protected] ...... 菀 Field Article ...... Pilot micronutrient powder distribution in Burundi: World Vision, South Sudan Vision, World Acting on lessons learned

By Leni Martinez Del Campo, Emily Sylvia and the Concern Burundi Team Leni Martinez del Campo was Emily Sylvia is a recent the food and nutrition security graduate of the MPA in officer at Concern Worldwide, Development Practice where she focused on programme at the advocating for greater political Columbia University support and financial School of International resources for nutrition. She is a and Public Affairs, where graduate of the MPA in Development Practice she specialised in agriculture and food security programme at Columbia University. with a focus on nutrition-sensitive agriculture. A young child enrolled in a treatment The authors acknowledge the contribution of the Concern Burundi team to the development of this programme article and thank Kirk Pritchard of Concern for helping coordinate inputs.

Location: Burundi What we know: Micronutrient deficiencies are prevalent amongst children in Burundi. Micronutrient supplementation is one means of tackling it. What this article adds: A pilot programme distributed a two-month supply of micronutrient powder (MNP) during Mother-Child Health Week, targeting children aged 6-23 months in two provinces of Burundi and supported by community health workers and peer educators. A post-distribution survey of mothers found high distribution coverage (97%), good acceptance of the product, and reported child health benefits (less sickness, more energy). Problems identified included inadequate community sensitisation and follow-up, mislabelled packaging (incorrect age group), and miscommunication between health workers and mothers. These likely affected uptake; 64% of mothers had not used all the supply by the end of the intervention period. Identified barriers were addressed to improve subsequent phases. This experience reinforces the importance of community engagement, feedback mechanisms and adaptive programming.

The current state of child MNP distribution project of MNPs and nutrition messaging. Concern nutrition in Burundi In an effort to tackle micronutrient deficiencies Worldwide Burundi was invited to join this In Burundi, four out of five people live on less within the 1,000-day window of opportunity, programme to assist in the implementation, than US$1.25 per day, making it one of the the Ministry of Public Health and the Fight sensitisation and education on the adequate use poorest countries in the world. It is also among Against AIDS of Burundi, in partnership with of MNPs. the countries with the highest prevalence of UNICEF, has undertaken widespread distribution Concern conducted a post-distribution survey stunted children: an estimated 58% of children of micronutrient powders (MNPs) for children (exit interviews and focus groups) in Cibitoke under five years of age are stunted (height for aged 6-23 months as part of the Burundian Na- Province three months aer the December 2014 age <-2 z scores). is is significantly higher tional Integrated Program for Food and Nutrition distribution. e December 2014 target was compared to other countries in the East Africa (PRONIANUT). is article shares experiences 28,666 children, of whom 28,007 were reached. region with similar per capita incomes1. In ad- from the pilot MNP distribution initiative in e survey evaluated the effectiveness of com- dition, 35% of children are underweight and 2014 and 2015. munication and messaging during MNP distri- 7% are wasted2. Less outwardly visible, micronu- bution, focusing on the level of knowledge and trient deficiencies are also prevalent. Twenty- A pilot MNP distribution was carried out in December 2014 and April 2015 during Mother- five per cent of children under five years of age 1 Child Health Week (a twice-yearly event) in Burundi Country Profile. Global Nutrition Report 2014. are vitamin A deficient and 56% are anaemic. http://globalnutritionreport.org/files/2014/11/gnr14_cp_ Zinc deficiency affects 47% of the population3. Cibitoke and Ngozi provinces. All mothers with burundi.pdf 2 Adequate micronutrient intake is important children aged 6 to 23 months received a two- Nutrition at a Glance. World Bank. http://siteresources.world month supply of MNP sachets (60 sachets) to bank.org/NUTRITION/Resources/2818461271963823772/ throughout life, but critical during the first 1,000 Burundi.pdf days (from conception to second birthday) to test acceptability and explore uptake. Community 3 See previous footnote. ensure adequate cognitive and physical devel- health workers/agents de santé communautaire 4 UNICEF and the Micronutrient Initiative. 2004. Vitamin and opment. It is estimated that Burundi loses ap- (ASCs) and peer health educators/maman lu- Mineral Deficiency: A Global Progress Report and World mières (MLs) provided mothers with support, Bank. 2009. World Development Indicators (Database), cited proximately US$30 million a year due to mi- in http://siteresources.worldbank.org/NUTRITION/Resources cronutrient deficiencies4. sensitisation and education on the adequate use /281846-1271963823772/Burundi.pdf ...... 菀 Field Article ......

Perceived effects of the use use of the product, storage, and perceived sec- Findings from the post- Figure 1 of MNPs ondary effects of use, to improve the sensitisation distribution survey 70 component for subsequent phases of the project. e survey identified a number of positive 58.77 61.4 Specifically, it examined: 60 outcomes. Most mothers perceived that their • Were mothers with children aged 6 to 23 50 children were healthier and more energetic months who received MNPs able to use (see Figure 1). Mothers reported fewer bouts 40 them correctly at home? 28.94 of child diarrhoea during the intervention pe- 30 • What determinants influenced the use of 21.92 riod. Mothers had a positive perception of the 20 MNPs among mothers with children aged 6 product; all mothers said they would give their to 23 months? 10 children MNPs again if provided. No significant cultural barriers were identified. e survey 0 A sample of 114 mothers was interviewed for Child is Child is Child has an Child the quantitative evaluation. A sample of 30 substantiated high coverage recorded (97.7%), more smiley and appetite remains mothers, divided into six focus groups, was in- and all mothers reported receiving MNP sachets awake and plays with and eats in good stronger others more health terviewed for the qualitative evaluation. free of charge from medical personnel. The survey also identified a number of key barriers, which are closely interlinked: Figure 2 Comparison of the educational pamphlets pre and post-pilot 1. Poor community mobilisation by ASCs and MLs; BEFORE 2. Poor follow-up with mothers and health workers; 3. Lack of clarity of the communication/ education pamphlet; 4. Mislabelling on packaging; and 5. Unclear messaging with regard to the treatment target group. e survey suggests that poor community mobilisation was closely linked to insufficient training of ASCs and MLs, who play a critical role in the dissemination of information and mir- roring of best practices in their communities. ey received only one day of training on the adequate use and importance of MNPs one week prior to Maternal-Child Health Week; this was insufficient to allow full understanding of the process and MNP utilisation (a new intervention to them). e short period between training and distribution did not allow the support agents to conduct visits to homes in their communities to sensitise mothers prior to distribution. In addition, there was no well-defined follow-up strategy to encourage mothers to use MNPs and to answer any questions that arose during the two months following distribution. e education pamphlet contained two key messages on the use of MNPs and the importance of a balanced diet but failed to explain how these two are linked, and did not contain sufficient and clear information on the use of the sachets. For example, the survey revealed that mothers were not clear on the types of foods that could be used with MNPs. e pamphlet indicated that porridge was the food with which the MNPs could be used, leading mothers to believe that they could only be served over porridge. Additionally, the images used failed to communicate accurately the preparation process, resulting in confusion over the time between adding the content of the sachets to the food and feeding it the child, and the temperature the food needed to reach for the powders to be added. e packages for the sachets displayed the incorrect age group, stipulating that the product should be consumed by children aged between 6 and 59 months rather than 6-23 months, resulting in mix-up among ASCs/MLs as well as mothers concerning who the product was in- ...... 菀 Field Article ......

communication and labelling that affected Figure 2 (Cont’d) Comparison of the educational pamphlets pre and post-pilot uptake and use, distribution coverage was high and mothers had a high acceptance of AFTER the product, a good perception of its effects, and were willing to use it. Recommendations to address the identified barriers in future MNP distributions were: • Better communicate general nutrition messaging and the role of MNPs in improving the nutrition status of infants (including improved health, reduction of diarrhoeal diseases and increase of child appetite); • Incorporate clear messaging, outlining best practices for daily use of MNPs, in ASCs and MLs community mobilisation activities, and engage care groups and other community structures in such messaging; • Correct the MNP packaging to reflect the target group (6 to 23 month-olds); and • Improve the educational pamphlet to address mother’s questions and confu- sions and improve the quality of the images to better reflect correct preparation. Concern subsequently worked with UNICEF to integrate these changes into the programme design and modify the pamphlet, using pictures rather than sketches to improve accessibility (see Figure 2). is was used in a cascade training by PRONIANUT, starting with national-level actors and reaching to community level, to enable the ASCs and MLs to sensitise mothers and teach them adequate use of MNPs more effectively. A new national packaging design will be used use for MNP supplies in 2016. Future rollout looks to integrate MNP distribution in the regular health system at both health facility and community levels. At the community level, the provision by community health workers will enable adequate coverage and good follow-up. Conclusions UNICEF and Concern worked together to identify weaknesses in the project and acted on them to improve subsequent phases of MNP distribution. is included investment by UNICEF and PRONIANUT in building the capacity of the ASCs and MLs. e experience highlights the importance of sensitisation, education and engagement of beneficiaries in planning and implementation; tended for. e survey revealed that during the still had leover sachets; at the estimated rate of of stakeholder coordination and community first day of distribution, MNPs were distributed use (1/day), none should have been leover following involvement in building communication to mothers with children aged 6-59 months, the two-month pilot period. e main reasons strategies; and of community awareness and instead of those with children aged 6-23 months. given by mothers for interrupted use were: they sensitisation to relieve pressure on mothers. Consequently, only 45% of mothers interviewed forgot (36%); the child was sick (24%); they were e project is a good example of how, through were aware that the MNPs should be given to not present (18%); there was no porridge (15%); or open lines of communication and feedback children between the ages of 6 and 23 months, they lost interest (7%). Mothers were uncertain mechanisms, it is possible to overcome bar- while 14.9% thought 6-59 months was the target whether MNPs could be consumed in tandem with riers, and how a project can be redesigned age; 16.6% did not know; 15.8% were ‘other’; and medications and therefore stopped their use if their to have greater impact and improve the lives 0.8% thought 0-6 months was the target group. child became ill. of the people it targets. At the time of the post-distribution survey, Recommendations and follow-up For more information, contact: Leni Martinez three months aer distribution, 64% of mothers Although there were problems around mobilisation, del Campo, email: [email protected] ...... 菀 Research ...... Snapshots

Factors influencing pastoral and agropastoral household vulnerability to food insecurity in Kenya

enya has a population of more than 38 household vulnerability to food insecurity in herd size, oﬀ-farm employment and gender of million, 10% of whom are classified as pastoral households of Kajiado County and household head for Kajiado County. agropastoral households of Makueni County in Kfood-insecure. e Kenyan drylands are e findings imply that Makueni County Kenya. Interviews were conducted with a ran- populated largely by livestock-dependent pastoral needs access to and control over land resources, domly selected sample of 198 households. Income tribes who are particularly vulnerable to food destocking through improved livestock breeds, per adult equivalent was used to estimate house- shortages. Prevalent high food and non-food and creation of a microclimate to enhance hold vulnerability to food insecurity, which was prices, crop failure, livestock diseases and conflict rainfall levels. e authors recommend that calculated as the proportion of households who have compounded the already precarious food policies in Kajiado County promote access to fall below the poverty line of Ksh 1,239 (£9.99) insecurity in the arid and semi-arid lands climate information, diversification of livelihoods per adult equivalent per month. Descriptive (ASALs). Factors contributing to food insecurity and female access to production resources. and related survival mechanisms are specific to analysis showed that 59% of pastoral households diﬀerent people and regions, but there is lack of of Kajiado County were vulnerable to food in- Amwata DA, Nyariki DM and Musimba NRK clarity in Kenya on possible causes and solutions security, compared to 27% of agropastoral house- (2016). Factors Influencing Pastoral and to the problem. Further research, particularly holds in Makueni County. Additionally, a two- Agropastoral Household Vulnerability to Food at the household level, is needed to inform stage least squares approach (regression analysis) Insecurity in the Drylands of Kenya: A Case policy and action in adapting to the impacts of established that vulnerability of households to Study of Kajiado and Makueni Counties. J. Int. climate change. food insecurity is determined by land size, Dev., 28: 771-787. doi: 10.1002/jid.3123. household size, rainfall and herd size for Makueni onlinelibrary.wiley.com/wol1/doi/10.1002/jid is study establishes the determinants of County, and by access to climate information, .3123/full

Determinants and trends of

WFP/David Orr WFP/David socioeconomic inequality in child malnutrition in Mozambique

ozambique has experienced a slow equalities in the distribution of malnutrition are decrease in absolute levels of child found for all years, and further analysis reveals Mmalnutrition over the last 15 years. that most of the inequality in malnutrition is However, levels remain very high, with chronic due to inequality in food consumption. e au- malnutrition (stunting) prevalence of more than thors claim that, while absolute levels of chronic 40% in children under five years of age, one of child malnutrition tended to decrease over time, the highest in the world. Previous studies on socioeconomic inequality in malnutrition did child malnutrition in Mozambique have mainly not; and actually seems to have increased slightly focused on absolute levels of malnutrition and over the same time period. relative trends. is study examines the extent Salvucci V. Determinants and Trends of Socioe- of socioeconomic inequality in child malnutrition, conomic Inequality in Child Malnutrition: e Measuring height of a focusing on height-for-age Z-scores, using data malnourished child at Case of Mozambique, 1996-2011. 2016. J. Int. from the Household Budget Survey 1996-1997 Moamba Health Centre Dev., 28: 857-875. doi: 10.1002/jid.3135. in Mozambique and 2008-2009, and from the Development and Health Statistics 2003 and 2011. Pro-rich in-

The migrant camp that doctors built

ll around the edges of Europe, as the Synthe near Dunkirk, to provide basic humani- the state hospital at Grand-Synthe has opened a numbers of refugees and economic mi- tarian assistance to people in need, regardless clinic specially for migrants. e new camp Agrants have surged in recent years, char- of their status. Normally the charity provides goes against French Government policy, which ities and individual volunteers rather than gov- medical aid at refugee camps in developing is to encourage migrants to give up their dream ernments have provided much of the humani- countries that are built and run by United of getting to Britain and instead claim asylum tarian assistance on the ground. Although many Nations agencies. Doctors at the camp, known in France and move to government-provided European countries have oﬃcially committed as La Linière, have been treating migrants for accommodation for migrants elsewhere in the to providing medical services to undocumented health issues such as respiratory problems and country. migrants, dermatological problems (including eczema and scabies). ere are also chronic diseases and Sophie Arie e migrant camp that doctors e medical charity Médecins Sans Frontières mental health problems. Aer months of lobbying built. BMJ 2016;352:i1696 (MSF) has built its first refugee camp, at Grand- by non-governmental organisations (NGOs), dx.doi.org/10.1136/bmj.i1696 ...... 菀 ...... Research Snapshots Trends in adult body-mass index in 200 countries from 1975 to 2014: A pooled analysis

nderweight and severe and morbid obe- from 21·4 in central Africa and south Asia to If post-2000 trends continue, the probability sity are associated with highly elevated 29·2 in Polynesia and Micronesia; for women of meeting the 2025 global obesity target – to Urisks of adverse health outcomes. is the range was from 21·8 in south Asia to 32·2 in halt the rise in obesity at its 2010 levels – is vir- study estimated trends in mean body mass index Polynesia and Micronesia. Over these four tually zero. Rather, if these trends continue, by (BMI) by using 1,698 population-based data decades, age-standardised global prevalence of 2025 global obesity prevalence will reach 18% sources, with more than 19·2 million adult par- underweight decreased from 13·8% to 8·8% in in men and surpass 21% in women; severe ticipants (9·9 million men and 9·3 million men and from 14·6% to 9·7% in women. South obesity will surpass 6% in men and 9% in women) whose height and weight had been Asia had the highest prevalence of underweight women. Nonetheless, underweight remains measured, in 186 of 200 countries for which es- in 2014, 23·4% in men and 24·0% in women. prevalent in the world’s poorest regions, especially timates were made; these 186 countries covered Age-standardised prevalence of obesity increased in south Asia. 99% of the world's population. from 3·2% in 1975 to 10·8% in 2014 in men, and from 6·4% to 14·9% in women. Globally, Trends in adult body-mass index in 200 coun- Global age-standardised mean BMI increased 2·3% of men and 5·0% of women were severely tries from 1975 to 2014: A pooled analysis of from 21·7 in 1975 to 24.2 in 2014 in men, and obese (BMI ≥35); the prevalence of morbid obe- 1,698 population-based measurement studies from 22·1 in 1975 to 24.4 in 2014 in women. sity (BMI ≥40) was 0·64% in men and 1·6% in with 19·2 million participants. 2016. e Regional mean BMIs in 2014 for men ranged women. Lancet 387 (10026) (October 15): 1377-1396

Effect of lipid-based nutrient supplements on

morbidity in rural Malawian children Orr WFP/David

he WHO recommends the use of iron contained a total of 6mg iron in the daily dose supplements or home fortificants (such provided. Morbidity outcomes (serious adverse Tas multiple micronutrient powders and events, non-scheduled visits and guardian-reported lipid-based nutrient supplements (LNS)) to im- morbidity episodes) were compared between prove iron status and reduce anaemia prevalence control and intervention groups. Findings were among infants and children aged 6-23 months that provision of 10 and 20 g LNS/d containing in low-income countries. However, safety of 6mg iron/d did not increase morbidity in the home fortificants in children is uncertain in children. Provision of 40g LNS/d did not aﬀect areas where infections are common. One large guardian-reported illness episodes, but may have trial using iron and folic acid supplements in increased malaria-related, non-scheduled visits. Zanzibar reported increased risk of malaria and Bendabenda J, Alho L, Ashorn U, Cheung YB, deaths. Dewey KG, Vosti SA, Phuka J, Maleta K and A randomised controlled trial in rural Malawi Ashorn P. 2016. e eﬀect of providing lipid- tested the hypothesis that provision of LNS con- based nutrient supplements on morbidity in ru- Nutrition taining iron does not increase infectious morbidity ral Malawian infants and young children: a ran- interventions for in children. Infants aged six months (n=1,932) domized controlled trial. Public Health Nutri- children under 5 in Mlomba were randomised to receive 10, 20 or 40g LNS/d tion, 19(10), pp. 1893-1903. doi: School, Malawi or no supplement until age 18 months. All LNS 10.1017/S1368980016000331.

Thailand eliminates mother-to-child transmission of HIV and syphilis

n June 7 2016, WHO certified that 1980s, with family education encouraging couples much higher rates of HIV have been recorded. ailand had eliminated mother-to- to be tested for HIV before having children. In 2015, 99·6% of infants born to HIV-positive Ochild transmission of HIV and syphilis. Aer research found that use of short-course mothers in ailand received antiretroviral pro- is is not only a public health success story for zidovudine could cut the risks of mother-to- phylaxis. ailand, but also an aﬃrmation of how inter- child transmission by half, ailand began a Sidibé, Michel, and Poonam Khetrapal Singh. nationally agreed goals –such as the UN’s 2001 countrywide programme that provided zidovu- 2016. ailand Eliminates Mother-to-Child Declaration of Commitment on HIV/AIDS and dine as a routine part of antenatal care, tripled Transmission of HIV and Syphilis. e Lancet the Sustainable Development Goals – can help the budget for prevention of mother-to-child 387 (10037) (October 15): 2488–2489. health ministries to mobilise political will and transmission (PMTCT) services, and lowered doi:10.1016/S0140-6736(16)30787-5. public funds, and commit to implementation. costs by manufacturing generic versions of zi- www.thelancet.com/pdfs/journals/lancet/PIIS0 dovudine locally. Universal healthcare began in ailand’s commitment to address mother- 140-6736(16)30787-5.pdf 2001 and was made free in 2007; this was ex- to-child transmission of HIV started in the tended to include migrant workers, in whom ...... 菀 ...... Research Snapshots Decline in the prevalence of anaemia among children through wheat flour fortification in Jordan

hildren of pre-school age are the most grammes of salt and wheat flour. is study children from rich households (−9·0 points); vulnerable to the detrimental long-term used retrospective analysis of the data from two children who had never been breast-fed (−17·0 Ceﬀects of anaemia, including impairment repeated, national, cross-sectional surveys con- points); and well-nourished children (−6·8 of cognitive and physical development and in- ducted in 2007 and 2009 of pre-school children points). In both surveys, presence of childhood creased morbidity and mortality. In developing aged 16-20 months and 34-36 months respectively anaemia was strongly associated with child age countries, 30-80% of pre-school children are aer implementation of wheat flour fortification ≤24 months, living in poor households, breast- anaemic at one year of age. WHO classifies with multiple micronutrients in Jordan. A total feeding for ≥6 months, malnourishment, poor anaemia prevalence of ≥40% as a severe public of 3,789 and 3,447 children aged 6-59 months maternal education and maternal anaemia. health problem and prevalence of 20-39·9% as were tested in 2007 and 2009 respectively. e Al Rifai R, Nakamura K and Seino K. 2016. a moderate public health problem. prevalence of anaemia in pre-school children Decline in the prevalence of anaemia among Deficiencies of vitamin A, iron, zinc and declined from 40·4% in 2007 to 33·9% in 2009. children of pre-school age aer implementation iodine have been identified as public health e decline in prevalence was more pronounced of wheat flour fortification with multiple mi- problems in Jordan. e Government has im- among children aged >24 months (−13·7 points); cronutrients in Jordan. Public Health Nutri- plemented nationwide food-fortification pro- children living in urban areas (−8·0 points); tion, 19(8), pp. 1486-1497.

Making progress towards food security in rural Rwanda

etermining interventions to address enrolled in the Food Security and Livelihoods WFP/Challiss McDonough food insecurity and poverty, as well as Programme (FSLP) were included in the study. Dsetting targets to be achieved in a specific ere were significant improvements (P < 0·001) time period, have been a persistent challenge in HFIAS and FCS. Severe food insecurity de- for development practitioners and decision- creased from 78% to 49%, while acceptable food makers. Food and agricultural assistance pro- consumption improved from 48% to 64%. e grammes have been widely implemented in sub- change in HFIAS was significantly higher Saharan Africa to tackle food insecurity, but (P=0·019) for the poorest households. However, there is little evidence demonstrating the impact future assessments are needed to evaluate the of those programmes. maintenance of HFIAS and FCS improvements and the programme’s sustainability. is study assessed the changes in food access and consumption at the household level of an Nsabuwera V, Hedt-Gauthier B, Khogali M, integrated food security intervention in three Edginton M, Hinderaker SG, Nisingizwe MP, rural districts of Rwanda. Household Food In- Tihabyona JdD, Sikubwabo B, Sembagare S, security Access Scale (HFIAS) scores and house- Habinshuti A and Drobac P. Making progress Mothers waiting at a distribution hold Food Consumption Scores (FCS) were towards food security: evidence from an inter- of nutrition products (Super compared at baseline and aer one year of pro- vention in three rural districts of Rwanda. Cereal) in southeastern Rwanda gramme implementation. All 600 households 2015:1-9 Public Health Nutr.

Global and regional health effects of future food production under climate change: A modelling study

ne of the most important consequences vegetable and red meat consumption and body- Adoption of climate-stabilisation pathways would of climate change could be its eﬀect on weight for deaths from coronary heart disease, reduce the number of climate-related deaths by Oagriculture. Although much research stroke, cancer and an aggregate of other causes. 29% to 71%, depending on their stringency. has focused on questions of food security, less Strengthening public health programmes aimed e model projects that by 2050 climate at preventing and treating diet and weight- has been devoted to assessing the wider health change will lead to per-person reductions of related risk factors could be a suitable climate impacts of future changes in agricultural pro- 3·2% (SD 0·4%) in global food availability; 4·0% change adaptation strategy. duction. is modelling study estimates excess (0·7%) in fruit and vegetable consumption; and mortality attributable to agriculturally mediated 0·7% (0·1%) in red meat consumption. ese Springmann M, Mason-D’Croz D, Robinson S, changes in dietary and weight-related risk factors changes will be associated with 529,000 climate- Garnett T, Charles H, Godfray J, Gollin D, by cause of death for 155 world regions in the related deaths worldwide (95% CI 314 000-736 Rayner M, Ballon P and Scarborough P. Global year 2050. e researchers linked a detailed 000). Twice as many climate-related deaths were and Regional Health Eﬀects of Future Food Pro- agricultural modelling framework (the Inter- associated with reductions in fruit and vegetable duction under Climate Change: A Modelling national Model for Policy Analysis of Agricultural consumption than with climate-related increases Study. 2016. e Lancet 387 (10031) (October Commodities and Trade (IMPACT)) to a com- in the prevalence of underweight, and most 14): 1937-1946. doi:10.1016/S0140- parative risk assessment of changes in fruit and were projected to occur in south and east Asia. 6736(15)01156-3...... 菀菀 ...... Research Snapshots Meta-analysis of associations between stunting and child development

espite documented associations between in three or four domains were considered ‘on- stunting and cognitive development, track’ overall. e authors found that stunting Dfew population-level studies have meas- is associated with many but not all developmental ured both indicators in individual children or domains across a diversity of countries and cul- assessed stunting’s associations with other de- tures. However, associations varied by national velopmental domains. Because stunting is more breastfeeding prevalence and developmental do-

easily measured, it is oen used as a proxy for main. Mean prevalence of breastfeeding at six WFP/Nyani Quarmyne Photo: developmental delay. Yet, although stunting and months was 89.1% and mean percentage of chil- developmental delay are associated and share dren aged 36-59 months with on-track devel- many risk factors (illness, poverty, low birth opment was 65.5%, ranging from 42.6% in Sierra weight, maternal depression, lack of breastfeeding), Leone to 85.9% in Belize. Severe stunting (height- other risk factors for developmental delay – such for-age Z-score <-3) was negatively associated as exposure to violence or toxic metals, lack of with on-track development. Any stunting, in- caregiver responsiveness and inadequate stimu- cluding severe stunting, was negatively associated lation – will not necessarily result in stunting. with physical development and literacy/numeracy development in high BF countries but not low is meta-analysis, using publicly available BF countries. Any stunting (Z-score <-2) was data from 15 Multiple Indicator Cluster Surveys negatively associated with on-track development (MICS-4) in low- and middle-income countries, in countries with high BF prevalence. assessed the association between stunting and development, controlling for maternal education, Miller AC, Murray MB, omson DR and Ar- family wealth, books in the home, developmen- bour MC, 2016. How consistent are associations tally supportive parenting and sex of the child, between stunting and child development? Evi- stratified by country prevalence of breastfeeding dence from a meta-analysis of associations be- (BF) (‘low BF’<90 %, ‘high BF’ ≥90 %). Ten- tween stunting and multidimensional child de- item Early Childhood Development Index (ECDI) velopment in fieen low- and middle-income scores assessed physical, learning, literacy/nu- countries. Public Health Nutrition, 19(8), A father waits for a check-up at a community meracy and socio-emotional developmental do- pp.1339-1347. 10.1017/S136898001500227X. clinic in the Northern Region of Ghana mains. Children (aged 36-59 months) on track

Who should finance the World Health Organization’s work on emergencies?

n May 2015, the 68th World Health Assembly is comment explores WHO funding options carbon emissions, air fuel and transportation approved the decision to reform the work of for the CFE. ese include: voluntary contribu- and tobacco have all been proposed as potential Ithe World Health Organization (WHO) on tions from member states (although less realistic new funding sources for global health). WHO emergencies by creating a single programme for due to global economic downturn); private should also seek to understand the institutional outbreaks and health emergencies. is is ac- sector foundations who have been responsive constraints, particularly with regard to budgeting, companied by a Contingency Fund for Emer- to fund appeals (although this would involve that precipitated the slow response to the 2014 gencies (CFE) to rapidly scale up WHO’s initial re-examining WHO rules on managing conflicts Ebola outbreak. Major changes at an organisa- response to outbreaks and emergencies with of interest relating to guidance norm setting tion-wide level will be required for WHO to health consequences (using the objective criteria (the authors suggest these might be less essential truly lead the process of response to health set out in WHO’s Emergency Response Frame- for its emergency programmes and cite WFP emergencies on a global scale. work), that merges two existing WHO funds1. (UN World Food Programme), who engage Y-Ling Chi, Krishnakumar J, Maurer J, Loncar Latest estimates are that core funding needs for with a wide range of private corporations, in- D, Flahault A. 2016. Who should finance WHO’s the programme and the initial capital of the cluding Coca-Cola, Unilever, and Danone)); work on emergencies? e Lancet 387 (June 25): CFE will range from US$100 to US$300 million collecting flexible voluntary contributions because 2584-2585. www.thelancet.com/pb/assets/raw (£81.77 to £245.32 million) per year respectively, of the unpredictable nature of emergencies (a /Lancet/pdfs/S0140673616305864.pdf but it is currently unclear how such resources challenge for WHO, since 93% of such contri- will be raised. Previous attempts to set up similar butions are earmarked for specific activities); contingency funds at WHO were hindered by and bilateral agreements with governments to 1 WHO Rapid Response Account and WHO-Nuclear Threat insuﬃcient funding. redirect resources from taxation systems (e.g. Initiative Emergency Outbreak Response Fund.

Hinari Access to Research for Health Programme provides free or very low cost online access to the major journals in biomedical and related social sciences to local, not-for-profit institutions in developing countries. Eligible categories of institutions are: national universities, professional schools (medicine, nursing, pharmacy, public health, dentistry), research institutes, teaching hospitals and healthcare centres, government offices, national medical libraries and local non-governmental organisations. All staff members and students are entitled to access the information resources. For more information, visit: www.who.int/hinari/about/en/

...... 菀菀 Research......

By Alexandra Rutishauser-Perera Tackling the double burden of Alexandra Rutishauser-Perera is a Humanitarian Nutrition Adviser with Save the Children. She has ten years of malnutrition in low and middle- experience of public health nutrition with several international non-governmental income countries: organisations in West and East Africa and South-East Asia. response of the This article summarises key ﬁndings of a Masters dissertation undertaken by the author in 2015. The author acknowledges international community her MSc supervisor, Dr Cecile Knai, for her support.

Location: LMICs sectors: Children (n=5), Food Security (n=1), Health (n=8), Nutrition (n=4) and Relief (n=1), What we know: e double burden of malnutrition (DBM) affects many low and middle- although most had overlap. Ten organisations income countries (LMICs); there is growing recognition of the emerging problem. had more than 20 years of experience. e majority of organisations implemented programmes What this article adds: A recent study assessed existing activities, barriers and enablers of (n=14); four were policy-based (three UN agen- 19 international organisations in tackling the DBM in LMICs. Most work has been at pol- cies) and one was an advocacy organisation. icy level which has not yet translated into interventions. Ten agencies were not imple- Ten agencies were working in both developed menting related programming; barriers included lack of funding, obesity prevention not a and developing countries; nine in developing life-saving intervention, lack of agency expertise, lack of guidelines and lack of impact countries only. evaluation. Shortage of evidenced interventions and donor engagement/funding particu- Nine (47%) of the organisations did not in- larly limit progress. Most respondents favoured using existing international fora to facili- tegrate any obesity or NR-NCD related activities tate necessary information exchange. Recommendations include systematically including within their work. ree agencies (16%) inte- overweight/obesity data in nutrition surveys; researching the impact of acute malnutri- grated the theme of DBM within health education treatment/rapid weight gain on chronic disease; and monitoring possible conflicts of tion and two agencies (11%) did so within interests in public/private partnerships. social and behaviour-change activities. Four agencies (26%) had a policy on DBM. Two organisations (10%) had no plans to address DBM, and seven (37%) had only just begun in- he double burden of malnutrition ere is growing international recognition ternal conversations about obesity prevention (DBM) affects many low and middle- of the emerging problem of overweight and and NR-NCD programmes. income countries (LMICs). e rate obesity in LMICs. However, in practice NGO- of increase of childhood overweight led nutrition programming focuses on alleviating Most work to date has been at a policy level andT obesity in LMICs is more than 30% higher wasting and stunting, with very few tackling and was conducted by UN agencies to address than in developed countries (Wang & Lobstein, the problem of obesity (INFPR, 2014). malnutrition in all its forms, mainly in response 2006) and there are more overweight and obese to the nutritional landscape faced in the Syria A recent study assessed existing activities of children in LMICs than in high-income countries crisis (UNICEF, 2014; (Dolan et al, 2014). How- international organisations and UN agencies in (WHO 2015). Physical inactivity and unhealthy ever, very few DBM interventions were identified tackling the DBM in LMICs, as well as evaluating diet characterise socio-economic transition amongst implementing agency respondents. the barriers and enablers they face in doing so. (Boutayeb & Boutayeb, 2005). Additionally, the Two programme examples were: a ‘One Goal’ programme led by World Vision in India (Ed- emergence of nutrition-related non-communi- Method wards, 2015) and the ‘Double Fardeau of Nu- cable diseases (NR-NCDs) may be compounded A mix of purposive and snowball sampling was trition’ (DFN) Project in West Africa, partly by problems of undernutrition, which themselves used to identify participants for semi-structured supported by Helen Keller International (Pôle increase the risk of developing NCDs in adult- interviews. e interview transcripts were analysed Francophone Africain, 2015). hood (Darnton-Hill et al, 2004). A child who using a framework analysis (Ritchie & Spencer, grows inadequately can be under-nourished in 1993). Participants (representatives of international Reported barriers to including DBM activities infancy but become overweight or obese later organisations involved in agency nutrition strategy were lack of funding (n=13), the fact that obesity in life if the individual consumes energy-dense development) were identified from International prevention was not a lifesaving intervention (n=12), foods in excess. e same household can some- Conference on Nutrition (ICN2) participants, lack of agency expertise (n=11), lack of guidelines times comprise both an under-nourished child those engaged in the Scaling Up Nutrition (SUN) and impact evaluation on prevention of obesity and an overweight adult (WHO, undated). Movement and researcher contacts. Nineteen in- (n=9), and lack of specific disaggregated data Childhood obesity increases the child’s risk of terviews were conducted (only one per agency). (n=7). Some found it difficult to judge whether mental and physical health effects, which most DBM was a health or nutrition problem. LMICs are not equipped to treat ((Boutayeb & Findings Boutayeb, 2005), placing an additional burden All participants were senior staff at agency e most commonly cited enabler for DBM on already fragile health systems. headquarters categorised in five programming programing was having more evidence (n=12)...... 菀菀 Research ......

e types of evidence needed included disag- economic consequences of obesity in adults Conclusion and recommendations gregated data on prevalence, the determinants in high-income countries are now well re- is study identified that, despite increased interest of obesity, evidence-based programming on pre- ported, but concentrate mostly on healthcare among international organisations and UN policy vention of obesity, and cost effectiveness of ac- expenditure; the consequences of childhood development on prevention of obesity and NCDs, tivities targeting overnutrition. Addressing mi- obesity are almost never mentioned (Bhutta there is an intervention gap in LMICs in catering cronutrient deficiencies by focusing on food et al, 2008). for the DBM. Lack of donor engagement/funding quality and higher intake of fruits and vegetables Many believe that the SUN Movement provides and lack of evidenced interventions limit progress. (e.g. school feeding in South Africa), or treating an opportunity to address the DBM. However, ere are concerns regarding consequences of undernutrition (which at a young age can pre- an external evaluation of the 2014 SUN movement current undernutrition treatment programmes dispose to obesity later in life) were suggested as suggested that the movement might dilute its ad- for future NCD burden. Key recommendations entry points to develop activities on DBM (n=7). vocacy if it stops focusing solely on undernutrition. emerging from this study include: Other factors that contributed to decisions to become involved in DBM programming included ICN2 focused on the problems of overweight, 1. e collection and reporting of childhood existence of a donor strategy to address DBM obesity and undernutrition. However, the timing and maternal overweight/obesity data should (n=6), being operational in a country affected of the event limits its utility for timely exchange be systematically included in all nutrition by obesity (n=4), obesity prevention included in of information. e Committee on World Food surveys; the targets of the World Health Assembly (WHA) Security (CFS), an intergovernmental body 2. Advocacy for the inclusion of the WHA (n=3), and internal expertise (n=2). created to serve as a forum for review and follow target on childhood obesity in the SDGs is up of food security policies, has agreed to integrate needed; Ten participants felt it was not necessary to the problem of overweight and obesity into its 3. Epidemiological and operational create a new forum to exchange information on agenda (FAO, 2015). e CFS is interlinked with information on DBM should be integrated DBM. Only three respondents favoured devel- the UN Standing Committee on Nutrition (UN- into existing international nutrition forums, opment of a DBM-specific forum. e top five SCN), which connects UN agencies and partners and particularly more systematically within forums suggested were the SUN Movement (n=7), working on nutrition and food policy. e UN- the SUN movement; ICN (n=5), ENN (n=5), UNSCN (n=5), and the SCN has a dedicated section on Nutrition and 4. More research is needed on the impact of Committee on World Food Security (CFS). NCDs (UN 2015), but funding issues seem to the promotion of RUTF and rapid weight gain in acute malnutrition treatment pro- Potential negative consequences of current impede its scope of work (WPHNA 2011). grammes; and nutrition programming on DBM were: promotion Among the most cited forums in the study, 5. Greater monitoring of possible conflicts of of energy-dense food (n=8); public/private or ENN is the most used by field nutrition workers. interests in public/private partnerships is NGO/private partnerships (n=7); and rapid Since its special edition of Field Exchange on required. catch-up growth in infancy for underweight in- the Syria response in March 2015, ENN now infants or young children potentially increasing cludes articles on the double burden of malnu- Further research, involving a full mapping of childhood obesity prevalence (n=4). Seven par- trition in its communications (Dolan et al, 2014). DBM activities of international organisations ticipants suggested ways to mitigate negative and an exploration of operational evidence on consequences, including more systematic quan- e potential for negative consequences of prevention of obesity in LMICs, has the potential titative analysis of those potential risks; con- prevention and treatment programmes for un- to contribute to the halt in the rise of diabetes centrating on effective activities such as breast- dernutrition on childhood obesity are reflected and obesity as recommended in the WHA feeding; having a more food-based approach in the literature. Examples include: target. The link between undernutrition and regarding the prevention of undernutrition; and • Promotion of sweet, energy-dense products overnutrition may also be an entry point to including nutrition and counselling in all food may send misleading messages to parents as advocating with donors to add the DBM to security and nutrition programmes. well as habituate children’s tastes for sugar- their development agenda. rich and calorie dense foods (GIFA 2014). Discussion • Rapid catch-up growth may lead to obesity, For more information, contact: a.rutishauser- Development assistance providers have started rather than increase the height of children, [email protected] to include prevention and management of NCDs especially when used in prevention Watch Alexandra Rutishauser-Perera’s talk on in their programme activities. However the (WPHNA; Gupte 2013). this topic at the TEDx LSHTM: scope of these interventions is still limited geo- • Action Contre la Faim argues that the https://www.youtube.com/watch?v=G7AG- graphically and not integrated into nutrition potential risk of ready-to-use therapeutic DvobHE programming. e US ASSIST project still food (RUTF) leading to obesity needs to be focuses on Europe and Central Asia, with only further researched, but will continue to use a few NCD projects in India and Uganda (US- RUTF to treat SAM until the risk is verified References AID).e UK Department for International De- (ACF 2012). velopment (DFID) is exceptional in that it in- e need to evaluate those risks objectively in AAH. Action Against Hunger. Measuring Mortality,Nutritional Status, and Food Security in Crisis cludes commitment to prevent and treat the field programmes persists. Situations: SMART Methodology. Version 1, 2006. four major NCDs (cardiovascular disease, cancer, An increase in public/private partnerships ACF 2012. Putting nutrition products in their place: ACF chronic respiratory disease and diabetes) in its position paper. Field Exchange. January 2012;Volume 2010-2015 policy. and inherent risks to public health are also con- 42:p57. cerns. e Lancet series on the global obesity Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Despite global improvement in reporting pandemic noted: “Governments and international Giugliani E, et al. What works? Interventions for maternal the prevalence of overweight/obesity in dif- organisations such as the UN need to provide and child undernutrition and survival. The Lancet ferent age groups, the data reported are still global leadership on these issues and not abdicate 2008.371(9610):417-40. national-level only (Global Nutrition Report, them to the private sector” (Swinburn et al, Boutayeb A and Boutayeb S. The burden of non- Malnutrition Mapping Project) (INFPR, 2014; 2013). A positive example of private sector en- communicable diseases in developing countries. GAIN 2015). The international guidelines on gagement was given in feedback, noting that International Journal for Equity in Health. 2005;4(1):2. nutrition surveys do not include indicators not all public-private partnerships are the same. Darnton-Hill I, Nishida C, James WP. A life course approach to diet, nutrition and the prevention of chronic diseases. on overweight/obesity (AAH, 2006). Addi- Actors working in the field of nutrition request Public Health Nutr. 2004;7(1a):101-21. tionally, there is also a lack of consensus on more transparency and monitoring of those Dolan C, McGrath M, Shoham J. ENN’s perspective on the how to define overweight/obesity in childhood partnerships in order to be able to “maximise nutrition response in the Syria crisis. Field Exchange. and adolescence (Poskitt, 2009). Data on the benefits and minimise risks” (Kraak et al, 2012). November 2014 (Issue 48)...... 菀菀 Research ......

Edwards E. CHNCA, World Vision International. ‘One Goal’ Nutrition Report 2014: Actions and Accountability to UN 2015. United Nations System Standing Committee on to end malnutrition in Asia - using the power of football Accelerate the World’s Progress on Nutrition. Washington, Nutrition 2015. Available from: www.unscn.org/. 2015. Available from: wvi.org/child-health- DC. 2014. UNICEF State of the World’s Children Report. now/article/%E2%80%98one-goal%E2%80%99-end-maln Kraak VI, Harrigan PB, Lawrence M, Harrison PJ, Jackson 2014;20Jan.pdf utrition-asia-using-power-football MA, Swinburn B. Balancing the beneﬁts and risks of public- USAID. United States Agency for International FAO 2015. Food and Agriculture Organization, editor The private partnerships to address the global double burden of Development Assist Project. Applying Science to 2nd International Conference on Nutrition (ICN2) and malnutrition. Public Health Nutr. 2012;15(3):503-17. Strengthen and Improve Systems. [cited 2015]. Available Sustainable Food Systems Post-2015. Advancing Nutrition Pôle Francophone Africain sur le double fardeau from: www.usaidassist.org/ from ICN2 to post 2015, which role for CFS?; 15 October nutritionnel [cited 2015]. Available from: 2014; Rome. Wang Y and Lobstein T. Worldwide trends in childhood http://poledfn.org/ overweight and obesity. International Journal of Pediatric GAIN. Malnutrition Mapping Project [cited 2015]. Poskitt EM. Countries in transition: underweight to Obesity. 2006;1(1):11-25. Available from: www.gainhealth.org/ obesity non-stop? Ann Trop Paediatr. 2009;29(1):1-11. WHO [undated]. World Health Organization Child Growth GIFA 2014. Breastfeeding briefs [press release]. Geneva Ritchie J and Spencer L. Qualitative data analysis for Standard, backgrounder 4. Available from: www.who.int Infant Feeding Association (GIFA), an aﬃliate of the applied policy reseach in analysing qualitative data. International Baby Food Action Network (IBFAN) 2014. WHO 2015. World Health Organization Interim Report of London: Routledge 1993. the Commission on Ending Childhood Obesity. 2015. Gupte S. Recent Advances in Pediatrics. Special Volume 23 - Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood Pediatric Gastroenterology, Hepatology and Nutrition: WPHNA. World Public Health Nutrition Association 2011. DT, Moodie ML, et al. The global obesity pandemic: Jaypee Brothers, Medical Publishers Pvt. Limited; 2013. Available from: shaped by global drivers and local environments. The www.wphna.org/htdocs/2011_feb_hp5_scn_crisis.htm INFPR. International Food Policy Research Institute. Global Lancet 2011. 378(9793):804-14.

Ethiopia’s Productive Safety Net Programme:

Power, Politics and Practice Summary of research1

Location: Ethiopia

What we know: e Productive Safety Net Programme (PSNP) is an established, large-scale social protection eﬀort by the Government of Ethiopia targeting rural, food-insecure households.

What this article adds: A recent qualitative study explored the role of power and politics in the PSNP in seven communities in two regional states of Ethiopia. e authors conclude that while there is positive impact, the implementation of the programme is problematic. In these communities, the PSNP was highly politicised, systematically neglected all of the participatory components outlined in the programme design, excluded the feedback mechanisms and entrenched political power. Understanding the existing political climate in operational environments is critical.

thiopia has made significant progress found to have positively impacted food-insecure gain insight that might not otherwise have been in reducing poverty, with a decrease households. Some studies claim that the impact shared. Interviews consisted of four group in- of the population living in poverty is modest compared with progress made in terviews with each community-based government from 46% in 2005 to 30% by 2010 (the comparable non-client households, although body (in groups of two to six staff members), Epopulation increased from 57 to 88 million even critical assessments point to significant and 46 key informant interviews with PSNP during the same period). e country has one positive change. e PSNP has three key com- clients, which were conducted voluntarily and of the fastest-growing economies in the world; ponents (see Box 1). A recent study explored anonymously. A large number of issues were gross domestic product (GDP) was between 8.6 the roles of power and politics in the imple- raised by both government staff and community and 13.6% from 2004 to 2016. e Productive mentation of the PSNP. e authors contrast members; this research focused primarily on Safety Net Programme (PSNP) is one of the the plan (the Programme Implementation Man- the common concerns and key discrepancies in Government of Ethiopia’s (GoE) most effective ual) with its practice and explore why divergences the experiences of PSNP clients. Due to regional programmes to support people living in rural may be occurring. diversity within Ethiopia, this study was never areas, who make up over 80% of the population. Methods expected to have great external validity. e PSNP began in 2005 to support food- e qualitative research methods involved detailed Findings insecure households and enable them to overcome interviews with clients and former clients of the Selection and graduation vulnerabilities without eroding their assets, and PSNP, as well as relevant government staff (com- • Fair and transparent selection is one of PSNP’s over time to support households to build assets. munity leaders, development agents, community core principles, yet current clients and In 2015, more than seven million people had health workers and school staff) in seven com- graduates in all the communities voiced been supported by it, with an expected expansion munities in southern Ethiopia from two regional to ten million people. e PSNP is mainly im- states. Given political sensitivities in the country, plemented by the GoE, with assistance from researcher connections were utilised to select 1 Cochrane, Logan, and Y Tamiru. 2016. Ethiopia’s Productive development partners. e programme, now in communities for the study. ese relationships Safety Net Program: Power, Politics and Practice. Journal of International Development 28 (5): 649–665. its fourth phase, has been widely studied and were pivotal in establishing the trust needed to doi:10.1002/jid.3234...... 菀菀 Research ...... concern regarding the lack of transparency • Selection decisions were also linked to Work commitment in client selection, and why and how political affiliation, with the exclusion of • ere is limited adherence to the per person graduation occurs. known opposition party supporters. working cap (no more than 15 days/month • Described in the Manual as “community- • Data supports claims that numbers of per adult household member) set out in the based targeting”, in reality local leaders and graduates are determined at higher levels of Manual to prevent overburdening clients. government staff selected clients without any government, based on quotas to ‘confirm’ • In practice, each public works client was re- community participation – a process that that the programme is successful (i.e. clients sponsible for working six days per week for resulted in bias, with family members and are expected to graduate aer five years). six months of the year; also ‘voluntary’ par- friends of local leaders gaining entry prefer- • A number of political purposes are at play; ticipation in works continued beyond six ence and holding longer terms. the PSNP is being used for political patron- months (refusal may be equated with age, punishment (clients were graduated for political opposition, resulting in exclusion political reasons), and for broader political from benefits). Box 1 Overview of PSNP objectives of meeting regional and national • e Government benefits from lack of ad- targets. herence to labour caps, as most of the work Public works programme Lodging an appeal involves government-run facilities such as Eligible households with able-bodied adults • According to the Manual, the grievance schools and roads. are enrolled on this programme, with work geared towards enhancing infrastructure mechanism is run by an Appeals Committee Power tends to corrupt and enriching community-based resources, at the community and district levels, but not • ere were multiple reports and examples such as schools. Public works activities occur one current or former client had heard of of corruption, e.g. public workers made to for six months each year, during which this. farm land belonging to the community chair clients receive a salary based upon • Overlapping responsibilities (i.e. staff likely man, or people with a good relationship with household size. Clients are expected to to be on both committees that select clients the chairman were enrolled in the PSNP but graduate from the programme when they as well as theoretical ones that handle not required to work. gain sufficient assets. appeals) reduce effectiveness. Direct support programme • Questions were not escalated to higher Discussion Those who are unable to work due to levels of government due to fear of reper- e study authors conclude that the programme disability, illness or age are enrolled in the cussions; e.g. being labelled as an anti-gov- has had a large and beneficial impact, but its direct support programme (payments are for ernment agent. implementation has been shaped and co-opted 12 months of the year). Participation to maintain and strengthen political power. Fur- Temporary programme thermore, the findings challenge donors and • e manual states that public works’ pro- Temporary clients are pregnant or lactating practitioners to recognise the ways in which grammes should be decided by the commu- mothers or caregivers for a malnourished their funding and approaches to programme child, who are enrolled in the public works nity members, but in practice government design are both empowering and disempowering component and temporarily shifted into staff choose and direct group leaders to individuals and to better understand the existing direct support. repair roads, etc. PSNP clients have no par- political climate in operational environments. ticipation in the decision-making process.

Admission profile and discharge outcomes for infants aged less than six months admitted to inpatient

therapeutic care in ten countries Summary of research1

Location: Global (Burundi, DRC, Kenya, Liberia, Myanmar, Niger, Introduction Somalia, Sudan, Tajikistan, Uganda) Acute malnutrition is a serious global health problem, with wasting aﬀecting 50 million children under five years old and accounting for What we know: e burden of acute malnutrition in infants less than 11.5% of mortality in this population. An estimated 8.5 million of six months old is significant; there is a weak evidence base to inform wasted children are infants aged less than six months (infants <6mo). guidance on their management. is high global burden has only recently been recognised, with the What this article adds: A secondary data analysis described the profile inclusion of infants <6mo in the latest World Health Organization and treatment outcomes of 4,002 infants<6mo relative to 20,045 chil- (WHO) guidelines for the management of severe acute malnutrition 2 dren aged 6-60 months from inpatient therapeutic feeding centres in (SAM) . Such recognition needs to be underpinned by developing ten countries. Infants <6mo accounted for 12% of admissions. In- the evidence base in order to improve care in this age group. fants<6mo had more missing length and MUAC data, weight-for- is study describes the profile and outcomes associated with the height that could not be calculated (length <45cm) and nutrition in- management of acute malnutrition in infants <6mo under prevailing dices that were extreme values. Infants <6mo had a higher relative risk treatment protocols (pre-2013 WHO guidelines) to expand under- of death, despite a better nutritional profile than older children at admission; this requires cautious interpretation due to the high level of 1 WHO (2013) Guideline: Updates on the Management of Severe Acute Malnutrition in Infants heterogeneity between countries in the dataset. Contextual data on and Children. World Health Organization: Geneva. SAM prevalence, disease burden and service quality for infants<6mo 2 Grijalva-Eternod CS, Kerac M, McGrath M, Wilkinson C, Hirsch JC, Delchevalerie P, and Seal AJ (2016) Admission proﬁle and discharge outcomes for infants aged less than 6 months was not available. Systematic compilation and analysis of routine data admitted to inpatient therapeutic care in 10 countries. A secondary data analysis. Maternal on infants<6mo and research on definition of SAM is needed. & Child Nutrition, doi: 10.1111/mcn.12345...... 菀菀 Mother and infant in Burundi Research ......

reason that WHZ could not be calculated (467 out of 471 cases) was that infant length was lower than 45 cm, the minimum reference value needed for calculating this index. at a greater number of WHZ were flagged for infants <6mo suggests that further work is necessary to better understand if the cleaning criteria developed for older children should be applied to this younger age group. Infants <6mo presented a better anthropometric profile than older children at admission to therapeutic care, even after ac-

WFP/Laura MeloWFP/Laura counting for oedema. Alternative non-anthropometric criteria, such as clinical signs of in- standing about the effectiveness of current care malnutrition. e quality of anthropometric fection, disability, feeding difficulties and ma- strategies and to provide the baseline evidence data at admission was more problematic in internal factors, may have been used for admis- to help guide improved future care. fants <6mo than in older children. Infants had sion; an assumption that is supported by a re- more missing length (a 6.9 percentage point view of admission criteria used for this age Study methods difference for length values, 95% CI: 6.0, 7.9; group (ENN & CIHD, 2010). The degree to A secondary analysis was undertaken of rou- p<0.01) and MUAC data, anthropometric meas- which use of non-anthropometric criteria may tinely collected and fully anonymised inpatient ures that could not be converted to indices (a have contributed to the better nutritional therapeutic care programme data in ten coun- 15.6 percentage point difference for weight- profile of admissions could not be quantified. tries. The data came from an appeal for for-length z-score values, 95% CI: 14.3, 16.9; Possible explanations for significantly lower datasets on acute malnutrition care of infants p<0.01, and nutrition indices that were extreme oedema amongst infants<6mo are difficulties <6mo. Twenty-three datasets from Action values (a 2.7 percentage point difference for in diagnosis in this age group, and clinically Contre la Faim containing individual-level any anthropometric index being flagged as an detectable oedema might only occur after cer- inpatient therapeutic care programme data outlier, 95% CI: 1.7, 3.8; p<0.01. tain developmental milestones. from 25,195 children aged 0-60 months from 34 field sites located in 12 countries were Infants <6mo had better nutritional status is analysis found that high proportions sourced. The majority (82%) of children in at admission to treatment centres than older of both infants <6mo and older children recover the study dataset were admitted to therapeutic children, with lower proportions of oedema aer receiving therapeutic care for acute mal- feeding centres (the remainder were admitted and global acute malnutrition (GAM). (A nutrition. However, a meta-analysis of the data to a day care, home treatment or stabilisation significantly larger proportion of infants revealed that infants <6mo have a higher centre). Data from two countries, Afghanistan <6mo were moderate acute malnutrition relative risk of death, despite a better nutritional and Ethiopia (n = 1150), was excluded as (MAM) and a significantly lower proportion profile at admission; these observations need their programme data comprised largely in- were SAM). cautious interpretation due to the high level fants<6mo and no older children for com- of heterogeneity between countries in the A high proportion of both infants <6mo parison. A final sample of 24,045 children dataset. ese results may reflect differences and older children were discharged as recovered. aged 0-60 months (4,002 infants<6mo; 20,043 in the quality of therapeutic care given to However, infants <6mo showed a greater risk 6-60 months) from ten countries was used infants <6mo and different infant profiles; for analysis. of death during treatment (risk ratio 1.30, 95% prevalence of acute malnutrition in the com- CI: 1.09, 1.56; p<0.01 than older children, al- munity, disease burden of infants <6mo, and Available data for most children at admis- though there was a high level of variation in data on service quality were not available. An sion included: age, the presence of bilateral the risk ratio between study sites (86.6% variation important limitation is that malnourished in- pitting oedema, and anthropometric data in risk ratio attributable to heterogeneity; X2 = fants<6mo may have been under-represented (weight, length or height and mid-upper arm 67.0 p<0.01). in this study; most programmes were less circumference (MUAC)). Anthropometric data likely to have actively sought malnourished were also available at discharge. However, Discussion and infants<6mo compared to older children. there was a large heterogeneity in the type recommendations and timing of data collected. As a consequence, To the authors’ knowledge, this was the first is study contributes to the call for priori- this analysis focused only on anthropometric analysis of programme data from a variety of tising research on how acute malnutrition is and oedema data at admissions and outcomes countries on infants <6mo receiving thera- defined among infants <6mo, which is funda- at discharge. Discharge outcomes were coded peutic care for acute malnutrition. A key mental to determining management strategies. differently within and between datasets: dis- finding is that infants <6mo make up an im- e authors conclude that there is an urgent charge codes were grouped into one of four portant proportion of the children in thera- need for monitoring programme performance sphere discharge codes: recovered, died, de- peutic feeding programmes run by interna- for infants <6mo involving systematic compi- faulted and non-recovered. tional relief agencies. lation and analysis of routine data. Data were manipulated and analysed in Collecting anthropometric data in infants Stata soware. Anthropometry was calculated <6mo was a challenge, highlighted by the References based on the 2006 WHO Growth Standards. greater proportion of missing data at admission, Extreme values were flagged as outliers using particularly length. MUAC data is not recom- Crowe et al, 2014. Crowe S., Seal A., Grijalva-Eternod C. and Kerac M. (2014). Effect of nutrition survey ’cleaning commonly applied cleaning criteria (Crowe et mended as an admission criterion for infants criteria’ on estimates of malnutrition prevalence and disease al, 2014). <6mo, since cut-offs were (and are still not) burden: secondary data analysis. PeerJ 2, e380. established for this age group. e WHZ index ENN & CIHD, 2010. ENN & CIHD, 2010. MAMI Project. Results could not be calculated for a significantly Technical review: current evidence, policies, practices & Infants <6mo accounted for 12% of children programme outcomes. Available at: greater proportion of the infants <6mo based www.ennonline.net/mamitechnicalreview receiving inpatient therapeutic care for acute on admission anthropometric data; the main ...... 菀菀 Research ......

Chronic disease outcomes after SAM in Malawian children (ChroSAM): A cohort study Summary of research1

Location: Malawi

What we know: Little is known about the long-term health eﬀects of survivors of severe acute malnutrition (SAM), particularly risk of non-communicable diseases (NCDs) in later life.

What this article adds: A cohort of Malawian SAM-survivor children were followed up seven years aer inpatient SAM treatment and compared with sibling and community controls. Seven years post-treatment, nearly one-third of discharged cases had died and another 15% were lost to follow-up. SAM survivors had lower height-for-age (HAZ) compared with controls, although with evidence of catch-up growth. Associated functional impairments were found, such as poorer physical strength, poorer physical capacity, and lower school achievement, compared to controls. Results suggest that SAM has long-term adverse eﬀects (patterns of growth associated with future NCDs), but with potential for rehabilitation (evidence of catch-up growth and largely preserved lung and cardiometabolic functions). Recommendations for future follow-ups include establishing the eﬀects of puberty and later dietary or social transitions.

xtensive research links nutrition in follow-up study (n=477). For comparison, the 117 were lost to follow-up. Of 398 children early life with adult health and non- researchers aimed to recruit one sibling control traced seven years post-discharge, 46 (11.5%) communicable diseases (NCDs), a field (the sibling closest in age to the case child) had died. us, of 786 children discharged from of research known as developmental and one community control (a child of the SAM treatment, nearly one-third (30%) were Eorigins of health and disease (DOHaD). Most same sex and close in age living in the same known to have died seven years later and another evidence for DOHaD describes associations be- community) per child in the case group. Chil- 15% were lost to follow-up. (See Figure 1.) tween in utero or very early postnatal exposures dren who had been treated for SAM were not and adult NCD risk. However, it is biologically eligible as controls. Key findings show: plausible that early life events such as severe • Case children had more severe stunting than The study’s outcomes of interest included: acute malnutrition (SAM) during late infancy controls (adjusted difference vs community anthropometry, body composition, lung func- or early childhood, and the rapid catch-up controls 0·4, 95% CI 0·6 to 0·2, p=0·001; ad tion, physical capacity (measured as handgrip growth that occurs during and aer treatment, justed difference vs sibling controls 0·2, 0·0 strength, step test and physical activity), school could have long-term health implications. to 0·4, p=0·04), although they showed evi- achievement and blood markers of NCD risk. dence of catch-up growth. e chronic disease outcomes aer SAM in Multivariate linear regression was used to com- • ese children also had shorter leg length Malawian children (ChroSAM) study followed pare all outcomes, adjusted for age, sex, HIV ((adjusted difference vs community controls up children seven years aer they had received status and socioeconomic status, as well as pu- 2·0 cm, 1·0 to 3·0, p<0·0001; adjusted SAM inpatient treatment. Researchers investi- berty in the body composition regression model. difference vs sibling controls 1·4 cm, 0·5 to gated the effects of SAM on growth, body com- Data collectors were not blinded to the case or 2·3, p=0·002), but similar sitting height. position, functional outcomes and risk factors control status of the children. With 320 cases, • Cases had other body composition differ- for NCDs. 217 sibling controls and 184 community controls, ences than controls, including: smaller mid- the authors calculated that the study was ade- Study overview upper arm circumferences (MUAC) quately powered (at least 90% to detect a Z (adjusted difference vs community controls The original prospective cohort comprised score difference of 0.5 between the cases and 5·6 mm, 1·9 to 9·4, p=0·001; adjusted 1,024 patients admitted for SAM treatment at controls based on reference data for growth difference vs sibling controls 5·7 mm, 2·3 to Queen Elizabeth Hospital in Blantyre, Malawi, and lung function outcome). The sample size 9·1, p=0·02); smaller calf circumference during a nine-month period (July 2006 to was considered adequate for all outcomes except (adjusted difference vs community controls March 2007). All patients were treated with physical activity (steps per day), which was 0·49 cm, 0·1 to 0·9, p=0·01; adjusted initial inpatient stabilisation using therapeutic underpowered. milk, followed by nutritional rehabilitation with ready-to-use therapeutic food (RUTF) at Results 1 Lelijveld, Natasha, Andrew Seal, Jonathan C Wells, Jane home. The median age at admission was 24 Of the 1,024 children originally admitted, 238 Kirkby, Charles Opondo, Emmanuel Chimwezi, James Bunn, months. The ChroSAM study group was made (23%) died during treatment. At one-year fol- et al. 2016. “Chronic Disease Outcomes after Severe Acute up of 320 surviving children from the original low-up, 24% of children were known to have Malnutrition in Malawian Children (ChroSAM): A Cohort Study.” The Lancet Global Health 4 (9) (September 14): cohort, identified from a one-year post-discharge died (192/786 of those discharged); an additional e654–e662. doi:10.1016/S2214-109X(16)30133-4...... 菀菀 Research ......

difference vs sibling controls 0·62 cm, 0·2 to 1·0, p=0·001); smaller hip circumference Figure 1 Recruitment of the case group (adjusted difference vs community controls 1·56 cm, 0·5 to 2·7, p=0·01; adjusted difference vs sibling controls 1·83 cm, 0·8 to 2·8, p<0·0001); and less lean mass (adjusted difference vs community controls –24·5, –43 1024 children admitted to –5·5, p=0·01; adjusted difference vs sibling controls –11·5, –29 to –6, p=0·19). • Survivors of SAM had functional deficits 238 deaths in hospital such as weaker handgrip (adjusted difference vs community controls –1·7 kg, 95% CI –2·4

to –0·9, p<0·0001; adjusted difference vs PRONUT study 117 not found sibling controls 1·01 kg, 0·3 to 1·7, p=0·005), and fewer minutes completed of an exercise 786 alive at discharget test (sibling odds ratio [OR] 1·59, 95% CI 1·0 to 2·5, p=0·04; community OR 1·59, 95% CI 1·0 to 2·5, p=0·05). 192 died • Community and sibling controls were more likely to be in a higher school grade aer ad- 477 known to be alive at justing for confounders (odds ratio [OR] 1 year post-discharge 1·70, 95% CI 1·2–2·4, p=0·003 compared post-discharge) FuSAM study (1 year FuSAM with community controls and OR 2·77, 95% 79 not found CI 1·9–4·0, p<0·0001 compared with sibling controls). 398 found 7 years Most of the other NCD risk factors assessed postdischarge (such as lipid profile and glucose tolerance) were not significantly different between cases and controls, except for diastolic blood pressure, 46 died which was higher for cases than for sibling controls (adjusted difference 1·91 mm Hg, p=0·03). study ChroSAM

Amongst cases, 28% were confirmed HIV- post-discharge) (7 years positive (compared to 4% in sibling controls and 3% in community controls). 32 declined to 320 recruited take part into ChroSAM e authors identified a number of limitations to their research, including: • Survivor bias, since only 352 out of 1,024 children in the original cohort were still alive for this follow-up (30 declined to take part); Flow diagram showing recruitment, starting with original recruitment in 2006 for the PRONUT study, followed by one-year follow up in the FuSAM study, and the present follow-up (ChroSAM). thus the study selected the fittest and healthiest survivors; • Sibling and community controls are not suggests that survivors of SAM might have un- up growth, as well as the apparent preservation fully healthy; and dergone so-called brain-sparing or thriy growth, of vital organs, suggests the potential for recovery • e study does not have data on potential whereby the growth of vital organs has been following SAM. Yet case study children remain confounders, such as exact birthweight and preserved at the cost of less vital growth. relatively small (compared with global population gestational age, which are linked to both for this age), and organ damage might only be- Large sitting-to-standing height ratio, short SAM and long-term health effects. come apparent when exposed to weight gain limb length, lower peripheral mass, and larger and unhealthy lifestyles (as seen in studies of waist-to-hip ratio have all been associated with Discussion LBW). SAM survivors may face potentially NCDs in adulthood. e pattern of lower lean e results from the study suggest that SAM greater NCD risks due to changes in dietary mass and preservation of fat mass seen in has long-term adverse effects, especially with trends in many African countries. regard to mortality, growth and body composi- children in the case group is similar to that tion. SAM survivors continue to have significantly seen in children born with low birthweight is study found high in-treatment and post- more stunting than their siblings and other chil- (LBW). is is an important predictor of physical discharge mortality amongst children treated dren in their community at seven years’ post- work capacity in later life. e combination of for SAM. e study period preceded the estab- discharge from inpatient nutritional treatment. reduced lean mass and greater stunting compared lishment of community-based management of Associated functional impairments include with controls might explain the deficiencies in acute malnutrition (CMAM) in Malawi with poorer physical strength, poorer physical capacity, physical function and strength seen in the SAM associated earlier detection of SAM and outpatient and lower school achievement than controls. survivors. Weaker handgrip is also associated care options. with lower bone mass, impaired cell membrane In conclusion, the study suggests that SAM Despite greater stunting among cases, sitting potential, and reduced muscle function, as well has long-term adverse effects, with survivors height was similar to controls, suggesting that as all-cause early mortality, risk of malnutrition showing patterns of ‘thriy growth’ associated torso growth had been preserved while limb and risk of NCDs. growth was compromised. Other outcomes such with future NCDs. Evidence for catch-up growth as head circumference were also similar in all However, SAM survivors did show signs of and preservation of vital organs suggests potential groups, while lung function and HbA1c were growth recovery, with gain in HAZ increasing for rehabilitation, but future follow-ups need to close to normal when compared with children at a steeper rate in cases who were catching up focus on how to optimise recovery and minimise of African-American origin in all groups. is to their sibling controls. e evidence for catch- any long-term adverse outcomes...... 菀菀 Research Adolescent nutrition in Mozambique: putting policy into practice

By Erin Homiak

Erin Homiak MPH is seconded to SETSAN Manica as Nutrition Advisor. Her role is funded by UKaid/DFID. She has been working for Concern Romana Cipriano with her daughters Inês and Beatriz at the Worldwide since January 2015 to improve Chimbadzuo primary school. Romana is the gender advisor coordination across government and non- for the school council. She makes sure girls stay in school and government sectors in order to reduce rates of provides support for other health and sanitation needs.

chronic undernutrition amongst women, Kieron Crawley, Manica, Mozambique. adolescents and children and to address the root causes of gender inequality to ensure improved nutrition outcomes. Erin has worked Location: Mozambique in Mozambique since 2013, previously with Helen Keller International on their Vitamin A What we know: Adolescents are typically not targeted in health and nutrition serv- Supplementation Team. ices; this has implications for health outcomes across generations. The research was carried out by the Technical Secretariat for Food Security and Nutrition What this article adds: A recent review examined the extent to which national (SETSAN-P, Manica) Focal Point and the SETSAN policy on adolescent nutrition (targeting anaemia control, reduced early pregnan- Technical Advisor (Nutrition Advisor, Concern cy and nutritional education) is being implemented in Manica province, Mozam- Worldwide). bique. It found few interventions in the province target adolescents; a gap in service implementation of the Ministry of Health’s unit for adolescents (SAAJ) servic- The author acknowledges Cosme Cabsela es; and underuse of established platforms to improve SAAJ access. Recommenda- Mandu, Focal Point for SETSAN-P, Manica and tions to inform nutrition programming at national, provincial and district levels Dionisio Oliveira, SAAJ Focal Point for Manica include defining female adolescents as a separate target group; including pregnan- Province for their support and participating in cy reduction in nutrition programmes that aim to reduce chronic undernutrition; this review. Thanks also to DFID and Irish Aid for funding support. designing a strategy to address early child marriage and engage men; targeting marginalised adolescents; and using existing outreach and service provision platforms to full capacity.

Global context Little is known about the micronutrient de- marriage is also needed, using a life-cycle ap- Adolescents are an underserved population; ficiencies at the population level in Mozambique proach to inform programme design and im- their needs are not reflected in services (Korkalo et al, 2014), although we do know that plementation. Programmes that address ado- (Hainsworth et al, 2009; Save the Children, 54% of girls and women between the ages of 15 lescent nutrition will help realise the SUN ob- 2015; Patton et al, 2014) and interventions do and 49 are anaemic (Ministerio da Saúde (MIS- jective to increase exclusive breastfeeding (ado- not define or target adolescents who are oen AU) et al, 2011). Teenage HIV infection rates lescents are 33% less likely to breastfeed); perceived as a healthy or low-risk group (Save suggest that the health needs of adolescents are reduce maternal and neonatal mortality; and the Children, 2015). Poor care-seeking behaviour not being addressed; young people (<25 years) decrease stunting (Save the Children, 2015; due to individual and structural barriers (Temin account for 60% of new HIV infections and Temin & Levine, 2009). & Levine, 2009) and stigma around family plan- young women (20 to 24 years old) are infected A recent review set out to understand the ning and use of the health system hinder service at a rate triple that of men the same age extent to which national policy regarding ado- access and delivery (Temin & Levine, 2009). (Hainsworth et al, 2009), highlighting the need lescent nutrition is being implemented in Manica Lack of evidence makes policy decisions difficult; to address the root causes of gender inequality. province, Mozambique. e aim of the review what does exist indicates that failure to target Adolescent pregnancy rate is high in Mozambique was to assist the provincial authority in advocating adolescents has major implications for health at 44.4% in rural and 33.2% in urban areas for an expansion of current delivery channels outcomes. Adolescent females are more likely (UNICEF, 2015); early marriage is one of the serving adolescents and to raise their profile to give birth to babies with low birth weight or strongest drivers. among the development community as an im- who are small for gestational age and children portant demographic to focus on and invest in. Under the Scaling Up Nutrition (SUN) who are more likely to become stunted and in Key findings are summarised here. turn give birth to small babies, thus perpetuating Movement 1,000 days window of opportunity an intergenerational cycle of chronic undernu- (Black et al, 2013), the pre-conception phase Context of Mozambique trition (Save the Children, 2015). Neglecting is not taken into account, which often coincides e first objective of Mozambique’s Multi-Sec- adolescent health means child mortality rates with adolescence. While the 1,000-day frame- toral Action Plan for the Reduction of Chronic and maternal health will remain relatively un- work encompasses adolescent pregnancies, at- Malnutrition (PAMRDC) (Republic of Mozam- changed (Sawyer et al, 2012). tention to prevention of pregnancy and early bique, 2010) specifically aims to improve the ...... 菀菀 Research ...... nutritional status of adolescent girls aged 10- not specifically targeted by the mobile brigades. needs are different from adult women. 19 (ibid, 2010). e PAMRDC is a guiding SAAJ in Manica was given technical support Interventions that define indicators specific framework designed by multiple ministries and through UNFPA from 2005 until 2013 and subse- to adolescents will generate data to inform civil society partners and is monitored by SET- quent support from Save the Children2 from 2015 services and interventions in the future. SAN at national and provincial levels. e in two of 11 districts in Manica Province (including • e ambition to reduce pregnancy rates in framework includes seven objectives, all with training of activists, service providers and teachers female adolescents should be mainstreamed defined impact results, for the reduction of and materials provision) in a two-year pilot pro- into nutrition programmes that seek to chronic malnutrition. gramme funded by the Norwegian Government. reduce chronic undernutrition, taking ere are Geração Biz activists in the district gender into account and engaging men. Serviços Amigos dos Adolescentes e Jovens schools, but only two districts have received • All outreach mechanisms should address (SAAJ) is the unit in the Ministry of Health refresher trainings (with the support of Save the early child marriage to align with Mozam- providing public health services to adolescent Children). Lack of resources limits further rollout. bique’s National Strategy for the Prevention males and females. e Department for Youth and Elimination of Early Marriage adopted and Sports is the only other provincial PAMRDC Result 1.3: Strengthened nutrition by the national Government in 2015. is partner that targets adolescents. At provincial education in different education includes engaging men, recognising that level, SAAJ consists of one Focal Point located levels as part of school curriculum, there are many determining factors that affect in the provincial capital who is responsible for including literacy curricula early marriage. the oversight of all the district-level service pro- ere is a national curriculum that includes a • e current delivery platform, Geração Biz, vision. ere is an established, country-wide nutrition component, which is implemented at should be utilised to full capacity in order to mechanism of peer-to-peer activists (Geração primary school level. FAO is supporting the increase care-seeking behaviour and ensure Biz), created to increase the number of adolescents training of teachers in nutrition in three districts access to SAAJ services. who access SAAJ services with the ultimate goal of Manica province. • Interventions should be equitable; female of addressing the sexual and reproductive health adolescents who are not in school and who is snapshot from Manica shows adolescent (SRH) needs of male and female adolescents. are likely to be most marginalised require nutrition and health is being addressed to some e activists are trained and supervised by SAAJ, alternative community outreach programmes, extent, and there are many opportunities to the Department of Education, and the Depart- such as youth care groups, youth centres and continue and increase the inclusion of adolescents ment of Youth and Sports. vocational training (Roche, 2015; Save the in public health interventions. At the national Children, 2015). Method level, several organisations, including Pathfinder e study used qualitative and quantitative re- International, UNFPA and UNICEF, work in For more information, contact search methods, including key informant in- adolescent health, focusing on SRH but not [email protected] terviews (KIIs) and review of secondary sources, taking account of nutrition. It is important to e full report is available at: https://www. including a literature review. Participatory ob- note that there may be interventions addressing concern.net/resources/adolescent-nutrition- servations of service provision of adolescent adolescent nutrition in Mozambique that have missing-link-life-cycle-approach. (SAAJ) health services in three district-level fa- not been captured in this review. cilities in Manica Province (Guro, Tambara and Discussion and 1 Dionisio Oliveira (SAAJ), conversation with author, 8 April Manica) and training of peer-to-peer activists 2015 (Geração Biz) in Gondola district were under- recommendations 2 Isabel Mateo (Save the Children), conversation with author, taken. KIIs were conducted with the provincial e findings presented demonstrate a lack of 12 June 2015.. SAAJ Focal Point in Manica; SAAJ health targeting and attention to adolescent nutrition References providers in Guro, Tambara, and Manica districts; within programmes that aim to improve nutrition the provincial Focal Point for the Ministry of in Manica province, despite national policy. e Black RE, Alderman H, Bhutta ZA, Gillespie S, Haddad L, review recognises the challenge for provinces Horton S, & Victora CG (2013). Maternal and child nutrition: Education; and several agencies including Building momentum for impact. The Lancet, 382(9890), 372- Pathfinder International, Save the Children, to keep in constant connection with the nutrition 375. FHI360, CARE, UNICEF and the UN Food and and policy community that is centralised in Concern Worldwide (March 2014). Barrier Analysis Report: Agriculture Organization (FAO). Maputo. On a positive front, Mozambique is Linking Agribusiness and Nutrition in Mozambique (LAN). ‘ahead of the game’ with regard to having an Hainsworth G, Zilhao I, Badiani R, Gregorio D & Jamisse L Results adolescent nutrition policy, which non-govern- (2009). From inception to large scale: The Geração Biz Under strategic objective 1 of the PAMRDRC, mental organisations (NGOs) and partners use Programme in Mozambique. there are three defined results. Evidence was as a framework to align programmes. Further- Korkalo L, Freese R, Fidalgo L, Selvester K, Ismael C & Mutanen M (2014). A Cross-Sectional Study on the Diet and gathered on the degree to which the results more, the PAMRDC is multi-sectoral and includes Nutritional Status of Adolescent Girls in Zambézia Province, were being met, as follows: the health, education and agricultural sectors Mozambique: Design, Methods, and Population Characteristics. [The ZANE Study] JMIR research protocols, 3(1). Result 1.1: Controlled anaemia in (Republic of Mozambique, 2010; Save the Chil- dren, 2015). ere are promising entry points Ministerio da Saúde & Instituto Nacional de Estatística adolescents (10-19 years) within (2011). Moçambique Inquérito Demográfico e de Saúde 2011. with existing programmes. and outside schools Retrieved August 13, 2013 dhsprogram.com/pubs/pdf/FR266/FR266.pdf In Manica province, iron supplementation is Mozambique will not see a reduction in chronic Republic of Mozambique (2010). Multisectoral Action Plan implemented through health clinics and mobile undernutrition unless adolescent health and nu- for the Reduction of Chronic Undernutrition in Mozambique brigades. Mobile brigades do not specifically trition is prioritised. A paradigm shi is needed 2011-2015. target adolescents in remote communities to in the way populations are targeted, taking into Roche M (2015). New Global Focus Placed on Reducing receive iron supplementations or family planning, consideration the life-cycle approach, including Anemia in Adolescent Girls. and until 2015 the adolescent target group for adolescents in target groups and not waiting for Save the Children (2015). Adolescent Nutrition: Policy and health clinics was 15-19 year-old females (rather adolescent girls to become pregnant before en- prgramming in SUN+ countries. than 10-19 year-olds)1. gaging with them and key influencers of early Sawyer SM, Afifi RA, Bearinger LH, Blakemore S-J, Dick B, Ezeh C & Patton GC (2012). Adolescence: A foundation for marriage (Concern Worldwide, March 2014). Result 1.2: Reduced early future health. The Lancet, 379(9826), 1630-1640. pregnancy in adolescents (10-19 To translate this framework into the action it Temin M & Levine R (2009). Start with a girl: A new agenda for global health. Washington, DC Center for Global years) merits, the following recommendations are made: Development. Family planning for adolescents is implemented • Nutrition interventions should define female UNICEF (2015). Child Marriage and Adolescent Pregnancy in through the health post; again, adolescents are adolescents as a separate target group whose Mozambique: Causes and Impacts...... 菀菀 Research ...... Robust evidence for an evidence-based approach to humanitarian action By Mike Clarke, Jeroen Jansen and Claire Allen

Mike Clarke is one of the Jeroen Jansen is the Claire Allen is the founders of Evidence Aid Director of Evidence Aid. part-time and is now voluntary He has been engaged in a Operations Research Director and Chair wide variety of sectors, Manager for of the Board of Trustees. He issues and working Evidence Aid. She has extensive experience in environments, mostly in worked for the evaluation of health management positions. Cochrane for 18 and social care and is Director of the Northern He worked for Médecins Sans Frontières (MSF) years and has a B.A. (Hons) in Ireland Hub for Trials Methodology Research at in Afghanistan, Liberia, Darfur and several Communication, Media and Culture. Queen’s University, Belfast. He has worked on other contexts. He has been successfully Claire’s background is in administration some of the largest randomised trials in speciﬁc employed in the private sector, managing the and ﬁnance. Her main tasks relate to areas of health and on dozens of systematic deployment of humanitarian aid and working the overall operations of Evidence Aid, reviews in a wide range of areas, with a strong as a department head for MSF in the UK. including management of information interest in increasing capacity for the conduct Formerly an engineer, he later obtained a to ensure that evidence is available in a and use of systematic reviews. He facilitates Masters in International Human Rights Law readily accessible format. trainings on systematic reviews for Evidence Aid. and worked for Marie Stopes International.

he increasing demand for ‘value for to provide the knowledge needed to resolve un- on ‘expert opinion’ and ‘best practice’, although money’, proof of impact and effective- certainties. In this way, systematic reviews provide this is changing as key influencers that straddle ness in the provision of humanitarian the vehicle by which evidence from earlier research the humanitarian and healthcare sectors, such as aid requires that decisions and activities can be brought together in ways that minimise the World Health Organisation (WHO), emphasise becomeT more evidence-based. Reliable and robust bias, avoid undue emphasis on individual studies, the need to underpin their guidance with sys- evidence will help those making decisions and maximise the power of research that has already tematic reviews. (See, for example, the ongoing choices, and those developing policies and stan- been done, and minimise waste from unnecessary work on a guideline for major radiation emer- dards, to know which interventions work, which duplication or inadequate uptake. gencies (Carr et al, 2016) and a systematic review don’t work and which remain unproven. For of accessibility in the home for an upcoming Systematic reviews begin with a focused ques- those interventions that work, people need to WHO guideline on healthy housing (Cho et al, tion and clear eligibility criteria, then seek out know how effective they are and for whom, so 2016)). is does not imply an unthinking adop- and appraise the relevant studies and compare, that they can choose the most appropriate and tion of evidence synthesis as a recipe for deci- contrast and, where relevant and possible, combine effective intervention in a specific context. Only sion-making. ere are situations where the use their findings. ey provide decision-makers and with reliable and robust evidence is it possible of ‘expert opinion’ or ‘best practice’ is justified, others making choices with a summary of the to maximise the impact, efficiency (‘value for just as an evidence-based approach, based on available evidence, which they can consider along- money’) and effectiveness of humanitarian action robust evidence, should only be applied when side other information, such as local values and and ensure more good than harm is done. and where appropriate. Nevertheless, it is important resources, before taking action. An up-to-date, that the humanitarian sector recognises the limits Evidence Aid1 engages with those guiding systematic review allows well-informed decisions of ‘expert opinion’ and ‘best practice’ and the the humanitarian sector to inspire and enable to be taken quicker and eases the evidence-gath- value of an approach based on evidence synthesis. them to apply a more evidence-based approach ering burden for people who need to take these to their decisions and actions. rough this en- decisions. e value of systematic reviews is Expert opinion is a valuable tool when applied gagement, and by working with others who gen- widely recognised in healthcare, and the concept appropriately, but applied inappropriately it can erate, disseminate and apply evidence, a large of drawing on the totality of evidence when cause considerable harm, getting in the way of and growing audience is revealed that supports making decisions is neither new nor outlandish effective action or promoting the use of ineffective a more evidence-based approach to humanitarian when explained to practitioners, patients, poli- or harmful actions. William J. Sutherland and action. A momentum is building, similar to what cy-makers and the public. is should be no Mark Burgman (2015) described the pitfalls of has happened in the healthcare sector since the different for disasters and other humanitarian applying expert opinion rather well in the journal latter decades of the twentieth century (Clarke, emergencies (Gerdin et al, 2014). Just as happened Nature. ey assert that the “accuracy and relia- 2015), generating a demand for robust evidence. in the healthcare sector several decades ago, the bility of expert opinions is … compromised by a One of the challenges is that this audience has a growing need and support for an evidence-based long list of cognitive frailties (Tversky & Kahne- wide range of interpretations regarding what re- approach in the humanitarian sector should result man, 1982). Estimates are influenced by experts’ liable and robust evidence entails. in a growing need for robust evidence and an in- values, mood, whether they stand to gain or lose crease in the investment required to generate from a decision (Englich & Soder, 2009), and by When it comes to identifying and using find- and disseminate this evidence. the context in which their opinions are sought. ings of research to decide what is likely to do Experts are typically unaware of these subjective more good than harm, the healthcare sector Despite a growing momentum for an evi- influences. ey are oen highly credible, yet recognises the need for evidence to come from a dence-based approach in the humanitarian sector, they vastly overestimate their own objectivity synthesis of similar studies, oen in a systematic progress seems limited by a strong sense of tra- and the reliability of their peers (Burgman et al, review. ese evidence syntheses provide users dition, an antipathy to change and continuing 2011).” is does not render ‘expert opinion’ use- with a critically appraised summary of the misapplication of ‘expert opinion’ or ‘best practice’. relevant research on a topic, allowing the existing Key documents in the sector, such as guidelines studies to be compared, contrasted and combined and policies, continue to be predominantly based 1 www.evidenceaid.org/ ...... 菀菀 Research ...... less, but demands a certain degree of care when something that we know works and is worth re- Evidence syntheses, or systematic reviews, of engaging experts and a need for awareness of the peating”4 . e variety of definitions of concepts reliable evaluations should be a key source of tools available to counter these pitfalls. such as best practice is one of the common prob- knowledge for all decision-makers who want to lems in the humanitarian sector. However, po- answer the question: What is likely to happen if An example of the appropriate use of expert tentially even more problematic is the fact that we do this, rather than something else? In the opinion is in determining the gaps in the evidence the blogger, like many others in the sector, does humanitarian sector, decisions, choices and base and prioritising the filling of those gaps. not reveal what their criteria are for something policies impact on the health and wellbeing of e identification of gaps in evidence in the hu- to ‘work’ and how it was established that any thousands, if not millions, of people and those manitarian sector is important for minimising particular practice adheres to these criteria. As responsible have a duty to ensure that the evidence unnecessary overlap of activities and waste of with ‘expert opinion’, the application of a trans- they use is reliable and robust. is requires the resources. Evidence Aid held a priority setting parent methodology to determine what ‘works’ use of appropriate methodologies; firstly to meeting in 2013, bringing together those who would overcome most of the hurdles, allowing evaluate humanitarian action, and then to bring influence and guide the humanitarian sector, and specific interventions, actions and strategies to together the findings of those evaluations. It will published the output in the journal PLOS Currents: be proven to be effective or efficient to the satis- mean that the best possible use is made of what Disasters (EAPSG, 2013). faction of decision-makers. happened in the past to predict what will happen irty high-priority research questions were in the future, and ensure that humanitarian action Proper evaluations can provide evidence of identified under ten themes that could be ad- does what those who fund it and those who im- the impact of a certain project or practice. Key to dressed by systematic reviews in the area of plement it want it to do: prevent and alleviate this is the application of an appropriate method- planning for or responding to natural disasters, the suffering of people in need in humanitarian ology, such as promoted by the Active Learning humanitarian crises or other major healthcare and disaster risk reduction contexts. Network for Accountability and Performance in emergencies. Some of these gaps have already Humanitarian Action (ALNAP)5. Nevertheless, been taken up by the Humanitarian Evidence an evaluation of one project only reveals something The next two courses An introduction to Programme2 and others, and relevant systematic about the impact in that particular context and systematic reviews in the humanitarian reviews will appear in coming months and years. does not allow us to derive strong conclusions sector, led by Mike Clarke, are to be held on As these new reviews are done, they will be about the likely effects of a similar project in a 16 November in Washington DC, USA and on added to the more than 250 systematic reviews different context. Just as the successful treatment 30 November in Oxford, UK. The cost is that are already freely available from the Evidence of one patient or the positive findings of one £225/person. For more information, contact: Aid resources3. clinical trial in the healthcare sector do not provide Claire Allen, email: [email protected] or visit http://www.evidenceaid.org/ Another concept frequently applied in the any certainty that it will work for others, we need context of decision-making in humanitarian re- a synthesis of the evaluations of similar projects 2 www.oxfam.org.uk/hep sponse is ‘best practice’. On e Guardian Global to determine the likelihood of success in another 3 www.evidenceaid.org/resources Development Professionals Network page, an place and time. Recognition of this in the healthcare 4 www.theguardian.com/global-development-professionals- anonymous blogger asserts that “best practices sector helped the drive towards evidence synthesis network/2015/jul/22/as-aid-gets-better-it-gets-more- are those things that we’ve somehow managed to and systematic reviews as a means to bring together boring-and-thats-as-it-should-be; last visited 15 August all the available evidence. 2016. figure out actually work, and work well” or “is 5 www.alnap.org/ References Burgman MA, McBride M, Ashton R, Speirs-Bridge A, Clarke M (2015). History of evidence synthesis to assess Decision Making Vol. 4, No. 1, February 2009, pp. 41-50. Flander L, Wintle B, Fidler F, Rumpff L, Tweedy C. (2011) treatment effects: personal reflections on something that is journal.sjdm.org/71130/jdm71130.pdf very much alive. JLL Bulletin: Commentaries on the history Expert status and performance. PLoS ONE 6(7): e22998. Gerdin M, Clarke M, Allen C, Kayabu B, Summerskill W, et of treatment evaluation. J Roy Soc Med 109:154-63. Doi: doi:10.1371/journal.pone.0022998. al. (2014) Optimal evidence in difficult settings: improving 10.1177/0141076816640243. Carr Z, Clarke M, Ak EA; Schneider R, Murith C, Li C, health interventions and decision making in disasters. PLoS www.jameslindlibrary.org/articles/history-of-evidence- Parrish-Sprowl J, Stenke L, Cui-Ping L, Bertrand S, Miller C. Med 11(4): e1001632.doi:10.1371/journal.pmed.1001632. synthesis-to-assess-treatment-effects-personal-reflections (2016) Using the GRADE approach to support the journals.plos.org/plosmedicine/article?id=10.1371/journal -on-something-that-is-very-much-alive/) development of recommendations for public health .pmed.1001632 EAPSG Evidence Aid Priority Setting Group. Prioritization interventions in radiation emergencies. Radiation Sutherland WJ and Burgman M. Policy advice: Use experts of themes and research questions for health outcomes in Protection Dosimetry (first published online 12 August wisely. Nature 2015 Oct 15;526(7573):317-8. doi: natural disasters, humanitarian crises or other major 2016) doi: 10.1093/rpd/ncw234. 10.1038/526317a. healthcare emergencies. PLoS Curr Disasters 2013 October Cho HY, MacLachlan M, Clarke M, Mannan H. (2016) www.ncbi.nlm.nih.gov/pubmed/26469026 16. Edition 1. doi: 10.1371/ Accessible home environments for people with functional currents.dis.c9c4f4db9887633409182d2864b20c31 Tversky A and Kahneman D. (1982) In: Kahneman D, Slovic limitations: a systematic review. Int J Environ Res Public P, Tversky A (editors) Judgement Under Uncertainty: Englich B, Soder K. (2009) Moody experts – How mood and Health 13: 826. doi: 10.3390/ijerph13080826. Heuristics and Biases. Cambridge University Press pp.23-30. expertise influence judgmental anchoring. Judgement and

ver 20 years, ENN has published Field Exchange to help achieve our purpose of strengthening the evidence and Evidence in humanitarian know-how for eﬀective nutrition in- terventionsO in countries prone to crisis and high emergencies: levels of malnutrition. It provides the experiences of those implementing nutrition programmes in acute and protracted emergencies. Most of these What does it look like? experiences and lessons learnt would not have been captured or disseminated without this type By Jeremy Shoham and Marie McGrath, Field Exchange co-editors of non-peer reviewed publication. Yet, for many, Field Exchange, and equivalent publications are ENN was invited by Evidence Aid to share our perspective regarding evidence in the ‘grey’ literature, oen seen as a source of findings emergencies in their online blog. Below is a comment posted in September 2016, that are ‘plausible’ but not evidenced. Hence the www.evidenceaid.org/evidence-in-humanitarian-emergencies-what-does-it-look-like question, what is evidence and what does it look like – especially in humanitarian contexts? ...... 菀菀 Research ......

e few reviews of evidence in humanitarian guided by what they know or suspect works, infor more of these studies to be done in challenging nutrition programming show that there is very fluenced by agency strengths, sometimes driven contexts. e current architecture makes such little ‘probabilistic’ evidence out there. Ran- by donor interests and sadly, oen underpinned research very difficult. At the same time, we domised trials that are held up as the “gold by the bureaucratic imperative that the implementing need to continue to capture the kind of ‘evidence’ standard” for assessing the effects of interventions agency must, itself, survive. e intention though provided by practitioners, which is critical to are particularly difficult to mount in humanitarian is always worthy – to alleviate suffering. shining a light on programme performance, contexts. ey require foresight and investment and to identify where greater institutional co- by donors; early collaboration between pragmatic, On the positive side, ENN has witnessed herence and joined up thinking is needed. creative academics and operational agencies; (and, through Field Exchange, has captured and A great example is the special edition of and long term commitment to plan, deliver and disseminated) innovation, programme devel- Field Exchange on the Syria nutrition response publish. And, many of them do not come cheap. opment and learning. Seen as a non-governmental in 2014 that documented detailed case studies Even where randomised trials are carried out organisation with no vested interest other than of more than 60 programmes (www.ennonline. (mostly in secure settings), they don’t necessarily to reflect learning, multiple agencies have shared net/fex/48). is single publication has had a tell us whether something will work or not in programming experiences though Field Exchange, significant impact on international guidance the complex environment and ‘ever shiing documenting perceived and measured successes around infant feeding in emergencies, the need sands’ of an emergency or, critically, how it and failures. is provides a collective memory for policies on non-communicable diseases works. is is a key uncertainty for programmers and exchange – and evidence of sorts – of what (NCDs) in emergencies and generated a con- looking to adapt and respond to the needs of works and what doesn’t work. e process of siderable research focus on how to address high specific populations and contexts. experience capture is cathartic for many. It helps them unpack and reflect, enabling both personal levels of stunting in protracted crises. ere are also challenges around the global and agency reflection and learning. It has also In conclusion, evidence is not just generated coordination of ‘robust’ research. Research agen- helped identify where urgent ‘robust’ research by academic researchers, statisticians and the das are not shared between research institutions is needed. e impact on programming and re- like but also by those at the sharp end of pro- and there is competition for scarce resources – search of this collective experience has been gramming. Many of those at the sharp end may even (shamefully) amongst research groups in substantial, not least on ENN’s research and re- well need to brush up on their epidemiology, the same research consortium. e culture views (www.ennonline.net/ourwork). just as many professional researchers may need around research is oen ‘secretive’ and conflict Should we aspire to more? Absolutely. We to familiarise themselves with the complex cir- of interests are not always apparent. need more randomised trials, complemented cumstances of humanitarian crises and the However, the fact that there is a gap in the evi- by theories of change, to help explain how and unique insights of the implementers on how dence doesn’t stop programming. Agencies on the when interventions are likely to impact nutrition. the programming they are intimately involved ground still need to respond, innovate and adapt, We also need institutional changes which allow in is playing out on the ground.

Recovery rate of children with moderate acute malnutrition treated with ready-to-use supplementary food (RUSF) or improved corn- soya blend (CSB+) Summary of research1

Location: Cameroon oderate and severe wasting are acute forms of undernutrition; children suffering from them face a markedly in- What we know: A wide range of nutritional products are currently creased risk of death. It is estimated that moderate acute used to treat MAM; there is no definitive consensus on the most effec- malnutrition (MAM) and severe acute malnutrition (SAM) affectM 52 million children under five years of age worldwide. Supplementary tive products to use. feeding programmes (SFPs) are designed to treat MAM and prevent What this article adds: A controlled randomised trial compared an progression from MAM to SAM, and thus have the potential to reduce improved CSB (CSB+) treatment with a ready-to-use supplementary child mortality and morbidity. A wide range of nutritional products are food (RUSF) treatment to treat MAM. Eighty-one MAM children currently used to treat MAM. ese include fortified blended flours, es- aged 25-59 months were enrolled and received a daily ration (50% en- pecially corn-soya blend (CSB) prepared as porridge; BP5 biscuits; and ergy) for 56 days. Fortnightly follow-up involved nutrition and gener- lipid-based nutrient supplements, in particular therapeutic and ready- al health counselling, clinical assessment and anthropometry. Recov- to-use supplements (RUTF and RUSF). Product formulation and ery was good (85% in RUSF group, 73% in CSB+ group) and was not quantities used have varied in published effectiveness studies; therefore significantly different between groups. Higher weight gain in the there is no definitive consensus on the most effective products to use in RUSF arm (similar total energy was provided to both groups) may be MAM treatment. due to the different nutrient contents of the products, cooking requirements and lower energy density of CSB. Fieen per cent of RUSF group and 20% of SAM group did not recover aer 56 days; 3% 1 Medoua GN, Ntsama PM, Ndzana ACA, Essa’a VJ, Tsafack JJT and Dimodi HT. (2016) Recovery rate of children with moderate acute malnutrition treated with ready-to-use supplementary food and 5% respectively deteriorated to SAM. Nutrition education may (RUSF) or improved corn-soya blend (CSB+): a randomized controlled trial, Public Health Nutri- have improved outcomes in this study. tion, 19(2), pp. 363–370. doi: 10.1017/S1368980015001238...... 菀菀 Research ......

relatively higher than those found in previous studies, despite the lower quantity of supplement provided to children. e authors suggest that this could be a reflection of the investment in education of caregivers on how best to use foods available in the house, since educational interventions have been shown to improve child- feeding practices. is suggests that, in the context of moderate food insecurity, nutrition education could improve the outcomes of supplementary feeding and reduce the quantity of supplement generally provided. e authors suggest that the higher weight gain in the RUSF arm (despite similar total energy provided to both groups) may be due to the diﬀerent nutrient contents of the products, the fact that RUSF does not require cooking, and the lower energy density of CSB+ (a child must eat eight times the mass of supplement compared to RUSF). is may have aﬀected the global dietary intake of the children and might CSB being prepared account for the lower weight gain and recovery for distribution rate in the CSB+ group. In Cameroon, as in

Gabriel Nama Medoua, Cameroon most African countries, national protocols for the management of MAM recommend the use e purpose of this study was to compare an Each caregiver also received nutrition and general of large doses of fortified blended flours, which improved CSB (CSB+) with an RUSF programme health counselling at enrolment and at every are usually imported. Based on the average time in the treatment of MAM to test the hypothesis follow-up visit, and was instructed to continue required for treatment in both groups and the that supplementary foods given at complementary to feed children their usual diet along with the cost of both products, the overall cost to treat a dose (about 50% of the child’s energy require- supplementary food as ‘medicine’. At each fol- child with CSB+ (3·48 euros) was relatively ment) result in high recovery rates (assuming low-up visit, caregivers reported on the child’s lower than the cost with RUSF (3·52 euros). the remaining energy requirements can be met clinical symptoms and tolerance of the study is calculation does not include transport, through the usual household diet). e study food; anthropometric measurements and nu- storage or staffing costs. If considering the op- was a comparative effectiveness trial that assessed trition education were repeated. Additional sup- erational limits of CSB+ requiring preparation, the treatment of MAM in children for a period plementary food was continued for those who RUSF could be a more cost-effective choice. of 56 days, using a controlled randomised design remained wasted. Standard methods for an- e authors conclude that both CSB+ and with parallel assignment for CSB+ or RUSF. thropometric measurements were used; anthro- RUSF were relatively successful for the treatment pometric indices (weight-for-age Z score (WHZ), Eight hundred and thirty-three children of MAM in children. Despite the relatively low weight-for-age Z score (WAZ) and height-for- aged 6-59 months living in the health districts ration size provided, the recovery rates observed age Z score (HAZ)) were based on WHO 2006 of Mvog-Beti (urban area) or Evodoula (rural for both groups were comparable to or higher Child Growth Standards. area) in the Centre region of Cameroon were than those reported in previous studies, a screened for eligibility. Children were excluded e study found no significant differences probable effect of nutrition education. if they did not have appetite, had a chronic de- between the malnutrition profile of CSB+ and bilitating illness, or had a history of peanut al- RUSF groups: all the children enrolled in the lergy. Eighty-one children aged 25-59 months study were moderately wasted, moderately un- with MAM (WHZ <-2 and ≥ -3 without oede- derweight and moderately stunted. No adverse ma) were enrolled in the study from February reactions to any of the foods were reported. to July 2012. Allocation to either CSB+ or Aer 56 days of treatment, 85% of children re- RUSF groups was performed by caregivers covered from MAM in the RUSF group (95% CI drawing from an opaque bag containing coded 73%, 97%) and 73% in the CSB+ group (95% CI numbers corresponding to one of the two sup- 59%, 87%). e mean duration of treatment re- plementary foods. The code was accessible quired to achieve recovery was 44 days in the only to the food distributor. Investigators and RUSF group and 51 days in the CSB+ group. nutrition educators were blinded to the child’s ere was no significant difference (P=0.276) in assigned food group. the recovery rate between the two groups (Fisher’s exact text). A non-response rate of 20% among On enrolment, children were examined by a children in the CSB+ group and 15% in the paediatrician to assess their health status and RUSF group was observed; thus these children de-wormed (500mg mebendazole). Caregivers remained moderately malnourished following were interviewed regarding the child’s socio- 56 days of treatment. Of children in the RUSF demographic characteristics and to assess house- and CSB+ groups, 3% and 5% respectively dete- hold food-consumption score. Nutrition and riorated to SAM. Children who received RUSF general health counselling and information showed higher rates of weight gain compared about the illness of their children and the benefit with those receiving CSB+ (P<0.05). of supplementary feeding were provided to all caregivers. Every child received a daily ration e observed recovery rates suggest that of 167 kJ (40 kcal)/kg body weight for 56 days, both products were relatively successful in treat- RUSF in production

provided as two-week rations every fortnight. ment of MAM in children, comparable to or Gabriel Nama Medoua, Cameroon ...... 菀菀 Research Impact...... of child support grant in in Rietvlei. Household income also differed across the three sites, with a median US$100 per month South Africa on child nutrition in Paarl and Umlazi and US$78 per month in Ri- Summary of research1 etvlei. Most of the mothers in Umlazi were single (85%), as was the case in Paarl (68%), while most mothers in Rietvlei were married (68%). Rietvlei had the highest proportion (70%) of participants Location: South Africa who were in the poorest quintile; in Umlazi, no participants fell within that quintile and Paarl had What we know: Stunting is an indicator of chronic undernutrition and is oen linked to 3%. Paarl had the highest proportion of participants poverty-related factors. ere is mixed evidence on the impact of cash on reducing child who were in the least poor quintile (34%), Umlazi undernutrition in low- and middle-income settings had 31% and Rietvlei had none. What this article adds: In South Africa, the Child Support Grant (CSG) is the largest cash trans- For two years of child age, Rietvlei had the fer programme targeting children from poor households. A recent paper explored predictors of lowest rates of CSG receipt (28%) compared with stunting, including exposure to the CSG, at a median age of 22 months among children from Paarl (38%) and Umlazi (34%). High rates of three diverse areas of South Africa. CSG receipt for 18 months or longer was not associated with stunting were observed in all three sites, with stunting aer controlling for risk factors such as HIV exposure status and low birth weight; Umlazi being the most affected (28%) compared higher levels of maternal education had a protective effect on stunting. An association found be- with Rietvlei (20%) and Paarl (17%). Duration tween mothers’ HIV-positive status and stunting supports previous research findings. Food- of CSG receipt had no effect on stunting, aer price inflation and limited progress in the provision of other important interventions and social adjusting for confounders. Both HIV-positive services, in the context of high unemployment, have likely limited nutrition impact of the CSG. status of the mother (adjusted OR=2·30; 95% CI 1·31, 4·03) and low birth weight (adjusted OR=2·01; n South Africa, child under-five mortality of about 130,000 in Western Cape Province; 95% CI 1·02, 3·96) were associated with more was estimated to be 45 per 1,000 live births (ii) Rural Rietvlei, which falls under the than double the probability of the child being stunted. Completing high school or having a ter- in 2012. ere has been a significant drop Umzimkhulu Municipality in KwaZulu- tiary education was associated with a 58% and in reported child hunger (from 30% of all Natal; and 84% reduction in child stunting respectively. Ichildren in 2002 to 16% in 2006), but in 2010 (iii)Umlazi, an urban township in Durban with Being from Umlazi was associated with a nearly three million children were still living in house- a population of 550,000 inhabitants. fourfold increase in probability of stunting (ad- holds where hunger was reported. Moreover, justed OR=3·89; 95% CI 2·30, 6·59). 27% of the country’s under-fives were stunted in In terms of key child-health outcomes, Paarl 2009, a decrease from 33% in 2003. fares better than the other two sites, with an infant mortality rate of 30/1,000 live birth, com- Discussion CSG receipt for 18 months or longer in this study Existing policy responses to childhood poverty pared with Umlazi (68/1,000 live births) and population was not associated with stunting aer and vulnerability in developing countries include Rietvlei (99/1,000 live births); and an antenatal controlling for important risk factors such as HIV- the provision of basic services such as education, HIV prevalence of 7% compared with Umlazi’s exposure status and low birth weight, and indicated healthcare, clean water, in-kind transfers (such as 47% and Rietlvei’s 28%. Umlazi is the largest higher levels of education as having a protective school-feeding schemes and nutritional supple- township in KwaZulu-Natal Province, with typical effect on stunting. e strong correlation between ments) and, more recently, cash transfers. e township problems, including severe housing stunting and being from Umlazi is likely explained Child Support Grant (CSG) is the largest cash shortages, high rates of unemployment and crime by the high prevalence of HIV in this site. e au- transfer programme in the country and the con- and little economic development. Rietvlei is a thors suggest several reasons for the apparent lack tinent, reaching more than 11 million children predominantly rural area where 90% of people from poor households in 2013. e grant is un- of association between CSG receipt and stunting live below the household subsistence level, much in households. e CSG is oen introduced in the conditional, means-tested and non-contributory, higher than the national average of 65%. with a small amount (R320/US$32 per month) context of high unemployment rates, where it becomes the only source of income in many house- transferred by the South African government to e main outcome of interest was stunting holds. e value of the grant has not been keeping children of poor families. However, children living (height-for-age z score (HAZ) <−2). Grant receipt up with inflation rates; at US$32 per month, it is a in the poorest households target group still report was defined as mother being in receipt of the small amount in the context of rising food prices high rates of hunger (26%) compared with children CSG on behalf of the index child at any point and unemployment. To maximise the potential in the wealthiest households (less than 1%). during the study (12 weeks, 24 weeks and two years). Duration of CSG receipt, the primary ex- positive impact of cash transfers, their cash value Methods posure, was defined as the age of child (in months) should be linked to food-price movements and A recent cross-sectional study assessed the uptake at the two-year visit minus the child’s age (in the cost of essential non-food items, and their and duration of receipt of the CSG and nutritional months) at first reported receipt of the grant. value adjusted for household size. outcomes in children at two years of age (i.e. e authors conclude that cash transfers need e researchers extracted baseline socio-de- median age 22 months) during 2008. e sampling to work in tandem with other poverty alleviation mographic characteristics (socio-economic status, frame was participants from the sites of a multi- measures such as education, housing and access mother’s educational level, geographical area, ma- country, cluster-randomised, intervention trial to quality healthcare in order to maximise their ternal age, marital status), maternal HIV status undertaken from 2005 to 2008 (the PROMISE- impact on child-health outcomes such as stunting. and exclusive breastfeeding status at 12 weeks of EBF trial to assess the effectiveness of communi- Findings suggest that in South Africa the effect age from the PROMISE-EBF trial data set for the ty-based workers in promoting and improving of the cash transfer on nutritional status may 746 children traced for the present study. Regression exclusive breastfeeding). Aer that trial ended have been eroded by food-price inflation and (2007), a new cross-sectional study (the present analysis was used to assess confounding factors. limited progress in the provision of other important one) was conducted, with participants from the Results social and environmental services. ese findings trial traced when the children were aged between add weight to calls for changes in the CSG allo- Socio-economic characteristics and status varied nine months and three years. A total of 871 out cation to be pegged to the inflation rate and to across the three sites. e mean age of mothers of 1,148 participants were traced, with 746 par- be based on the cost of raising a child. ticipants ultimately included. was similar in Umlazi and Rietvlei (23·9 and 24·0 years, respectively) and slightly older in Paarl (24·9 1 Zembe-Mkabile W, Ramokolo V, Sanders D, Jackson D & e study was conducted in three diverse years). e prevalence of HIV amongst mothers Doherty T (2016). The dynamic relationship between cash areas in South Africa: was 5.9% in Paarl, 8.1% in Rietvlei and 28.2% in transfers and child health: can the child support grant in South Africa make a difference to child nutrition? Public Health (i) Peri-urban Paarl, a town with a population Umlazi. Educational levels of mothers were lower Nutrition, 19(2), 356-362. doi.org/10.1017/S1368980015001147...... 菀菀 Research ...... Public health nutrition capacity: The quality of workforce for scaling up nutrition programmes

Summary of research1 WFP/Berta Tilmantaite WFP/Berta

Location: Global

What we know: Priority for scaling up multi-sector programmes to tackle undernutrition in LMICs is growing. Public health nutrition (PHN) workforce capacity is critical to programme delivery.

What this article adds: A position paper by the World Public Health Nutrition Association (WPHNA) Capaci- ty Building Task Force describes existing nutrition workforce capacity and potential mechanisms for building capacity (considering workforce size, organisation, and pre-service and in-service training) in LMICs. Nutri- tion-specific interventions are mostly delivered through health services that depend on decent staﬀ ratios; community health workers are critical for impact. Guidance on multi-sector nutrition programming at scale is scarce, and estimates (where they exist) of PHN workforce numbers suggest they are inadequate. Applicable pre-service nutrition training is mostly clinical and/or food-science oriented; tools for in-service nutrition training largely relate to infant and young child nutrition and food security. Increased priority and funding for building capacity for scaling up nutrition is needed to realise global targets.

Introduction trition-sensitive interventions are delivered link between communities and health and social Overnutrition and undernutrition problems through other sectors such as education, agri- services and are effective at implementing evi- affect at least half the global population, espe- culture, water and sanitation, and social welfare. dence-based interventions. cially those in low and middle-income countries Much less consensus has been created around interventions needed to reduce overnutrition. Workforce structure (LMICs). Programme guidance exists for un- An ideal PHN structure includes a pyramid e importance of employing multi-sector ap- dernutrition and overnutrition; priority for (see Figure 1), where the specialist PHN manager proaches has been widely agreed, but documented scaling up multi-sector programmes to tackle should have oversight of the delivery of all experience of how such programmes are imple- undernutrition in these contexts is growing. A curative and preventive nutrition interventions mented is quite rare, with little or no guidance position paper by members of the World Public delivered through the health system in the existing on how to develop and manage such Health Nutrition Association (WPHNA) Ca- district. e delivery of such interventions is programmes. pacity Building Task Force outlines the case typically done by others, including nurses, mid- for and defines the desirable character¬istics Many countries report having national, wives, dietitians and doctors. ey in turn may of a system for developing the capacity of nu- multi-sector nutrition plans, but very few of provide support to other district actors, including trition workforces for scaling up nutrition pro- them are actually being implemented at any CHWs, teachers, agricultural exten¬sion workers grammes in LMICs especially. It uses evidence scale. Community-based health and nutrition and social workers. from the literature and the joint experience of programmes can be very successful, especially the Task Force to describe the existing nutrition if they have the essential elements of Workforce size workforce capacity and the potential mecha- commu¬nity ownership, adequate population Few estimates of PHN specialist numbers exist, nisms for building capacity. The World Health coverage, targeting, and central support for but all suggest that they are either insufficient Assembly (WHA) has urged that member states supplies and training. and/or largely missing in most national nutri- should include a comprehensive approach to tion/health workforces. A recent survey of 13 capacity building and workforce development To achieve impact requires a cer¬tain level countries in West Africa detected a critical in implementing plans for maternal, infant of intensity of effort, with optimal ratios of not shortage of skilled nutrition professionals in all and young child nutrition, with the capacity more than 20 mobilisers, or community health countries, with limited supervision of nutrition indicator being the number of nutrition workers (CHWs) per facilitator/ supervisor and activ¬ities, especially at implementation level profes¬sionals per 100,000 population. not more than 20 households per mobiliser. by front-line health workers. Doctors, nurses CHW volunteers typically receive some locally and midwives (as well as dietitians in some Key findings on the public organised cascade training in order to be able health nutrition workforce to carry out their work, oen from trainers who 1 Shrimpton, R., du Plessis, L.M., Delisle, H., Blaney, S., Atwood, Nutrition programmes do not themselves have capacity to train health S.J., Sanders, D., Margetts, B. and Hughes, R. (2016) Public Nutrition-specific interventions for reducing workers; there does not appear to be any national health nutrition capacity: assuring the quality of workforce maternal and child undernutrition are mostly or international standard for these. Recent preparation for scaling up nutrition programmes, Public Health Nutrition, 19(11), pp. 2,090–2,100. doi: delivered through the health sector, while nu- reviews confirm that CHWs provide a critical 10.1017/S136898001500378X...... 菀菀 Research ...... countries) make up the majority of workers guide decision-making processes for the double and young child feeding (IYCF) counselling de- currently entrusted to deliver nutrition inter- burden of malnutrition across the different veloped by UNICEF. FAO has also developed e- ventions globally, but training is particularly sectors and levels of government. learning courses for professionals working in poor. For example, Asian regional country case food and nutrition security, social and economic A key challenge for scaling up community- studies (UNICEF and the WPHNA) concluded development, and sustainable management of based programmes is institutionalising and that the nutritional knowledge of health workers natural resources. was outdated; their nutrition competencies were mainstreaming community participation. e limited to more clinical and curative activities; largest and most successful programme is the Continuing professional development is an- and for nurses and midwives especially, their Brazilian Family Health Programme, which has other important area to be considered when job descriptions did not include nutrition re- integrated 250,000 CHWs into its health services developing the PHN workforce. Some universities sponsibilities. ese findings are not surprising, and institutionalised community health com- offer online continuing education courses for since even in the USA and the UK the nutrition mittees as part of municipal health services. nutrition and health-care professionals; e.g. the content of nurses’ and medical doctors’ training Workforce preparation London School of Hygiene and Tropical Medi- cine’s distance learning course on multi¬-sector is also considered outdated and inadequate. ere does not seem to be any authoritative nutrition programming. ere is a lack of a dedicated workforce (es- source of information (either regional or global) pecially in the health system) in most LMICs to for graduate courses on nutrition. Programmes Improved availability of the internet has rev- provide outreach for community-based nutrition identified in a survey of nutrition education in olutionised the possibilities for capacity building services. Scaling up CHWs was considered a West Africa found that all of them failed to in PHN. Initiatives include the Public Nutrition crucial part of achieving the Millennium Devel- provide a comprehensive coverage of all essential Virtual University (still awaiting funding) and opment Goals (MDGs), but this did not happen. aspects of human nutrition, being heavily oriented the eNutrition Academy, a global nutrition- to food science (46%), with little emphasis on training platform (courses are still in develop- Workforce organisation PHN (24%) or overnutrition (2%). ment). Mentoring, defined as ‘a reciprocal, Organisational difficulties are as great a hurdle mutual and sup¬portive learning relationship’, to scaling up nutrition actions as the lack of On-the-job training to develop the workforce is one more tool that should be used to strengthen PHN specialists, although the two are interrelated. to act in nutrition at scale will obviously require workforce development in PHN. No programme guidance exists that discusses new and/or unconventional methods; e.g. a mix dimensions of multi-sector nutrition programme of distance learning and periodic coming together Conclusions with tutors and mentors, which are both eco- governance; e.g. the need for a PHN specialist Unless increased priority and funding is given nomically and logistically feasible. at all levels – in local government district to building capacity for scaling up nutrition planning office; in the central unit of each sector Considerable material is available for in- programmes in LMICs, maternal and child un- to oversee district-level implementation; and in service training of health-sector workers in the dernutrition rates are likely to remain high and the central unit to help plan, budget and oversee nutrition actions needed to improve maternal nutrition-related non-communicable diseases development. and child undernutrition; e.g. generic tools (such are likely to escalate. A hybrid, distance-learning None of the countries studied had in place a as counselling cards) for programming and ca- model for in-service training of PHN workforce unified nutrition information system that could pacity development of community-based infant managers is urgently needed in LMICs.

Figure 1 Multi-layered PHN workforce development

Capacity building for these levels of the PHN workforce through on-the-job training Academia with distance learning as well as concurrent in-service training

Public health nutritionist

Nutritionists/dietitians and other health professionals (doctors, nurses, midwives)

Community health workers and other nonhealth sector actors (e.g. teachers)

...... 菀菀 Research ......

mitigate seasonal peaks in undernutrition (both wasting and stunting)?” is scored particularly highly against ‘answerability’. Research priorities on the 3. “What is the optimal formulation of Ready to Use erapeutic Food (RUTF) to promote relationship between optimal ponderal growth and also support linear growth during and aer severe acute malnutrition (SAM) recovery?” is ques- wasting and stunting tion scored highly against the ‘usefulness’ 1 criteria. Summary of research 4. “What is the role of pre-pregnancy nutritional status in determining risk of being born stunted and/or wasted?” 5. “What are the effective packages of inter- Location: Global ventions for both maternal nutrition and new-born outcomes?” What we know: ere is global momentum to bring down levels of undernutrition. Wasting and stunting frequently co-exist, but are oen considered separately. Eight of the top ten questions (including the top three) were categorised as ‘research for the What this article adds: A research prioritisation was conducted to investigate the relation- development of new interventions/to improve ships between wasting and stunting, using the CHNRI (Child Health and Nutrition Re- existing interventions’, showing that the group search Initiative) methodology. A group of 18 experts in nutrition, growth and child health prioritised research that directly related to pro- prioritised 30 research questions against three criteria (answerability, usefulness and im- gramming and public health, rather than epi- pact). ere was strong support for prioritisation of research related to interventions and demiological research. programming that can impact on both wasting and stunting. Greater commitment from funders, academics and implementing agencies is needed to carry out clinical trials or Discussion large-scale programmatic evaluations, with robust research design. e strong support for prioritisation of research related to interventions and programming, as found in this CHNRI exercise, reflects the complexity of underlying causes of wasting and as possible to complete the survey. ese were: Background stunting; outcomes that cannot necessarily be Answerability: Was the research question Wasting affects 52 million (19 million severe predicted from observational research alone. well framed, with well defined end points, wasting) and stunting affects 165 million children Moving this agenda forward needs greater com- and likely to gain ethical approval? under five years old each year. Wasting and mitment from funders, academics and imple- stunting frequently co-exist in the same population Usefulness: Would the intervention that would menting agencies to carry out clinical trials or (sometimes in the same child), but they are be developed/improved though this research large-scale programmatic evaluations. ese usually separated in terms of policy, guidance, be deliverable, effective and efficacious? must have rigorous designs, adequate sample programming and financing. Both forms of un- sizes, and follow-up for health outcomes. dernutrition share causal factors such as infectious Impact: Would the research endpoints for this diseases, poor diet and suboptimal infant feeding question have high impact (i.e. the capacity to Question 1: “Can interventions outside of the and caring practices, yet the physiological rela- remove 5% or more of the disease burden)? 1,000 days, e.g. pre-school, school-age and tionship between them and how interventions adolescence, lead to catch-up in height and in irty research questions were tabled against other developmental markers?” for one affect the other are poorly understood. each of the three criteria, which formed an Consequently, there is a need for a closer look at is area has had little attention but could have online survey with a total of 90 queries. All TIG important implications; for example with ado- how children experience both wasting and stunting members were sent a link to the online survey lescent girls where the evidence shows that ma- over time, and how to sharpen programming and invited to take part. Each of the 30 research ternal stature may predict a child’s size at birth. focus (particularly on prevention) to achieve im- questions received three scores, one for each e timing of interventions to promote catch- pacts for both. is research aimed to establish criterion ranging between 0-100%. e overall up growth in mid-childhood and adolescence research priorities to fill critical gaps in this area research priority score (RPS) was calculated as is not well understood, but may be important. and to guide future research investments. a mean of all three priority scores so that the e group identified further investigation of priority of research questions was ranked ac- other lifecycle opportunities (apart from the Study methods cordingly. e authors used the Child Health and Nutrition first 1,000 days), particularly those concerned Research Initiative (CHNRI) methodology for Findings with adolescent growth, as potentially crucial for meeting undernutrition targets. setting research priorities. e method enables Of the 25 TIG members, 18 (72%) took part in individual experts to systematically develop pos- the survey, with 16 completing it in full. Most Question 2: “What timely interventions work sible research questions by scoring them against respondents were academics (n=10); some were to mitigate seasonal peaks in undernutrition pre-defined criteria. It was agreed to use an ex- engaged in operations and programming (n=3); (both wasting and stunting)?” isting Technical Interest Group (TIG) facilitated one worked primarily in policy; while others A number of countries have strong seasonal by ENN, comprising 25 individuals from a range declared involvement in a mix of these activities patterns of stunting and wasting that may il- of organisations (including academia and non- (n=4). lustrate some correlation between the two governmental organisations (NGOs)) with ex- forms of undernutrition, but there are many e highest ranking questions were: pertise in research and programming for wasting unanswered questions in this area. Recent 1. “Can interventions outside of the 1,000 and stunting. trials have shown the provision of seasonal days, e.g. pre-school, school-age and ado- nutritional supplementation in Niger to have e resulting list of possible questions was lescence, lead to catch-up in height and in then refined using a recommended theoretical other developmental markers?” is ques- framework with a set of criteria with which to tion scored very highly against all three 1 Z Angood C, Khara T, Dolan C, Berkley JA, WaSt Technical judging criteria. Interest Group (2016) Research Priorities on the judge the questions. e criteria were reduced Relationship between Wasting and Stunting. PLoS ONE to three in order to encourage as many experts 2. “What timely interventions work to 11(5): e0153221. doi: 10.1371/journal.pone.0153221...... 菀菀 Research ...... effects on both wasting and stunting (Isanaka considered to be a research priority by this the research priorities, and most of these were et al, 2008). The prioritisation of this question expert group. academics from Western institutions. However, is a call for future studies to measure both given that the global pool of experts in the field wasting and stunting. Questions 4 and 5: “What is the role of pre- is also small, the results were still regarded as a pregnancy nutritional status in determining useful guide for research investment. High-pri- Question 3: “What is the optimal formulation risk of being born stunted and/or wasted?” and ority research questions are those where trial of RUTF to promote optimal ponderal growth “What are the effective packages of interventions can inform the appropriate timing and also support linear growth during and interventions for both maternal nutrition and of treatment and prevention to impact on both aer SAM recovery?” new-born outcomes?” wasting and stunting. is question reflects the fact that few studies ere is an increasing call for research on pre- of SAM or moderate acute malnutrition (MAM) conceptual interventions for improving maternal treatment have looked at linear growth during pre-pregnancy Body Mass Index (BMI), and or aer treatment, or compared different for- that can influence adult height in order to Reference mulations of RUTF in trials of adequate size. benefit foetal growth. Other investigations into Isanaka et al, 2008. Isanaka S, Nombela N, Djibo A, Where such studies exist, findings suggest no support for maternal nutrition could help pro- Poupard M, Van Beckhoven D, Gaboulaud V, et al. Effect of positive effect of RUTF on stunting. However, grammers break the inter-generational cycle of preventive supplementation with ready-to-use therapeutic food on the nutritional status, mortality, and there is evidence that linear growth ceases or undernutrition. slows down during periods of wasting; therefore morbidity of children aged 6 to 60 months in Niger: a cluster randomized trial. Jama. 2009;301(3):277–85. doi: timing of restarting linear growth and how to e study’s main weakness was that a relatively 10.1001/jama.2008.1018 pmid:19155454; PubMed Central support this during treatment for wasting was small number of experts were involved in setting PMCID: PMCPMC3144630.

Co-trimoxazole prophylaxis to prevent mortality in children with complicated severe acute malnutrition Summary of research1

Location: Kenya months without HIV admitted to hospital and diagnosed with SAM. All study hospitals provided What we know: Children with complicated severe acute malnutrition (SAM) are at high risk inpatient care for SAM and therapeutic and of infection. Daily co-trimoxazole prophylaxis is effective in reducing mortality and prevent- supplementary feeding clinics. ing admissions in HIV-infected children. Children were randomly assigned to six months of either daily oral co-trimoxazole pro- What this article adds: A randomised, placebo-controlled trial in four Kenyan hospitals as- phylaxis (given as water-dispersible tablets: 120 sessed the efficacy of daily co-trimoxazole prophylaxis for six months on survival in children mg per day for age <6 months; 240 mg per day aged 60 days to 59 months without HIV treated for complicated SAM. Daily co-trimoxazole for age six months to five years); or matching did not reduce mortality (14% in co-trimoxazole group; 15% in placebo group) or improve placebo. Assignment was done with computer- growth, but did result in a lower incidence of both malaria and some bacterial infections. generated randomisation. Treatment allocation Mortality rate among infants aged two to 11 months was particularly high, despite follow-up. was concealed in opaque, sealed envelopes; pa- Results suggest children with complicated SAM, especially infants, remain susceptible to se- tients, families and all trial staff were masked to vere infections and death, despite follow-up. Findings suggest fundamental differences in the treatment assignment. e dose regimen of co- immunopathology of malnutrition and HIV infection that require further investigation. trimoxazole was that recommended by WHO for HIV care. Children were given recommended medical care and feeding and followed up for hildren with complicated severe acute sibly by reducing inflammation and preventing 12 months. 2 malnutrition (SAM) require initial or treating infections. e drug is inexpensive e primary outcome was mortality during hospital treatment with antibiotics, and widely available, with a known safety profile. the 365 days of the study period. Secondary out- treatment of specific medical condi- However, long-term use of antibiotics can po- comes were frequency of readmission to hospital Ctions, and specialised therapeutic feeding. Com- tentially cause toxicity and resistance. and illness episodes treated as an outpatient. plicated SAM is associated with high inpatient Scheduled follow-up to enrolment was once each mortality; even post-discharge, ‘recovered’ SAM is study tested the hypothesis that daily children remain at increased risk of death most co-trimoxazole would reduce mortality and likely due to infectious disease. Daily co-tri- morbidity and improve nutritional recovery in 1 Berkley, James A, Moses Ngari, Johnstone Thitiri, Laura moxazole prophylaxis has been found to reduce children without HIV being treated for compli- Mwalekwa, Molline Timbwa, Fauzat Hamid, Rehema Ali, et mortality and hospital admissions in children cated SAM. al. 2016. Daily Co-Trimoxazole Prophylaxis to Prevent with HIV who are susceptible to infection, pro- Mortality in Children with Complicated Severe Acute Malnutrition: A Multicentre, Double-Blind, Randomised tecting against malaria, pneumonia and sepsis. Method Placebo-Controlled Trial. The Lancet Global Health 4 (7) It also prevents pneumonia in children with A multicentre, double-blind, randomised, place- (October 4): e464–e473. doi: measles and recurrent urinary tract infections. bo-controlled study was conducted in four hos- 10.1016/S2214-109X(16)30096-1. 2 A systematic review found that antimicrobials, pitals in Kenya (two rural hospitals in Kilifi and Complicated SAM is defined as children who have signs of infection or present with one or more Integrated including co-trimoxazole, had beneficial effects Malindi and two urban hospitals in Mombasa Management of Childhood Illness danger signs (see on ponderal and linear growth in children, pos- and Nairobi) with children aged 60 days to 59 references) or do not pass an appetite test...... 菀菀 Research ...... month for the first six months, then every two hospital admission or outpatient illness were 100 CYO among infants aged one to 11 months months for the second six months. Anthropometric noted between intervention groups. e fre- reported in the 2014 Kenya Demographic & measurements were taken at each visit and re- quency of pneumonia episodes was similar be- Health Survey). maining study drugs and empty blister packs tween groups, but diarrhoea occurred more fre- e study results raise a number of questions: were counted to assess adherence. A full blood quently in the group assigned to co-trimoxazole. • Did low bacterial susceptibility to count was done at enrolment, two, six and 12 Other infections such as skin or so tissue and co-trimoxazole contribute to an absence of months. Analysis was by intention to treat. urinary tract, as well as malaria, were less frequent in the co-trimoxazole group. protective effect against death? If so, this has Findings implications for the use of co-trimoxazole A total of 1,778 eligible children were recruited Aer 12 months, 1,209 (68%) of 1,778 children prophylaxis in HIV-infected children. and assigned to treatment (887 to co-trimoxazole enrolled were alive and in follow-up with a mid • Although the bacteria found in blood and prophylaxis and 891 to placebo) between 20 upper arm circumference (MUAC) above the urine samples were largely non-susceptible November 2009 and 14 March 2013. Median threshold for moderate acute malnutrition (≥12·5 to co-trimoxazole, the drug did prevent two age was 11 months (IQR 7-16 months); 306 cm). However, this outcome varied with age, bacterial conditions, namely urinary tract (17%) were younger than six months; 300 (17%) ranging from 160 (52%) of 306 infants younger and skin and so tissue infections. Absence had oedematous malnutrition (kwashiorkor); than six months at enrolment to 154 (78%) of of efficacy in this trial compared to those of and 1,221 (69%) were stunted (length-¬for-age 197 children aged 24 months or more at enrol- children with HIV suggests fundamental Z score <–2). ment, p<0·0001. differences in the immunopathology of malnutrition and HIV infection, their asso- During 1,527 child-years of observation Discussion ciated infections and interaction with (CYO), 257 deaths occurred (14%, 16·8 per 100 e authors conclude that daily co-trimoxazole antimicrobials. CYO; 95% CI 14·9–19·0); 60 (23%) of which given for six months to a trial group of Kenyan • Few positive blood cultures were found occurred during the index admission; 64 (25%) children with complicated SAM (but without during the trial, despite high numbers of during a readmission to a study hospital; 29 HIV) did not reduce mortality or improve death and readmission and a high (11%) in other hospitals; and 104 (40%) in the growth. However, it did result in a lower incidence prevalence of antimicrobial resistance. community. Mortality did not differ between of malaria and some bacterial infections. Findings Results raise the possibility that a the groups: 122 (14%) of 887 children in the co- suggest that children with complicated SAM substantial proportion of serious infection trimoxazole group died, compared with 135 remain susceptible to severe infections and death might not have been bacterial. (15%) of 891 in the placebo group. aer discharge from hospital, despite medical care and follow-up, with a rate of readmissions e paper concludes by suggesting that tackling ere were 616 non-fatal admissions to hos- to hospital or death of 57 per 100 CYO. Mortality SAM requires better understanding of infections pital and 3,266 non-fatal episodes of illness for rates among infants aged two to 11 months (both its causes and determinants of susceptibility), which children were treated as outpatients. No were much higher than national mortality esti- and other strategies need to be tested in clinical significant differences in the overall rates of mates (22 per 100 CYO, compared to 1·7 per trials to reduce deaths in this population group.

The impact of intensive counselling and a mass media campaign on complementary feeding practices and child growth in Bangladesh Summary of research1

Location: Bangladesh angladesh has made dramatic health advances for its population over the last two decades and is hailed as What we know: In Bangladesh there has been little to no progress in improv- a remarkable health success story. However, rates of ing children’s diets and little evidence available on what works to improve ma- stunting and wasting remain high; in 2014 an estimated 36%B of children were stunted and 14% wasted. Between 2011 ternal knowledge and practices related to complementary feeding (CF). and 2014 stunting reduced nationally by 4 percentage points What this article adds: A cluster-randomised impact evaluation compared the (pp); wasting declined by only 1pp in the last 10 years. impact of two ‘Alive and rive’ intervention packages (one intensive, one less Appropriate infant and young child feeding (IYCF) practices intensive) on CF practices and anthropometric outcomes, delivered at scale are a critical component of optimal child growth and develop- (1.7 million mothers in 50 sub-districts) over a four-year period. A cross-sec- ment. is includes exclusive breastfeeding until six months of tional household survey of feeding practices (6-23.9 months) and stunting age and the provision of safe and nutritionally rich foods in prevalence (24-47. 9 months) was conducted at baseline and endline. Core sufficient quantity in addition to breastmilk from 6 to 23 WHO CF indicators improved over time (P < 0.0001 for all indicators) in both months of age. In Bangladesh, although rates of exclusive groups. For all CF indicators except timely introduction of solid, semi-solid or so foods, the increases were significantly higher in the intensive group and 1 Menon, P., Nguyen, P.H., Saha, K.K., Khaled, A., Sanghvi, T., Baker, J., Afsana, K. et al. achieved levels were high. Stunting declined significantly in all children 24- (2016) Combining Intensive Counseling by Frontline Workers with a Nationwide 47.9 months of age and did not differ significantly between groups. In conclu- Mass Media Campaign Has Large Differential Impacts on Complementary Feeding sion, intensive intervention had substantial and significant impact on CF: evi- Practices but Not on Child Growth: Results of a Cluster-Randomized Program Evaluation in Bangladesh. Journal of Nutrition. Published ahead of print August dence that behaviour-change interventions can be implemented at scale. 31, 2016 as doi: 10.3945/jn.116.232314...... 菀菀 Research ...... breastfeeding increased to an estimated 55% in that targeted mothers, family members, health Results 2014, there has been little to no progress in im- workers and local doctors with messages on Results showed that the groups were similar at proving children’s diets, with only 23% consuming various aspects of IYCF, three of which were fo- baseline. e levels of all core WHO CF indi- a minimally acceptable diet. ere is currently cused on CF. In intensive areas with low electricity cators improved over time (P < 0.0001 for all little evidence available on what works to improve and limited access to television, local video indicators) in both the intensive and non-in- maternal knowledge and practices related to screenings of the television broadcasts and other tensive groups. For all CF indicators except complementary feeding (CF), how these changes IYCF films produced by the project were used. timely introduction of solid, semi-solid, or so in turn lead to positive child outcomes, and In intensive areas, CM included sensitisation of foods, the increases were significantly higher what factors enable successful scale-up of these community leaders to IYCF and community in the intensive groups. e DDEs of programme interventions. theatre shows focused on IYCF. In non-intensive impact were 16.3 pp, 14.7 pp, 22.0 pp, and 24.6 areas, CM was less structured and covered is paper reports on findings from a clus- pp for minimum dietary diversity, minimum general healthcare topics and did not include ter-randomised impact evaluation of an at-scale meal frequency, minimum acceptable diet, and IYCF-related information. programme in Bangladesh. e objectives of consumption of iron-rich foods, respectively. the evaluation were to compare the impact of Evaluation method All DDEs were statistically significant in adjusted models. Achieved levels of CF indicators in the two ‘Alive and rive’ intervention packages on A cluster-randomised, non-blinded impact eval- intensive areas were high, ranging from 50.4% CF practices and anthropometric outcomes. e uation design was used to compare the impact for minimum acceptable diet to 63.8% for min- first intervention package involved intensified of the two intervention packages. A cross-sec- imum diet diversity, 75.1% for minimum meal interpersonal counselling (IPC), a mass media tional household survey was conducted at baseline frequency, and 78.5% for consumption of iron- campaign (MM), and community mobilisation (2010) and exactly four years later (2014) in the rich foods. ere was also a significant differential (CM); the second package involved standard same communities in households with children shi between groups from early and late intro- nutrition counselling, less intensive MM and 0-47.9 months of age (n=600 children 6-23.9 duction of water and other foods to a more non-intensive CM. e programme model months of age and n=1,090 24-47.9 months of well-timed introduction between the ages of 6 reached a large scale, with an estimated 1.7 age at baseline (2010); n=500 children 6-23.9 and 8.9 months. ese programme impacts million mothers of children under two years months and n=1,100 children 24-47.9 months were large and significant, ranging from 16 to old in 50 sub-districts. at endline (2014)). Primary outcomes measured 39 pp for different foods. e shi was primarily were CF practices in children 6-23.9 months of Interventions from early to timely introduction for water, age and the prevalence of stunting in children IPC (both intensive and standard) was delivered rice, and semi-solid foods, and from late to 24-47.9 months of age. Five CF indicators were by a large non-governmental organisation (NGO) timely introduction for animal source foods examined using 24 hour recall of the mother/caer- in 50 rural sub-districts through its existing coun- (ASFs) and other foods. giver: 1) minimum dietary diversity; 2) minimum trywide essential healthcare programme. Standard meal frequency as appropriate for age and breast- IPC involved routine home visits through which Stunting declined significantly in children feeding status; 3) minimum acceptable diet (de- information on IYCF practices were delivered. In 24-47.9 months of age in both groups between fined as breastfeeding and achievement of num- intensive areas, a new cadre of nutrition-focused baseline and endline, by 5.2 pp in the non-in- bers 1 and 2); 4) consumption of iron-rich or frontline workers conducted multiple age-targeted tensive and 6.3 pp in the intensive group. The iron-fortified food; and 5) timely introduction IYCF-focused counselling visits to households declines in the prevalence of stunting did not of solid, semi-solid or so foods. Anthropometric with pregnant women and mothers of children differ between groups. A similar pattern was data were collected using standard methods by under two years of age, coached mothers as they observed for the proportion of children classified trained field staff. Difference-in-difference impact tried out the practices, and engaged other family as being underweight (decline of 5.2pp in the estimates (DDEs) were derived, i.e. the effect of members to support the behaviours. non-intensive, 6.6pp in the intensive) and the intensified versus standard programme ad- wasted (decline of 1.4pp in non-intensive and e MM component, implemented in both justing for geographic clustering, infant age, 2.5 in intensive). intensive and non-intensive areas, consisted of sex, differences in baseline characteristics, and the national broadcast of seven television spots differential change in characteristics over time. Conclusions e results show that a programme providing intensified IPC, MM, and CM (the ‘Alive and rive’ intensive intervention) at scale had a substantial and significant impact on several CF practices in comparison with changes observed with a less intensive behaviour-change intervention in Bangladesh. Large-scale programme delivery was feasible and, with the use of multiple platforms, reached 1.7 million households. Although improvements in child growth were observed in both groups and for all age groups over time, the DDEs for linear growth and stunting at 24-47.9 months were not statistically significant and therefore cannot be at- tributed to the intensified interventions. e authors suggest that non-differential impacts on stunting were likely due to rapid positive secular trends in Bangladesh and the further acceleration of linear growth requires accom- panying interventions. e authors conclude that this study offers compelling evidence that behaviour-change interventions can be implemented at scale to deliver impact on what remains a substantial global challenge: improving children’s diets. Alive and Thrive, Bangladesh, 2010 Thrive, and Alive ...... 菀菀 Research ...... Direct procurement from family n June 2009, the Federal Government of Brazil passed legislation (Law 11,947/2009) which reg- ulates the National School Feeding Programme farms for national school (PNAE) and consolidates its links with family farmsI (FFs). Under the legislation, at least 30% of all feeding programme in Brazil funds which the federal government transfers to States and municipalities must be used to buy food from FFs, and a bidding process is not required . A recent study found that 47% of municipalities in the State of São Paulo had bought food from FFs at least once between June 2009 and August 2011 (Slater et al, 2013). is confirms that local procurement for the PNAE had not yet been implemented in all the municipalities analysed. e implementation of local procurement is known to be a complex process involving different sectors and levels of government Iris Emanuelly Segura, Ana Paula Cantarino Frasão de Carmo, Daniela Bicalho and and demands coordinated action. Consequently, the Vanessa Manfre Garcia Souza are nutritionists and postgraduate students at the School aim of this study was to check the percentage of of Public Health at Universidade de Sao Paulo. They research family farming and school direct procurement from FFs for the PNAE in the feeding under the supervision of Professor Slater. State of São Paulo in 2012 and describe the main features of the process. Claudia Rodriguez Method Claudia Rodriguez is a researcher at the School of Public Health at A cross-sectional survey was conducted in São Paulo Universidade de São Paulo (USP), Brazil. She is a nutrition in 2012 as part of a research project to assess the graduate of the Universidad Industrial de Santander in Colombia. level of implementation of direct procurement from In 2013 she joined a research project on the impact of family FFs for the PNAE (Slater, 2011). e survey was farming in a school feeding programme at USP under the based on a probability sample of 40 municipalities. supervision of Professor Betzabeth Slater. A structured questionnaire was completed (telephone or email) by a civil servant in the school meals man- Flavia Schwartzman agement department of each municipal council.

Flavia Schwartzman has a PhD in Public Health Nutrition from the The direct procurement of food from FFs for Universidade de São Paulo. She has worked as an international the PNAE was the dependent variable. The inde- consultant for the Food and Agriculture Organization of the United pendent variables were: PNAE management method, Nations (FAO) since 2011, supporting the strengthening of school- value of the municipality contribution, value of feeding programmes in Latin America and the Caribbean. funds transferred by the federal government for the PNAE, and provenance of the farmers who sold food for the PNAE. Proportions and averages Betzabeth Slater were used for the descriptive analysis; to analyse Betzabeth Slater is a professor and researcher at the School of Public the correlation between variables, these were di- Health at USP. A nutrition graduate from the National University of chotomised and Fisher’s exact test was used with a San Marcos, Peru, she has a PhD in Public Health. In 2012, she statistical significance level of p≤0.05. initiated a research project on the impact of family farming in school feeding programmes at USP, reflected in this article. Results e percentage of direct procurement from FFs for the PNAE in 2012 was 67.5%. In the same year, the This article describes the preliminary investigation directed by Professor Betzabeth average funds in US dollars which the central govern- Slater. The authors gratefully acknowledge the Foundation for Research of the State of ment transferred to the municipalities was $317,910.87, São Paulo (FAPESP) for funding this work. ranging from $14,733 to $2,103,721, while the average municipality contribution for the PNAE was $680,746, ranging from $0.00 to $8,785,240. Of the 40 municipalities analysed, four did not make any contribution and six did not respond. PNAE management was centralised in 80% of municipalities; decentralised in 10%; mixed in 7.5%; and outsourced in 2.5%. Location: Brazil Of the 27 municipalities that had implemented direct procurement from FFs for the PNAE, 59% What we know: Brazilian legislation obligates minimum purchase levels of food from used FFs in the actual municipality. ese comprised family farms to supply the National School Feeding Programme (PNAE) when using fed- 44 individual farmers, 23 farming associations and eral funds. 16 farming cooperatives. Analysis of the correlation between direct procure- What this article adds: A cross-sectional study of 40 municipalities in São Paulo, Brazil, ment from FFs for the PNAE (dependent variable) suggested an upward trend in the proportion of municipalities procuring family-farmed and the existence of municipality contribution and food for the PNAE from 47% to 67.5%. Purchases are largely local, from individual farm- centralised PNAE management method (independent ers, farming associations and cooperatives. Challenges remain when it comes to the suc- variables) did not reveal any correlation when they cessful implementation of policy; political will, government support and the organisational efficiency of the family farmers involved may impact on the success of local pro- 1 Brazil. Presidency of the Republic. Law No. 11,947 of 16 June curement. 2009. Articles 12 and 14...... 菀菀 Research ...... were dichotomised, (p-value 0.63; 0.68, respec- between January 2012 and November 2013 (Ban- curement has increased, when it comes to the tively). Similarly, no correlation was found be- doni et al, 2014). successful implementation of public policies tween the remaining variables examined. challenges remain which go beyond economic It is encouraging that purchases are largely resources. Political will, government support being made in the same municipality; this pre- Discussion and the organisational efficiency of the family supposes that there is not only a dialogue Since the enactment of Law 11,947/2009, the farmers involved may well impact on the success between the various players involved in the PNAE has played two crucial roles: as a public of local procurement, but these factors must be process, but the political will to implement it policy vehicle for guaranteeing the human right confirmed by more extensive studies. to adequate food, and as a key food safety and (Bezerra et al, 2013; De Camargo et al, 2013). For more information, contact: Claudia An- nutrition strategy affecting both schools and The minimum purchasing power of the mu- drea Rodriguez Mora, email: [email protected] family farmers. e results suggest an upward nicipalities that did not buy products from trend in the percentage of municipalities that FFs was US$4,419, a sum that would support For more experiences from Latin America and have implemented direct procurement from FFs at least one family farm per year. The maximum the Caribbean, including detailed case studies, for the PNAE, rising from 47% (Slater et al, sale value by a family farm in 2012 was see FAO, 2014. School feeding and possibilities 2013; Saraiva et al, 2013) to 67.5%. e findings US$4,404. for direct purchases from family farms. Case are consistent with a similar analysis of 63 mu- studies from eight countries. www.fao.org/3/a- In conclusion, although the percentage of nicipalities in the State of São Paulo, where i3413e.pdf 76.2% bought products from FFs for the PNAE municipalities that have implemented local pro-

References De Camargo RAL, Baccarin JG, Silva DBP. The role of the Schwartzman F. Situation of the Municipalities of São Paulo Food Acquisition Program (PAA) and the National School State in relation to the purchase of products directly from Bandoni et al 2014 – Bandoni DE, Stedefeldt E, Amorin Feeding Programme (PNAE) in strengthening family family farms for the National School Feeding Programme ALB, Barbosa Gonçalves HV, De Rosso VV. Health agriculture and promoting food security. Temas de (PNAE). Revista Brasileira de Epidemiologia v 16, n 1, p. regulation challenges for the safety of food acquired from Administração Pública. v 8, n 2, 2013. 223-26, 2013. family farms for School Meals. Vigilância Sanitária em seer.fclar.unesp.br/temasadm/article/view/6846 www.scielo.br/scielo.php?script=sci_arttext&pid=S1415- Debate: Sociedade. Ciência & Tecnologia. v 2, n 4, p. 107– 790X2013000100223 14. 2014. Saraiva et al, 2013 – Saraiva EB, Ferreira da Silva AP, Araújo de Sousa A, Cerqueira Fernandes G, Chagas dos Santos Slater, 2011 – Slater BV. The National School Feeding Bezerra OM, Bonono É, Da Silva CAM, Da Silva Correa M, CM, Toral, N. Panorama of purchasing food products from Programme (PNAE) and family farming: evaluation of the De Souza AA, Dos Santos PCT, Da Silva ML et al. Promoting family farmers for the Brazilian School Nutrition Programme. implementation process and the possible eﬀects of local the purchase of family farm products for school meals in Ciênc. saúde coletiva. v 18, n 4: p. 927-35, 2013. purchases, under Law 11.947 / 2009. São Paulo; 2011. Minas Gerais and Espírito Santo States, Brazil. Revista de Technical-scientiﬁc report presented to Fundação de Nutrição. v 26, n 3, p. 335–42, 2013. Slater et al, 2013 – Slater BV, Januario BL, Jamile FR, Amparo à Pesquisa do Estado de São Paulo.

Relationships between wasting and stunting and their concurrent occurrence in Ghanaian

pre-school children Summary of research1

Location: Ghana stunting (height-for-age z score (HAZ)), wasting (weight-for-age z score (WHZ)), and concurrent What we know: Wasting is a short-term health issue, but repeated episodes may lead to stunt- wasting and stunting. e independent variables ing (long-term or chronic malnutrition). is may occur in resource-poor settings, where were maternal weight and height, reproductive poor dietary intake and infectious disease are highly prevalent and persistent. factors (parity, level of education, place of What this article adds: A reanalysis of the 2014 Ghana Demographic and Health Survey delivery, and prenatal care utilisation), child (DHS)2 assessed the magnitude of and relationship between concurrent wasting and stunting characteristics (e.g., sex and birth weight), among 2,720 pre-school children aged 0-59 months, along with factors associated with both malarial infection, child dietary intake, and conditions. Results found children who had low WHZ scores were at higher risk of stunting, household wealth index. e analyses included especially children aged less than three years. e study confirms that wasting relates to linear other household characteristics such as household growth, moderated by child age. Wasting and stunting share many common risk factors. wealth, region of residence, urban/rural, source of drinking water, type of toilet facilities, and educational level of the mother/caretaker. e wealth variable categorised respondents into to the development of their concurrence within Background quintiles according to the household score on the same children and the magnitude of these Ghana’s most recent Demographic and Health the DHS wealth index, which is based on house- factors. is study investigated the relationships Survey (DHS) found a fall in stunting among hold amenities, assets and living conditions. pre-schoolers (28% in 2008 to 19% in 2014), between wasting and stunting and associated factors in the Ghanaian population. though masking great regional disparities, with the highest prevalence of 33.1% in Northern Methods 1 Mahama Saaka and Sylvester Zackaria Galaa, Relationships Region. Many countries, including Ghana, have e study involved reanalysis of the 2014 Ghana between Wasting and Stunting and Their Concurrent information on the prevalence and factors as- DHS dataset of 2,720 pre-school children aged Occurrence in Ghanaian Preschool Children, Journal of Nutrition and Metabolism, vol. 2016, Article ID 4654920, 11 sociated with chronic and acute undernutrition, 0-59 months. e main outcome variable was pages, 2016. doi:10.1155/2016/4654920. but lack knowledge of the factors that contribute the nutritional status of the child measured as 2 dhsprogram.com/pubs/pdf/FR307/FR307.pdf ...... 菀菀 Research ......

All data were coded for weighted analysis to low birth weight (LBW), whether child is wasted sociation, whereas others have found evidence take into account the complex design of multi- or not, child age, low utilisation of antenatal care that ponderal growth faltering can increase the stage cluster surveys, and to ensure the sample (ANC) services, poverty, and increased parity. e risk of linear growth faltering. Findings in this data were statistically valid. Effect modification only amenable behavioural variable was utilisation study confirm this. (where wasting and stunting is moderated by of ANC services. Key predictors for wasting were ere is no clear mechanism by which wasting the age of the child) was identified and adjusted LBW, age of child, wealth index and living in rural may lead to stunting. Some studies suggest that for effect through multiple regression analyses. areas (accounting for 10% variance). Low percentage growth in height only takes place when the of variance accounted for in stunting and wasting body has a minimum level of energy reserves. Results suggests that there are a larger number of possible Body fat plays a critical role in regulating bone Results showed that malnutrition prevalence variables that were not measured in the study. mass, but although fat stores are needed to pro- among the study population was 17.9% stunting ree variables – LBW, age of child and household mote linear growth, they are not sufficient, since (HAZ <-2); 4.7% wasting (WHZ <-2); and 10.8% wealth index – were found to be significant common stunting and overweight can co-exist in some underweight (weight-for-age z score (WAZ)<- predictors of wasting and stunting. Children whose populations (and individuals). e relationship 2). National prevalence of concurrent wasting birth weight was less than 2.5kg were about 2.0 between fat stores and stunting requires further and stunting was low at 1.4%, but with geo- times more likely to be wasted and 2.7 times more investigation. graphical variations. e Upper East Region had likely to be stunted than children with normal the highest prevalence of 3.2%; the lowest preva- birth weight (>2.5kg). is study shows that predictors of stunting lence was in the Volta Region, with 0.5%. Further were more common than those for wasting, but analysis of undernutrition according to age group, Discussions and this may be due to the lower prevalence of gender and geographical location indicate that: recommendations wasting compared to stunting in the same pop- both wasting and stunting frequently occur as e authors discuss and compare their findings ulation, therefore statistical power to detect sig- early as 0-5 months; levels of global acute mal- with other research and make recommendations. nificant associations between wasting and other nutrition (GAM) were highest among the 6-11 variables was low. All the risk factors for wasting Low national prevalence of concurrent wasting months age group, and in the Upper East Region; were also associated with stunting, apart from and stunting (1.4%) among the Ghanaian study and stunting was highest among children aged rural/urban residence. population may partly be due to seasonal varia- 24-35 months in the Northern Region and lowest tions in wasting prevalence, depending on when Low maternal height and household wealth among children aged 0-5 months. the data was collected. index were strongly associated with child nutri- e study confirmed that the relationship tional status. Household wealth index was a WHZ relates to linear growth, but the nature common predictor of both stunting and wasting, between wasting and stunting is moderated by and strength of the association was moderated child age; a 1-unit increase in WHZ was associated confirming that child undernutrition is strongly by child age. e association was strongest among associated with poverty. Low maternal height with a 0.07 standard unit increase in HAZ [∂= children aged 0-5 months and 12-23 months. 0.071 (95% CI: 0.03, 0.15)]. (below 45cm) increased the risk of stunting but Consistent with other studies, the study found not wasting; interventions should focus equally Predictors of stunting and that increasing child age is associated positively on children and mothers to improve child health. with stunting but negatively with wasting. wasting LBW was the most consistent risk factor for Predictors of stunting were more common than Cross-sectional studies at the population both WHZ and HAZ for all ages, which concurs wasting, with some factors associated with both. level have demonstrated conflicting views on with other research from birth cohorts and lon- e greatest predictors of stunting (accounting the relationship between wasting and stunting gitudinal studies. LBW infants should be a focus for 17.8% variability) were: low maternal height, in childhood. Some have found little or no as- for intervention.

Local spatial clustering of stunting and wasting among children under the age of five years Summary of research1

Location: Ethiopia thiopia has documented a significant decline in the prevalence of both stunt- What we know: e prevalence of stunting and wasting in Ethiopia has fallen but remains a ing and underweight between 2000 considerable burden. Effective nutrition strategies must target where there is greatest burden. and 2014; 31% decrease in stunting E(58% to 40%) and 39% decrease in underweight What this article adds: A recent study in the Meskane Mareko District of Ethiopia used a spatial point process to investigate whether undernutrition indicators (stunting and wasting) have (41% to 25%) (CSAE & ICF, 2012; CSAE & a tendency to cluster in order to determine the physical location and scale of clustering and ORC, 2006; CSAE & ORC, 2001; CSAE, 2014). discover risk factors for the observed clustering. A total 2,371 children under five years of age However, prevalence remains considerable (WHO were anthropometrically assessed in 1,744 households. Overall stunting prevalence was 40.2% classification: medium to high grade). Effective (19.1% severe); wasting prevalence was 9.8% (5.3% severe). Older children, poorest children nutrition strategies in Ethiopia, as elsewhere, and male children were more likely to be stunted; male children were more likely to be wasted. require targeting on the basis of nutritional vul- Only wasting and severe wasting clusters were observed in two of the six kebeles surveyed (4x nerability and burden to maximise benefit. is and 10x more likely to be wasted/severely wasted within clusters). Across all six kebeles, likely requires the identification of specific locations significant clusters for stunting (1.5x risk) and severe stunting (1.7x) were identified. For stunting, household locations (elevation of the house and place of residence) were risk factors. For 1 Gebreyesus SH, Mariam DH, Woldehanna T and Lindtjørn B. severe stunting, household dietary diversity, food-security status and latrine availability were (2016) Local spatial clustering of stunting and wasting risk factors. Spatial locations of high-risk areas for stunting could be an input for geographical- among children under the age of 5 years: implications for ly targeting and optimising nutritional interventions. intervention strategies. Public Health Nutrition, 19(8), pp. 1,417–1,427. doi: 10.1017/S1368980015003377...... 菀菀 Research ...... of at-risk populations in a given geographical area, a process that is aided by the use of spatial analytical approaches. is paper attempts to use such an approach, spatial point process, to investigate the local spatial structure of stunting and wasting among children under the age of five years (U5s) in a particular area of Ethiopia. e study aimed to evaluate whether undernutrition indicators (stunting and wasting) have a tendency to cluster in order to determine the physical location and scale of clustering and discover risk factors for the observed clustering. A community-based, cross-sectional study was conducted between December 2013 and April 2014 in the Meskane Mareko District of Ethiopia (around 513.65km2 in size) in the Gurage Zone South of Addis Ababa. e study district houses the Butajira Rural Health Pro- gramme (BRHP) run by Addis Ababa University, a health and demographic surveillance system Seifu Hagos, Ethiopia that collects data on vital events and demographic e overall prevalence of stunting among e authors found no difference between cases patterns in the district. e BRHP includes one U5s was 40·2%; 19.1% were severely stunted. of stunting within and outside the cluster with urban and nine rural communities (kebeles) e highest prevalence of stunting was in children and is divided into three agro-ecological zones, regard to child and household dietary-related aged 24-35 months (49·9 %). e lowest was in each containing three kebeles. e study ran- factors such as child morbidity, household dietary children below the age of six months (14·6 %); domly selected two out of three kebeles from diversity and food-security status, nor household prevalence increased with the age of child. Male each agro-ecology zone. Data were then collected socio-economic conditions and latrine availability. children (42·9 %) were more stunted than female from the six kebeles, totalling 4,077 households. e only factors that continued to be different children (37·9%) and children in the poorest Out of these, 737 households were excluded were household locations (elevation of the house wealth stratum (45.1%) were more stunted than (vacant or inhabitants very old and unable to and place of residence). Stunted children within those in the richest (35·2 %). e prevalence of respond), leaving 3,340 eligible households. an identified spatial cluster were positioned at stunting varied considerably among the six ke- From these households, weight and length/height lower elevations than those outside a cluster beles. e highest prevalence (52%) was docu- were measured in all U5s. A team of 20 local re- (P<0.05). For severe stunting, significant differences mented in Dobena kebele (1,853m above sea search assistants was used to take anthropometric were found between cases within and outside the level). e prevalence of wasting and severe measurements, all of whom had initial training cluster with regard to household dietary diversity, and evaluation of performance. wasting was 9·8% and 5·3% respectively. A food-security status and latrine availability. In smaller difference in wasting prevalence was these cases, no differences were found with regard e survey collected a range of socio-demo- found between male children (10·7 %) and to the elevation of the house and place of residence. graphic and health data of children and respon- female children (8·9 %). e highest prevalence dents; e.g. child’s age, sex, morbidity, mother’s of wasting was documented in Shershera Bido e authors conclude that the distribution of education, religion, marital status and occupation, (13·5 %) and Dirama (11·7%) kebeles (≥1977m wasting and stunting was partly spatially structured and household data; e.g. ownership and size of above sea level). Concurrence of wasting and in the communities analysed. Distinct areas were land, type of house and construction materials stunting in children was not reported. identified within and between villages that have and possession of certain items. Household food a higher risk than the underlying at-risk population. security was measured using the Household Spatial scan statistics were applied separately is indicates that the spatial distribution of Food Insecurity Access Scale (HFIAS) tool. for the six kebeles to find out whether there was wasting and stunting may not be a completely Household food intake was qualitatively captured a distinct spatial cluster in the distribution of random process, but could be determined beyond through 24-hour recall on food group con- stunting and wasting at a smaller scale. Results the individual or household level. Spatial locations sumption. Interviews were conducted by the 20 showed most likely significant clusters only for of high-risk areas for stunting could therefore be research assistants, overseen by two supervisors. wasting and severe wasting in two of the six ke- an input for geographically targeting and opti- Household geographic locations and elevations beles. In Dirama, a single cluster of 31 cases mising nutritional interventions. were determined using a hand-held GPS (Garmin (18.2 expected) in 129 households was identified. GPSMAP®). EpiData version 3.1 was used for Children in this cluster were four times more at data entry. e statistical soware package Stata risk of wasting than children outside the cluster. References version 11.0 was used for data cleaning and In Bati Lejano, a smaller cluster of seven cases CSAE & ICF, 2012 – Central Statistical Agency of Ethiopia & analysis. Anthropometric indices (Z-scores) (0.88 expected) in 15 households was identified; ICF International (2012) Ethiopia Demographic and Health were calculated using the WHO Anthro soware cluster children were ten times more at risk. e Survey 2011. Addis Ababa and Calverton, MD: CSA and ICF International. version 3.2.2; analysis of spatial clustering was presence of significant clusters of undernutrition carried out using Kulldorf’s spatial scan statistics on a higher scale across the six kebeles was also CSAE & ORC, 2006 – Central Statistical Agency of Ethiopia examined; this indicated a most likely significant & ORC Macro (2006) Ethiopia Demographic and Health and SaTScanTM version 9.1. Survey 2005. Addis Ababa and Calverton, MD: CSA and cluster for stunting and severe stunting. For ORC Macro. Results stunting, a single large cluster size of 390 cases A total of 3,340 households was visited, of which CSAE & ORC, 2001 – Central Statistical Agency of Ethiopia (304.19 expected) in 756 households was identi- & ORC Macro (2001) Ethiopia Demographic and Health 53.4% (1784) households had one or more U5s. fied; cluster children were 1.5 times more at risk Survey 2000. Addis Ababa and Calverton, MD: CSA and Response rate was 97·8 % (1,744 households), of stunting than children outside the cluster. For ORC Macro. resulting in anthropometric assessment of 2,371 severe stunting, a single cluster size of 106 cases CSAE, 2014 – Central Statistical Agency of Ethiopia (2014) U5s. Sixty-nine houses were not surveyed aer (69.39 expected) in 364 households was identified; Ethiopia Mini Demographic and Health Survey 2014. Addis repeated visits because of unavailability or refusal. cluster children were 1.7 times more at risk. Ababa: CSA...... 菀菀 Research ......

of absorption of different types of carbohydrates Carbohydrate was also done in several studies, which revealed that lactose intolerance is a concern for children with SAM. One study in particular looked at malabsorption in acutely lactose malabsorption in different types of SAM and found that the proportion of children with lactose malabsorption was highest in those with malnourished children and kwashiorkor, second highest in those with maras- mic kwashiorkor, and lowest in those with infants: A systematic marasmus (James, 1972). Some studies measured faecal pH and output Summary of research1 of water and carbohydrate as markers of car- review bohydrate malabsorption. A pH of less than 5.5 (normal pH values range between 7 and 7.5) and the presence of reducing substances in the faeces are indicative of carbohydrate intolerance and malabsorption as a result of Location: Global villous atrophy. A higher mean stool weight and a higher lactic acid content are also consistent What we know: Diarrhoea is commonly associated with SAM; carbohydrate malabsorption with carbohydrate malabsorption. Reduced may be a contributing factor. faecal pH was observed in children with SAM compared with controls in the studies that con- What this article adds: A recent systematic review finds a consistently reported reduced ca- ducted carbohydrate tolerance tests, although pacity for carbohydrate absorption in severely malnourished children. Evidence is lacking on the average pH was still more than 5.5 in all the extent of malabsorption, the impact on clinical outcomes and the relationship with infec- malnourished cohorts studied. Four studies tions. Malabsorption of monosaccharides and disaccharides is common (most observed is demonstrated a significant reduction in mean lactose malabsorption); this has implications for current SAM treatment since therapeutic stool weight in children on a disaccharide-free products tend to be high in carbohydrates. Intervention studies are needed to determine diet compared with children on a lactose-con- whether different therapeutic food carbohydrate profiles affect outcomes of SAM complicated taining diet. For example, Maclean and Graham by carbohydrate malabsorption, and how. (1975) demonstrated that children with SAM on a low-lactose diet had a mean stool weight nearly three times lower than that of convalescent children. Overall, the data from faecal exami- evere acute malnutrition (SAM) accounts children with malnutrition. The most common nation in included studies suggests the prevalence for approximately one million child deaths technique was blood glucose rise after carbo- of carbohydrate malabsorption in children with per year. SAM is associated with multiple hydrate tolerance tests using a glucose response SAM, as determined by increased mean stool co-morbidities that may contribute to an curve after an oral carbohydrate load. For an mass, the presence of reducing substances, and increasedS risk of death, a prominent one being oral tolerance test, generally 2g of carbohydrate an acidic faecal pH. diarrhoea. A common cause of diarrhoea in de- per kilogram of body weight dissolved in a e other indirect method used for assessing veloping countries is enteric infection, which, 10% solution was given orally after a six-hour carbohydrate absorption is the measurement of when associated with underlying malnutrition, fast and capillary blood was then sampled metabolic enzymes, namely lactase, sucrose and can lead to villous blunting and, as a result, im- every 30 minutes for two hours. If the blood maltase in jejunal mucosal biopsy samples. Mu- paired carbohydrate absorption. In turn, significant glucose rises less than 30mg/100ml after oral cosal disaccharidases, specifically, are essential decreases in carbohydrate absorption can lead to carbohydrate is administered, intolerance is for disaccharide absorption. Different studies severe osmotic diarrhoea. To inform future mod- considered likely; increments of less than observed reduced levels of disaccharides in mal- ification of therapeutic feeds, it is necessary to 20mg/100ml are considered diagnostic of malnourished children. James (1972) further illus- determine the prevalence of carbohydrate malabsorption. When compared with controls, trated a rise in disaccharidase levels aer treatment absorption and to understand the possible impact children with SAM showed a decline in the of both children with moderately acute malnu- of carbohydrate malabsorption on the recovery average maximum glucose rise. Other studies trition and children with SAM. In another study, of malnourished children. is systematic review compared malnourished children before and two children with SAM showed normal lactase, aims to evaluate the research to determine the after treatment. One study (Viteri et al, 1973) sucrose and maltase activities; one child with extent to which carbohydrate malabsorption reporting a significant improvement in car- SAM had low sucrose and maltase activities and occurs in children with SAM, to find out what bohydrate absorption after treatment and an- borderline low lactase activity, and eight children types of carbohydrate are malabsorbed, and to other (James, 1972) showing no significant with SAM had low lactase and sucrose activities, find out if carbohydrate malabsorption in children improvement after treatment in lactose or su- six of whom also has low maltase activity. with SAM is associated with osmotic diarrhoea. crose absorption. Measurement of anthropometric markers A comprehensive literature search was per- Other studies, instead of comparing treated can be indirectly related to carbohydrate mal- formed in PubMed and Embase and reference subjects with control subjects, investigated plasma absorption and is harder to control for influencing lists of selected articles were further screened glucose increments in children with SAM to in- factors. A study conducted in a cohort of 20 for additional relevant publications. All obser- dicate malabsorption aer administration of a male children with SAM indicated that, despite vational and controlled intervention studies in- carbohydrate load. Rothman et al (1980) showed the increased incidence of diarrhoea in the volving children with SAM in which direct or that glucose increments in eight of 12 children indirect measures of carbohydrate absorption with SAM fell below the cut-off value of were analysed were eligible for inclusion. A 1 20mg/100ml, while increments in the remaining Kvissberg, MA; Dalvi, PS; Kerac, M; Voskuijl, W; Berkley, total of 20 articles were selected for this review. JA; Priebe, MG; Bandsma, RH (2015) Carbohydrate four were less than 30mg/100ml. ese findings malabsorption in acutely malnourished children and Some of the included studies performed indicate that carbohydrate malabsorption is infants: A systematic review. Nutrition reviews. ISSN 0029- dynamic tests of carbohydrate absorption in prevalent in children with SAM. Comparison 6643 DOI: 10.1093/nutrit/nuv058 ...... 菀菀 Research ...... cohort on a lactose-containing diet compared other adverse clinical outcomes, and the rela- References with the cohort on a lactose-free diet, both tionship between malabsorption and infection Eichenberger JR, Hadorn B, Schmidt BJ. A semi-elemental cohorts recovered well and in a similar fashion are unclear owing to the lack of conclusive diet with low osmolarity and high content of hydrolyzed with regard to anthropometric characteristics studies. Most of the observational studies reviewed lactalbumin in the treatment of acute diarrhea in (Prinsloo et al, 1969). In contrast, two studies by the authors suggested a prevalence of lactose malnourished children. Arq Gastroenterol. 1984;21:130–135. showed a decreased weight gain in children on malabsorption and an increase in diarrhoea and James WP. Comparison of three methods used in assessment a lactose-free diet. In one study in 20 malnour- of carbohydrate absorption in malnourished children. Arch reduced weight gain in children on a lactose- Dis Child. 1972;47:531–536. ished children placed on a semi-elemental diet containing diet. e consistent observation of containing glucose and maltodextrin as the car- MacLean WC Jr and Graham GC. Evaluation of a low-lactose malabsorption of both monosaccharides and nutritional supplement in malnourished children. J Am Diet bohydrates, the average weight gain aer 21 disaccharides could have profound implications Assoc. 1975;67:558–564. days was 420g, while in the 18 malnourished for current treatment of severe malnutrition, Prinsloo JG, Wittmann W, Pretorius PJ, et al. Effect of different children on the cow’s milk-based diet, the average since the therapeutic foods in most treatment sugars on diarrhoea of acute kwashiorkor. Arch Dis Child. weight gain aer 21 days was 110g (Eichenberger protocols have a relatively high carbohydrate 1969;44:593–599. et al, 1984). content. Additional well-designed intervention Rothman D, Habte D, Latham M. The effect of lactose on is review finds a consistently reported re- studies are needed to determine whether outcomes diarrhoea in the treatment of kwashiorkor. J Trop Pediatr. 1980;26:193–197. duced capacity for carbohydrate absorption in of SAM complicated by carbohydrate malab- severely malnourished children. e extent of sorption could be improved by altering the car- Viteri FE, Flores JM, Alvarado J, et al. Intestinal malabsorption in malnourished children before and during recovery. carbohydrate malabsorption, the impact of mal- bohydrate/lactose content of therapeutic feeds Relation between severity of protein deficiency and the absorption on severe diarrhoea, dehydration and and to explain the precise mechanisms involved. malabsorption process. Am J Dig Dis. 1973;18:201–211.

Location: Kenya Kamal Singh, Kenya Kamal Singh, Kenya What we know: Internally displaced persons (IDP) are vulnerable to nutrition and food insecurity. Nutrition among men What this article adds: A 2013 study investigated the nutritional status of 251 men and their household food-security status during a pre-harvest period in an and household food established IDP camp in Kenya. Nutritional status was comparable to non-displaced men in Kenya (the majority (68.9%) were of normal body mass index; one security in an internally quarter (23.9%) were undernourished). Household food insecurity, measured using three assessment displaced persons scales, was relatively high. e most common source of food was own production (63.2%). Each had access to land; a minority depended on food aid. Recommenda- camp in Kenya tions to improve food security include initiatives to im- A typical camp setting where Summary of research1 prove access to credit and enabling investment and ca- the research was conducted pacity development in agriculture.

n 2007, disputed election results led to 0.25 acres of land for housing. e study was index (BMI) and mid-upper arm circumference the outbreak of ethnic violence in Kenya, undertaken over one week in June 2013 during (MUAC) were measured. centred on the Ri Valley Province where the pre-harvest season of high food insecurity. the Kikuyu minority, among others, was e study was descriptive and cross-sectional, Results targeted.I Up to 600,000 people were displaced using a questionnaire and biometric measure- A total of 251 responses were included in the from their homes and eventually settled in In- ments. A total of 267 men aged ≥ 18 years analysis. e mean age of participants was 37 ternally Displaced Persons (IDP) camps. Reports residing within the camp were recruited via re- years, 84·5% were of Kikuyu ethnicity and 82·1% suggest that access to basic needs, including spondent-driven sampling. e questionnaire had resided in the former Ri Valley Province food, water, sanitation and healthcare, continues comprised 72 questions divided into three main prior to displacement. ree fihs of participants to be irregular throughout these camps. To date, areas: demographic characteristics, nutrition, had completed up to or more than primary ed- no study has been published on nutrition and and food security. e nutrition and food security ucation; half were married and the mean house- food security among Kenya’s IDPs. e purpose section incorporated three assessment scales: hold size was seven. Half were employed, pre- of the present study was to determine the nutri- Individual Dietary Diversity Score (IDDS) (using dominantly in agriculture, and the median tional status of men and their household food- 24-hour recall of the consumption of diﬀerent monthly household income was 2,500 KES security status in an IDP camp in Kenya. food groups); Household Food Insecurity Access (US$32). Scale (HFIAS), involving recall over the previous Method During the previous 12 months, most par- four weeks; and Household Hunger Scale (a ticipants (95·2 %; n=239) consumed at least one e study was conducted in 2013 within an newly emerging measure of hunger in regions IDP resettlement camp in Rongai District, which may already be experiencing significant Nakuru County, for those displaced from the food insecurity, calculated using HFIAS data). 1 Singh KP, Bhoopathy SV, Worth H, Seale H and Richmond RL Ri Valley. Currently there are over 400 families (2015) Nutrition among men and household food security in e questionnaire was self-completed by par- an internally displaced persons camp in Kenya, Public residing in the study camp who have each been ticipants in either English or Kiswahili with the Health Nutrition, 19(4), pp. 723–731. doi: 10.1017/S1368980 allocated two acres of land for agriculture and optional use of an interpreter. Both body mass 015001275...... 菀菀 Research ...... meal every day. e most common food source mon condition of household hunger reported with being older, having less income and being was from own production (63·7%; n=160); fol- was going to sleep hungry at least once in the married or living with a partner. e mean lowed by purchase (28·3%; n=71); food from previous four weeks (62·5 %; n=157). e con- MUAC was 26·4cm (20.5-36.5). friends/relatives (4.4%; n=11); and government dition experienced most was having no food of Anthropometry was similar to other studies food aid (3·6%; n=9). e majority (86·1 %; any kind in the household: 7.2% (n=18) experi- among non-displaced men in rural Kenya, which n=216) reported poor access to household fuel. enced this more than ten times. e majority of contrasts with other findings, suggesting IDPs participants were from households with moderate HFAIS Scale responses revealed that the ma- have poorer nutritional status than comparable hunger (46·6%), followed by little or no hunger jority (80.5%; n=202) of participants had to eat non-displaced populations. is may be due to (40·2%) and severe hunger (10·0%). Men aged a limited variety of foods and reported missing the study being undertaken in a relatively stable over 45 years and from households earning less out on preferred foods (79.3%; n=199). One and well-developed camp, five years post-dis- than 2,000 KES (US$25) per month were more fih of respondents experienced limited food placement, among households with access to likely to report being in the severe household variety (22.3%; n=56) or missed preferred foods agricultural land and low reliance on food aid. hunger category. (21.1% (n=53) more than ten times in the past However, levels of food insecurity among camp four weeks. Half of respondents (49·0%; n=123) IDDS results show that starchy staples (e.g. households are worse than those in average reported going a whole day and night without thick maize porridge (ugali) and thin maize rural settings in the region. is may in part be eating anything. e HFIAS score was 11.6 (po- porridge (uji) were eaten by 92% of participants. due to the lack of household capital to support tential range 0-27). Organ meat (e.g. liver, heart and kidney) was agriculture; community conversations suggest HFIAS score was associated with income. the least common (21·9%). e mean IDDS was lack of income means that fertiliser, agricultural ose earning less than 2,000 KES (US$25) per 6 out of a possible 9 (SD 1·8). Low dietary implements and seeds are diﬃcult to access. diversity (score ≤4) was associated with income, month had a significantly (P< 0.001) higher Recommendations: Recommendations to im- food insecurity and household hunger. mean HFIAS score (14·26), suggesting greater prove food security include registering land allo- food insecurity. e majority of participants e mean BMI of respondents was 20·3 (SD cations under the name of the owner to provide (71·7%) were from severely food-insecure house- 2·5). e majority (68·9 %) had a normal BMI. access to credit and encourage investment in holds; 13·5% were moderately food insecure; One quarter (23·9%; n=60) were underweight, agricultural implements, as well as agricultural 4·8% were mildly food insecure; while only 4·8% of whom 85% had mild thinness (BMI=17·0- education programmes. Such steps will be essential were food secure. 18·4); 13·3% had moderate thinness (BMI=16·0- to address severe food insecurity and minimise e median HHS score was 2 (SD 1·5) out of 16·9); and a single participant had severe thinness its impact on mental health, disease profiles and a maximum possible score of 6. e most com- (BMI ≤15·9). Being underweight was associated family wellbeing documented in other IDP settings.

How to engage across sectors: Lessons from agriculture and nutrition in the Brazilian School Feeding Programme Summary of research1

Location: Brazil

What we know: Historically, successful collaboration between agriculture, nutrition and health sectors has proved challenging.

What this article adds: A recent study identified five key lessons for promoting inter-sectorality for nutrition, based on the Brazilian experience of linking family farming with the National School Feeding Programme. e lessons were: identifying a common political, philosophical or governance space to enable sectors to convene; form coalitions with more powerful sectors with a shared (non-nutrition) goal which can help deliver on nutrition objectives; position nutrition and health goals as solutions (not problems) to the interests of other sectors; obtain evidence of successful inter-sectoral work; be bold in ideas for cross-sectoral work.

razil’s National School Feeding Pro- farms. is study examines integrating family the nature of the inter-sectoral approach, gramme, Programa Nacional de Ali- farming and nutrition into a legal framework in interests and values involved, and factors both mentação Escolar (PNAE), is a universal Brazil to identify lessons on how to successfully facilitating and presenting barriers to the ap- and free programme that began in shi other sectors toward nutrition goals. proval of Article 14. Documentation on the 1954B and that currently serves 45.6 million public history of the development of the law and key school students. In June 2009, a law was signed Information and perspectives on the devel- in Brazil requiring that 30% of the food budget opment of Article 14 were obtained from in- 1 Hawkes C, Brazil GB, Castro IR, Jaime PC (2016). How to of the national school feeding programme should terviews with 18 leading actors involved, during engage across sectors: lessons from agriculture and nutrition in the Brazilian School Feeding Program. Rev Saude Publica. be used to purchase foods directly from family February and July 2010. Questions explored 2016 Aug 11;50:47. doi: 10.1590/S1518-8787.2016050006506...... 菀菀 Research ...... antecedent actions from published documents istries and agencies who had first discussed family ese experiences suggest that the political was also examined. farming-PNAE links. e second coalition consisted process of identifying and participating in a of food security advocates, Frente Parlamentar strong coalition that is able to cause change in e study provided five key lessons for pro- de Segurança Alimentar e Nutricional (Parlia- the right direction, and that is focused on moting inter-sectorality for nutrition, based on mentary Front on Food and Nutrition Security), fighting for a common goal into which nutrition the Brazilian experience of linking family farming comprising over 230 deputies and senators in and health can fit, is more important than an with the National School Feeding Programme, 2007, led by an influential politician who partnered explicit nutrition goal, which is oen called for as follows: with civil society. e third coalition was a group by the international nutrition community in Lesson One: Identify or create a triage of family farming advocates, which provided nutrition-focused development (UNSCN, 2015). of spaces to bring together diﬀerent strong mobilisation and extensive, well-organised advocacy activities. Lesson ree: Positioning nutrition sectors – political, philosophical, and and health goals as a solution that governance spaces Improving nutritional outcomes was not the meets the interests of other sectors primary goal of Article 14. e stated aim was In 2003, food security moved to the centre of Article 14 explicitly met the interests the political stage with the develop- of family farmers through new mar- ment of a new programme, Fome WFP/Isadora Ferreira kets and income generation, which Zero. is emphasised the need for secured the backing of family farming structural reform to address income interests. us the incentive for in- poverty and encourage the production ter-sectorality came from a solution, of lower-cost food, including by sup- rather than a problem. Article 14 porting family farmers. A large, cross- met the interests of a more powerful sectoral government civil society sector, family farmers, and nutrition group, CONSEA, was established to and health goals were met as a by- advise the President on policies and product. actions needed to promote food and nutrition security. e new Govern- Lesson Four: Obtaining ment also created the Programa de evidence that the inter- Aquisição de Alimentos (PAA – Food sectoral approach can work Acquisition Programme), which pur- Article 14 was not the first initiative chases food directly from family farms in Brazil linking family farmers with and distributes it to institutions and markets. Most notable was the Food families at risk of food and nutritional Acquisition Programme (PAA) es- insecurity by social programmes. tablished in 2003. is group had a e addition of nutrition into the crucial role in the approval of Article concept of food security was forged 14 by providing evidence that family during this process and formally ap- farming works; specifically and no- proved at the second Conferência tably that the pricing and procurement Nacional de Segurança Alimentar e mechanism could work and family Nutricional (CNSAN – National Con- farmers could supply suﬃcient food. ference on Food and Nutrition Secu- Lesson Five: Not being rity) in 2004. According to this broader concept, as a way of ensuring the hu- afraid of bold ideas when man right to adequate food, public working with other sectors policies on food and nutrition security Article 14 was a bold and appealing should not only encompass actions idea. It not only had the political ap- to improve availability of and access peal of supporting family farmers to food, but also promote and protect and economic development, but “it sustainable and healthy diets. is was an important political force in concept links the nutritional dimen- the minds of the population, the sion of food security that puts all social imagination and the enhance- sectors and their priorities and agen- ment of self-esteem of the farmers das in the same space. because it will nourish the children”. Principles, to support local economic development, not to language, assumptions and approaches change Crucial to this was an inter-sectoral framework improve nutrition. Nutrition interests were rep- when working with other sectors: they can be of food and nutrition security that provided the resented within the various groups, but not exploited for mutual advantage. philosophical space to put the two problems of central to discussions, and the process lacked a food security and nutrition together, the policy clearly distinguishable coalition formed around is study on policy processes shows how a space provided by the new Government for this nutrition and health interests. Nutritionists did convergence of factors enabled a link between joint issue, and the governance provided by advocate to ensure that, by law, a nutritionist family farming and school feeding in Brazil. It CONSEA to make it happen. should design the menus for the PNAE and to highlights key strategies in engaging other sectors include specific nutritional standards for school on working towards nutrition goals to benefit Lesson Two: Forming coalitions with meals within the final Bill. e authors argue all sectors involved. more powerful sectors focused on that politically it served the nutrition interest achieving a common political goal not to focus on the nutrition technicalities but References that can help move them toward on a common goal: to change the PNAE. En- UNSCN 2015 – United Nations Standing Committee on nutrition and health goals gagement of nutritionists with a clear nutrition Nutrition. A road map for scaling-up nutrition (SUN). Successful lobbying for Article 14 was strengthened objective was important; however not focusing [Place unknown]: Scaling Up Nutrition Road Map Task on that goal as the foundation of the coalition Team; 2010 [cited 2015 Mar 27]. Available from: by three overlapping advocacy coalitions. e scalingupnutrition.org/wp- first was between the relevant government min- was politically advantageous. content/uploads/pdf/SUN_Road_Map.pdf ...... 菀菀 Research ......

An investment framework for nutrition: Reaching the global targets for stunting, anaemia, breastfeeding and wasting Summary of research1

Location: Global wasting) are further enshrined within the United Nations Sustainable Development Goal 2 (SDG What we know: Child malnutrition has lifelong consequences for heath, human capital, 2), which commits to ending malnutrition in economic development, prosperity and equity. Global nutrition targets (2012) focus on all its forms by 2030. stunting, anaemia, low birthweight, childhood overweight, breastfeeding and wasting; the cost of achieving this is unknown. Nutrition targets: Investment case and constraints What this article adds: A recent comprehensive analysis by the World Bank estimates an Ending malnutrition is critical for economic additional investment of $70 billion (£62 billion approx) over ten years is needed to and human development. Childhood stunting achieve global targets for stunting, anaemia in women, exclusive breastfeeding and scaled- has lifelong consequences not just for health, up treatment of severe wasting. is would avert 3.7 million child deaths; every dollar in- but also for human capital and economic de- vested would yield between $4 and $35 in economic returns. Investment in a subset of pri- velopment, prosperity and equity. Reductions ority interventions would cost $23 billion (£19 billion approx); global targets would not be in stunting may increase overall economic pro- reached, but 2.2 million lives would be saved. Achieving global goals is feasible but con- ductivity. Nutrition interventions are consistently certed efforts in financing, scale-up and sustained commitment are needed. Research pri- identified as one of the most cost-effective de- orities include scalable strategies for delivering high-impact interventions, how to improve velopment actions. However, although the in- the technical efficiency of nutrition spending, and costs and impacts of nutrition-sensitive vestment case for nutrition is strong, factors interventions. limiting achievement of nutrition SDG targets include insufficient financing, complexity of implementation, difficulty determining the methods and costs involved in monitoring n 2015, 159 million children under the community around improving nutrition, the SDG targets, and the resources required for age of five were chronically malnourished 176 members of the World Health Assembly scale-up. There is little evidence on the estimated or stunted, underscoring a massive global endorsed the first-ever global nutrition targets, costs of achieving the global nutrition targets, health and economic development chal- focusing on six areas: stunting, anaemia, low including the SDG targets. No previous study lengeI (UNICEF, WHO, and World Bank 2015). birthweight, childhood overweight, breastfeeding has systematically linked the costs with the In 2012, in an effort to rally the international and wasting. Some of the targets (stunting and potential for impact and the interventions’ returns on investment, nor assessed the financing shortfall between what is required and global Figure 1 2025 target spend. Finally, no prior study has presented a comprehensive global analysis of domestic financing from governments and official development assistance. This report aims to close these knowledge gaps by providing a more comprehensive estimate of costs as well as financing needs, linking them both to expected impacts, and laying out a potential financing framework. An in-depth understanding of current nutrition investments, future needs and their impacts, and ways to mobilise the required funds, are included. Estimated financing needs An additional investment of $70 billion (£62

1 Shekar, Meera; Kakietek, Jakub Jan; Dayton, Julia M.; Walters, Dylan David. 2016. An investment framework for nutrition: reaching the global targets for stunting, anemia, breastfeeding and wasting: executive summary. Washington, D.C. : World Bank Group. documents. worldbank.org/curated/en/847811475174059972/ executive-summary ...... 菀菀 Research ...... billion approx) over ten years is needed to value-for-money development actions, they also ing and ensuring accountability, and to undertake achieve the global targets for stunting, anaemia lay the groundwork for the success of investments national-level public expenditure reviews. in women, exclusive breastfeeding and scaled- in other sectors. Research on which interventions prevent up treatment of severe wasting. e expected Recent country experiences suggest that meet- wasting is urgently needed. It is also essential to impact of this increased investment is the pre- ing global nutrition targets are feasible, although learn more about cost-effective strategies for vention of 65 million cases of stunting and 265 some, especially those for reducing stunting in managing moderate acute malnutrition, and million cases of anaemia in women in 2025, as children and anaemia in women, are ambitious whether or not these can contribute toward the compared with the 2015 baseline . In addition, and will require concerted efforts in financing, prevention of wasting. at least 91 million more children under five scale-up and sustained commitment. On the years of age would be treated for severe wasting Costs and impacts of nutrition-sensitive in- other hand, the target for exclusive breastfeeding and 105 million additional babies would be ex- terventions; i.e. interventions that improve nu- has scope to be much more ambitious. clusively breastfed during the first six months trition through agriculture, social protection of life over 10 years . Such investment would Priority research areas include: and water and sanitation sectors, among others. also result in at least 3.7 million child deaths Research on scalable strategies for delivering high- It is evident that stunting and anaemia have being averted. Every dollar invested in this pack- impact interventions, including how to address multiple causes and can be improved through age of interventions would yield between $4 bottlenecks to scaling-up. increasing quality, diversity and affordability of and $35 in economic returns. foods; increasing the control of income by e assessment of allocative efficiency, i.e. women farmers; and reducing exposure to faecal In an environment of constrained resources, identifying the optimum funding allocation pathogens by improved water, sanitation, and prioritisation of a subset of interventions is nec- among different interventions or an allocation hygiene practices. However, the attributable essary – scaling-up of interventions with the that maximises the impact under a specific fraction of the burden that can be addressed by highest returns, that are scalable now, with the budget constraint. these interventions is unknown. strong caveat that global targets would not be reached. Costing $23 billion (£19 billion approx) Research to improve the technical efficiency e authors end with a call to action. Invest- over next 10 years, when combined with other of nutrition spending, including identifying new ments in the critical 1,000-day window of early health and poverty reduction efforts, an estimated strategies for addressing complex nutritional childhood will pay lifelong dividends, not only 2.2 million lives would be saved and there would problems such as stunting and anaemia, as well for the children directly affected but also for us be 50 million fewer cases of stunting in 2025 as technologies to help take these solutions to all in the form of more robust societies that will than in 2015. scale more rapidly and at lower cost. drive future economies. A mix of domestic on-budget allocations Strengthening the quality of surveillance data, from national governments, oversees development unit cost data for interventions in different country aid (ODA), newly emerging innovative financing contexts, and building stronger data collection mechanisms and household contributions could systems for estimating current investments in nu- References finance the remaining gap. A society-wide effort trition (from both domestic governments and UNICEF, WHO, and World Bank (United Nations Children’s is needed for financing the achievement of the ODA). Further research is needed on the costs Fund, World Health Organization and World Bank). 2015. of interventions and significant resources will Joint Child Malnutrition Estimates: Levels and Trends. Global nutrition targets; this mix of financing is also in Database on Child Growth and Malnutrition. line with other SDG challenges. Not only do in- be required to build a living database of current www.who.int/nutgrowthdb/ estimates2014/en/ (accessed vestments in nutrition make one of the best investments, including closely monitoring spend- October 2015).

Advancing Early Childhood Development: From Science to Scale

Location: Global Introduction e 2016 Lancet Series Advancing Early Childhood Development: From What we know: ere have been major improvements in child Science to Scale has just been released, comprised of six comments and survival over the last 30 years. A major focus of the 2030 Sustain- five papers. Building on the findings and recommendations of the previous able Development Goals (SDGs) is now on early childhood devel- Lancet Series, this highlights new scientific evidence for interventions and opment (ECD) to ensure that every child can achieve their full hu- recommends pathways for scaling up ECD programmes. man potential. Focus of the 2030 Sustainable Development Goals (SDGs) is on early What this article adds: e 2016 Lancet Series Advancing Early childhood development (ECD) to ensure that every child can achieve Childhood Development: From Science to Scale, has just been re- their full human potential. e first three years of life offer a window to leased. It estimates that 250 million (43%) of children under five amplify ECD interventions if stimulation through parenting, educational years of age in low- and middle-income countries (LMICs) are at support and adequate health and nutrition are provided. Despite the risk of poor development outcomes. Risks to health and wellbeing decrease in child mortality over the past 30 years, the extremely high go beyond stunting and extreme poverty to include factors such as burden of risk for poor developmental outcomes remains, affecting an es- low maternal education and physical maltreatment. is Series timated 250 million (43%) of children under five years of age in low- and highlights emerging scientific evidence and proposes pathways for middle-income countries (LMICs). Sub-Saharan Africa’s burden is even implementation of ECD programmes at scale. ‘Nurturing care’ is greater, with two thirds of children affected. e burden of poor child de- emphasised, especially of children below three years of age, and velopment has been underestimated because risks to health and wellbeing multi-sector interventions starting with health. go beyond stunting and extreme poverty to include factors such as low ...... 菀菀 Research ...... maternal education and physical maltreatment. experience. A young child’s developing brain is Overview of papers Multi-sector policies and funding for ECD have patterned by the ‘nurturing care’ of adults, in- Objectives of the first paper (Black et al, 2016) are increased, but few countries have institutionalised cluding age-appropriate learning experiences. to update the estimates of children at risk of not at- the implementation of these policies. Services Many families cannot provide these due to taining their developmental potential and to present for ECD remain fragmented and programmes stresses and conditions that affect their ability a life-course, conceptual ECD framework. e at scale are rare and poorly evaluated. to parent, including extreme poverty and family paper also examines current access to, and describes and societal conflict. Families need support to is Series provides compelling new evidence opportunities to implement, centre-based and provide nurturing care; e.g. material and financial in two areas. First, new research on early human home-based cross-sector ECD programmes. resources, knowledge, time and skilled assistance. development shows that adaptations (e.g. epigenetic Support should be provided through policies e second paper (Britto et al, 2016) provides and psychological) to the environment begin at such as paid parental leave, time at work for a comprehensive, updated analysis of ECD inter- conception and affect development throughout breastfeeding and the provision of free pre-pri- ventions across the five sectors of health, nutrition, life, with implications for targeted interventions. mary education. education, child protection and social protection. Second, evidence is presented on long-term outcomes in LMICs. For example, a programme to A start can be made through e third paper (Richter et al, 2016) presents increase cognitive development in stunted children health new analyses showing that the burden of poor in Jamaica 25 years ago resulted in a 25% increase e health sector has unique advantages, since development is higher than estimated, taking in average adult earnings. it has existing maternal and child health services into account additional risk factors. National that can be expanded to feasibly and affordably programmes are needed with greater political Key messages from the Series include evidence-based nurturing care inter- prioritisation key to scale-up of available effective e burden and cost of inaction is ventions; most important are those strengthening programmes to support ECD. All sectors, par- high the growth and health of mothers and young ticularly health, education and social and child A poor start in life limits children’s abilities to children. Other essential services are child pro- protection, must play a role to meet the holistic benefit from education, resulting in lower protection for violence prevention, social protection needs of young children. ductivity and social tensions. Consequences are for financial stability, and education for quality e fourth paper (Shawar & Shiffman, 2016) inter-generational: poor ECD leads to a cycle of early-learning opportunities. describes multiple opportunities to advance lost human capital and perpetuation of poverty political priority for ECD, including an increas- for both the individual and future generations. Scale up what we know works ingly favourable political environment, advances Predicted losses are 25% average adult income Small-scale civil society initiatives can be scaled in ECD metrics, and the existence of compelling per year; nationally, this could mount to twice up to effective and sustainable national pro- arguments for investment in ECD. However, current GDP spend on health. grammes. Government leadership and political proponents will need to overcome the framing prioritisation are prerequisites, but different and governance challenges to leverage these Early means early pathways may be followed to achieve ECD targets, opportunities. Child development starts at conception and de- from staged enhancement of existing strategies pends on good nutrition and certain types of to transformative, whole-government initiatives. e fih and final paper (Chunling et al, 2016) updates the 2004 estimates (published in 2007) of children exposed to stunting or extreme poverty with the use of improved data and methods and generated estimates for 2010. e 2007 study underestimated the number of children at risk of poor development. Progress has JoanBardeletti/Panos been made in reducing the number of children exposed to stunting or poverty, but it has been insufficient: targeted interventions are urgently needed.

References Black MM, Walker SP, Fernald LCH, Andersen CT, DiGirolamo AM, Lu C, … Grantham-McGregor S (2016). Early childhood development coming of age: science through the life course. The Lancet. doi:10.1016/S0140- 6736(16)31389-7 Britto PR, Lye SJ, Proulx K, Yousafzai AK, Matthews SG, Vaivada T … Bhutta ZA (2016). Nurturing care: promoting early childhood development. The Lancet. doi:10.1016/S0140-6736(16)31390-3 Chunling L, Black MM, Richter LM (2016). Risk of poor development in young children in low-income and middle-income countries: an estimation and analysis at the global, regional, and country level. The Lancet. Doi:10.1016/S2214-109X(16)30266-2 Richter LM, Daelmans B, Lombardi J, Heymann J, Boo FL, Behrman JR, … Darmstadt GL (2016). Investing in the foundation of sustainable development: pathways to scale up for early childhood development. The Lancet. doi:10.1016/S0140-6736(16)31698-1 Shawar YR & Shiffman J (2016). Generation of global political priority for early childhood development: the challenges of framing and governance. The Lancet. doi:10.1016/S0140-6736(16)31574-4 ...... 菀菀 Research ...... Location: Global Role of nutrition What we know: Early child development (ECD) is a key predictor of future social capital and national productivity. Worldwide, 250 million children under five years old may fail in integrated to reach their developmental potential due to extreme poverty and social injustice. What this article adds: A special issue of Maternal and Child Nutrition that compiled early child previously published articles on ECD related to nutrition shows that nutrition-specific interventions, though essential, are not sufficient for children to reach their full developmental potential. Non-nutrition factors such as social determinants of health, parenting development style and early childhood stimulation affect other ECD dimensions (psychosocial, cogni- Summary of research1 tive and educational); poverty and social exclusion limit access. Multi-sector programmes are needed at scale that consider responsive parenting, learning stimulation, education and social protection, in addition to health and nutrition.

Introduction years of age, was independently associated with A randomised controlled trial in India (Vazir Child development has multiple dimensions, in- cognitive development (Teivaanmäki et al, et al, 2013) found that responsive feeding edu- cluding physical, sensorimotor, social, emotional, 2016), strongly suggesting the importance of cation of caregivers improved dietary intake, language and cognitive. Children develop rapidly promoting linear growth post-1,000 days for growth and mental development among toddlers, during the first five years of life from being unable long-term cognitive development. underlining the need for integration of parenting skills as part of nutrition interventions targeting to speak and walk to having fairly advanced Liu and Raine (2016) found that malnourished young children. motor, social and cognitive skills. e importance children in a large sample of three-year-olds in of the first 1,000 days (from gestation to two Mauritius had impaired social functioning, with Fabrizio et al (2014) identified key components years) in helping a child develop healthy growth a dose-response relationship; i.e. increased mal- of effective behaviour-change interventions to is well established. e brain grows very rapidly nutrition was associated with more impaired improve complementary feeding practices as during the same period; between three and five social behaviour. identifying barriers and enablers and delineating years of age its development continues with new abilities building on those already acquired. Findings from studies investigating the asso- programme-impact pathways, pointing to the ciation between micronutrients and ECD remain need for inter-disciplinary partnership in ma- Early child development (ECD) is recognised inconclusive. Makrides et al (2011) confirmed ternal-child nutrition. as one of the most important predictors of future that the effect of maternal fatty acid supplemen- In a review of water, sanitation and hygiene social capital and national productivity, yet the tation on global neurobehavioural outcomes for recent ECD Lancet Series reports that about 250 (WASH) interventions, Cumming and Cairncross children remains unclear, although fatty acid (2016) add to the strong evidence that malnu- million children under five years old are at risk supplementation of women expressing milk for of not reaching their developmental potential trition and infectious diseases are interrelated their pre-term infants appears to improve infant and that WASH should be part of multi-focal (see summary in this edition of Field Exchange). neurodevelopmental performance. is special issue of Maternal and Child Nutrition ECD interventions. brings together important, previously published Social and behavioral articles on ECD (with priority given to the last Policy mediators Subramanian et al (2016) call for a rethinking of two years) to identify how the nutrition sector Mallan et al (2015) found that maternal postpartum can contribute to ECD in the context of multi- policies to address child stunting in South Asia, depression, assessed at four months postpartum, the region most affected, and conclude that up- sector interventions. is is crucial given the had a negative association with the mother’s stream social determinants of health must be centrality of ECD indicators as part of the 2030 ability to feed her two-year-old children respon- urgently addressed to tackle the problem. Sustainable Development Goals (SDGs). sively (i.e. pressure to eat, restrictive feeding style e 14 papers in the series are identified under and emotional feeding). Such practices may un- Conclusions four headings: dermine child self-regulation of intake, which is is collection of papers shows that nutrition- associated with increased risk of overweight. specific interventions, though essential for child Nutrition and child development Interventions development, are not sufficient for children to across the life-course reach their full developmental potential. is is A meta-analysis by Larson and Yousafzai (2015) Auduchon-Endsley et al (2016) found that ex- concludes that the mental development of children due to the many non-nutrition factors, such as cessive maternal weight and gestational weight under two years in low and middle-income coun- social determinants of health, parenting style gain was associated with poorer neurobehaviour tries (LMICs) is more strongly influenced by and early childhood stimulation that affect other in infants via hormonal pathways, highlighting their motor development than their growth status ECD dimensions (psychosocial, cognitive and the importance of peri-conceptual nutrition. resulting from postnatal nutrition interventions. educational). Poverty and social exclusion limit e positive association between breastfeed- is important finding underscores the need to the access of families to most, if not all, of these ing and academic ability at 12 years of age was integrate child psychosocial stimulation with nu- factors. Multi-sector programmes need to confound to be independent of socioeconomic trition as part of ECD interventions. sider including responsive parenting (including status and parenting behaviours, according to responsive feeding), learning stimulation, edu- e Baby-Friendly Hospital Initiative (BHFI) a prospective study by Huang, Vaughn and Kre- cation and social protection, in addition to Ten Steps were found to have a positive impact mer (2016). health and nutrition. Programme scale-up by- on short, medium and long-term breastfeeding governments to adress multiple factors in an Crookston et al (2011) found concurrent outcomes, with a dose-response relationship be- integrated way is crucial. Research is needed to stunting (stunted at 4.5-6 years of age) to have tween the number of BFHI steps women are ex- better understand if and how childhood obesity a greater impact on cognitive skills than early posed to and breastfeeding outcomes (Pérez-Es- affects the different dimensions of ECD. stunting (6-18 months of age) in Peruvian chil- camilla et al, 2016). Such findings have major im- dren participating in the Young Lives study. plications for ECD, since strong and consistent All references and papers are free to access on- Another cohort study in Malawi found that evidence supports the impact of breastfeeding on line at onlinelibrary.wiley.com/journal/ improved height gain between two and 15 a child’s intellectual development, an effect which 10.1111/(ISSN)1740-8709/homepage/virtu- years of age, but not between birth and two carries on into adulthood (Victora et al, 2016). al_issue_integrated_early_child_development ...... 菀菀 Field Article ......

Special thanks to the donors who funded this work: USAID’s Oﬃce of U.S. Foreign Disaster Assistance (OFDA); particularly Mark Phelan, Erin Boyd, Sonia Walia and Jonathan Hamrell, and the Children’s Investment Fund Foundation (CIFF); particularly Claire Harbron. anks to MSF-France and MSF-Spain for sharing data and to IRC, ACF- Combined protocol for USA, ACF-UK and the London School of Hygiene & Tropical Medicine colleagues for their collaboration and input during the development of this

SAM/MAM treatment: Vluchteling Torfinn/Stichting Sven work, particularly Angeline Grant, Bethany Marron, Lara Ho, Silke Pietzsch, Ruwan Ratnayake, Viddah Owino, Bijoy Sarker, Sophie Woodhead, Saul Guerrero, Amy Mayberry, Kerstin Hanson, Nuria Salse, Candela LaNusse, The ComPAS study Stien Gijsel and Severine Frison. anks to WFP and UNICEF for their support and guidance to ComPAS, particularly Saskia de Pee, Britta Schumacher, Lynnda Kiess, Dolores Rio, By Jeanette Bailey, Rachel Chase, Marko Kerac, André Diane Holland, Grainne Moloney and Tewoldeberha Daniel. Briend, Mark Manary, Charles Opondo, Maureen Gallagher and Anna Kim A more detailed version of this article will be prepared for publication in a peer-reviewed journal. Jeanette Bailey is the Project Director for ComPAS, based at the International Rescue Committee (IRC) Location: Chad, Kenya, Yemen, Pakistan, South in New York. She has an MSc in Public Health Sudan. Nutrition and is undertaking her PhD at the London School of Hygiene & Tropical Medicine. She What we know: Different protocols, products and service has more than 10 years’ experience of working in systems are used to treat severe and moderate acute nutrition programmes in humanitarian contexts. malnutrition, which complicates management of the conditions. Dr Rachel Chase received her PhD from the Department of International Health at Johns What this article adds: Stage 1 of the three-year Combined Hopkins Bloomberg School of Public Health. She Protocol for Acute Malnutrition Study (ComPAS) currently works as a qualitative and quantitative retrospectively analysed treatment data (growth, energy data analyst for universities and non-governmental requirements) from acutely malnourished children to develop organisations. (by expert committee) a simplified MUAC-based dosing chart Dr Marko Kerac is a lecturer in Public Health to treat both SAM and MAM (Combined Protocol). The Nutrition and the course director for the MSc in study found that growth trends in MUAC mirror those of Nutrition for Global Health at the London School of proportional weight gain during treatment. Rates of gain in Hygiene & Tropical Medicine. He is a medical MUAC and weight slow with increasing MUAC and as they doctor with a PhD in nutrition and many years of do, proportional energy needs decrease. Total energy needs of experience in leading research on malnutrition in 95% of all children with a MUAC <125mm can be met with developing countries. 1,000 kcals/day. Given this, a Combined Protocol is proposed Dr André Briend is an Adjunct Professor in the that admits children with MUAC<125mm and/or oedema Department of International Health, University of and treats as follows: MUAC <115mm - 2 sachets RUTF/d; Tampere and Affiliated Professor in Child Nutrition MUAC 115mm- <125mm -1 sachet RUTF/d). The next phase at the Department of Nutrition, Exercise and Sports of ComPAS aims to examine the effectiveness and cost- at the University of Copenhagen. He is a medical effectiveness of this simplified protocol. doctor with a PhD in nutrition and has more than 30 years of experience in research in paediatric nutrition in he Combined Protocol for Acute Malnutrition Study (ComPAS) developing countries. aims to simplify and unify the treatment of uncomplicated Dr Mark Manary is the Helene B. Roberson severe and moderate acute malnutrition (SAM/MAM) for chil- Professor of Paediatrics at the Washington dren aged 6-59 months into one protocol in order to improve Tthe global coverage, quality, continuity of care and cost-effectiveness of University School of Medicine in St. Louis. He is a medical doctor with many years of experience acute malnutrition treatment in resource-constrained settings. Building leading research on the treatment of acute on a number of studies (see Box 1), the Combined Protocol proposes to malnutrition. use only one product (ready-to-use therapeutic food (RUTF)), at doses tested to optimise growth and minimise cost at each stage of treatment. Dr. Charles Opondo is a Research Fellow at the Admission, progress and discharge will be assessed using mid upper arm London School of Hygiene & Tropical Medicine, circumference (MUAC) and oedema only. It is hypothesized that this ap- and a Researcher in Statistics and Epidemiology at proach will eliminate the need for separate products/infrastructure/ad- the University of Oxford. He is a pharmacist with an ministrative procedures for MAM treatment; enable earlier treatment of MSc and PhD in Medical Statistics from the LSHTM. cases before deterioration into more costly SAM treatment; enable better continuity of care; and lead to more positive community perceptions of Maureen Gallagher is the Senior Nutrition & Health the programme. Advisor for Action Against Hunger U.S., based in ComPAS began in October 2014 and completed its first stage of New York. She is a public health specialist with an secondary data analysis in January 2016. e second stage will consist of MSc in Social Policy and Planning, specialising in a multi-country cluster randomised trial in two countries and is expected health policy. She has been working in nutrition programming for the last 15 years in Niger, East to be completed by December 31, 2017. It is guided by a scientific Timor, Uganda, Chad, DRC, Burma, Sudan and Nigeria. committee of global experts in paediatrics and nutrition and comprised of partnerships between the International Rescue Committee (IRC), Anna Kim is a Senior Health Communications and Action Against Hunger-USA (AAH-USA), Action Against Hunger-UK Advocacy Officer at the IRC in New York. She has (AAH-UK) and the London School of Hygiene and Tropical Medicine an MA in International Relations and Journalism ...... 菀菀 Field Article ......

What is known? Research Box 1 underpinning ComPAS retained in the analysis, ranging from 75% in Method for objective 2: Calculate energy Kenya to 90% in Chad. Reasons for exclusion requirements by MUAC category The current SAM treatment protocol bases included uninterpretable or unfeasible data that Daily energy needs were estimated as: limited interpretation of individual course of RUTF dosage on 175-200 kcal/kg/day until Current weight (in kg) * resting energy needs recovery. children are discharged as cured. However, (82 kcal/kg) + weight gain (in grams) * energy research indicates food intake drops To balance the contributions of each of the costs of weight gain (5 kcal/g) (FAO, 2001) (Ashworth, 1969) and growth rate (weight five countries in the analysis when using local and MUAC-based) slows (Goossens et al, Changes in energy needs were calculated for polynomial estimation (described below), 1,300 2012) towards the end of treatment. Similar each child as kcal/day as per the above formula cured/death/defaulter results have been visits were randomly selected from each country and as kcal/kg weight. Both values are reported found where RUTF dosage was reduced at for a total of 6,500 visits (from, at most, 2,798 by MUAC at last visit. As an example, consider the end of SAM treatment (Cosgrove et al, children) in a sub-sample used for the visual a child who weighed 7.1 kg, had a MUAC of 2012); this observation is being further analysis of growth. is visual analysis of the 116mm on their 5th visit to the clinic, and explored through ACF research . A recent local polynomial estimation of growth by MUAC weighed 7.4 kg on their 6th visit 7 days later. trial in Sierra Leone suggests that an at last visit guided the decision to assess energy is means that the child gained, on average, integrated SAM/MAM programme using needs over ranges of MUACs at last visit in 42.9 g in weight per day between visits. To esti- RUTF had more favourable outcomes on meaningful but theoretical groups. mate the child’s daily energy needs to achieve coverage and is an acceptable alternative to standard treatment (Maust et al, 2015). Method for objective 1: Assess rate of MUAC that growth, we calculate: and proportional weight gain and energy 7.1 kg * 82 kcal/kg + 42.9 g * 5 kcal/g = 796 kcal. requirements of children and valuate (LSHTM). It is funded by USAID’s Office of Because the child’s MUAC was 116mm at their differences in the response to treatment 5th visit, this energy need estimate is reported U.S. Foreign Disaster Assistance (OFDA) and Using local polynomial smoothing, we visually Children’s Investment Fund Foundation (CIFF). along with other children’s calculated energy assessed the relationship between: needs who had a MUAC of 116mm at their Stage 1 of ComPAS retrospectively analysed (1)One-week MUAC growth (mm); and prior visit. treatment data from acutely malnourished children (2) Proportional weight gain (g/kg/day) compared aged 6-59 months to assess growth trends and to last-measured MUAC among children Method for objective 3: MUAC dosage table energy requirements and develop a simplified discharged as “recovered”. An expert scientific committee reviewed the results of objectives 1 and 2 and proposed a dosing chart based on MUAC. Preliminary findings One-week MUAC growth was calculated as the MUAC/RUTF dosage table that would cover are summarised in this article; a more detailed difference between two MUAC measurements the total energy needs of >95% of children aged final analysis is planned for future peer-reviewed when a child’s visits are one week apart. When 6-59 months with a MUAC <115mm, and half publication. Further initial findings, Figures 1-4 a child’s visits were recorded as being two weeks the energy needs of >95% of children aged 6-59 and Table 3 are available online at: apart, the difference between the first and second months with a MUAC 115-<125mm. http://www.ennonline.net/fex/53/thecompasstudy visit MUAC is divided by two to estimate weekly Objectives MUAC growth. Proportional weight gain was Results calculated as the weight gain (in grams) divided e objectives of Stage 1 of ComPAS were to: Growth trends in MUAC mirror those of by weight at last visit (in kg) divided by number 1) Assess rate of growth and proportional weight gain and rates of MUAC of days since the last visit prior to the reference a. Calculate energy requirements for ob- and weight gain slow with increasing MUAC visit(hereaersimplyreferredtoasthe“last visit”). served growth in children recuperating Amongst children with similar MUACs at a in Outpatient erapeutic Programmes is analysis was performed for all data to- given visit, MUAC and proportional weight (OTPs) and Supplementary Feeding Pro- gether (unweighted), by region (Africa and gain show roughly the same growth trend. grammes (SFPs); Asia), by country, and by age group. Except Proportional rate of growth tends to be lower b. Evaluate differences in the response to when compared by country, reported values for children with higher MUACs, and rates of treatment according to geography, age, and figures reflect results from the n=6,500 sub- growth appear to plateau over ranges of anthropometric status on admission, and sample described above. MUACs (see Figure 1 online). treatment outcome; 2) Calculate energy requirements by MUAC category; and Table 1 Summary of data provided by three agencies from five countries 3) Propose a physiologically appropriate Country Source Total patient Admitted to Admitted to Admitted with Admitted with (organization) count OTP facility SFP facility SAM MUAC or MAM MUAC or dosage table based on MUAC that could be WHZ* WHZ** used in a simplified and unified protocol. Yemen (IRC) Patient registers 1,099 315 784 317 782 Method Kenya (IRC) Patient cards 1,685 421 1,260 527 1,158 A secondary analysis of data from children re- Chad (IRC) Patient cards 2,054 639 1,415 529 1,525 covering from SAM in OTP and from MAM in Pakistan (ACF-USA) Patient cards 2,619 551 2,068 661 1,958 South Sudan Patient 2,613 2,613 0 2,407 162 SFP programmes was used to evaluate growth (MSF-France) database trends in response to treatment, using registration TOTALS 10,070 4,539 5,527 4,441 5,585 book/patient card data from the following pro- * SAM defined as MUAC < 115mm and/or WHZ <-3z grammes and countries: ** MAM defined as MUAC 115-< 124mm and/or WHZ-3- <-2z • International Rescue Committee (IRC): Chad, Kenya, Yemen. Table 2 Counts of patients excluded from the analysis by country • Action Against Hunger-USA (AAH-USA): Pakistan. Kenya Pakistan Chad Yemen South Sudan Total • Médecins Sans Frontières-France (MSF- Patient retained in analysis 1,259 2,260 1,849 853 2,012 8,233 France): South Sudan. 75% 86% 90% 78% 77% 82% Patient removed from analysis 426 359 205 246 601 1,837 Data from 10,070 acutely malnourished children 25% 14% 10% 22% 23% 18% between the ages of 6 and 59 months were avail- TOTALS 1,685 2,619 2,054 1,099 2,613 10,070 able (see Table 1); 8,233 were retained for analysis Note on Table 2: Most patient from each country were retained in the analysis, ranging from 75% in Kenya to 90% in Chad. Reasons (Table 2). Most patients from each country were for exclusion included uninterpretable or unfeasible data that limited our ability to interpret a patient’s course of recovery ...... 菀菀 Field Article ......

No significant difference was observed in is protocol remains in line with globally ac- 115mm would have at least 111% of their energy growth trends across MUAC at last visit by age cepted practice, with children recovering from needs covered by the protocol. group (under two years and over two years) or SAM receiving enough therapeutic food to cover Consistent with the design, 95% of children by stunting status (greater/equal to or less than their total energy needs (as a replacement for with 115mm-< 125mm would have 49% or height for age (HAZ) <-2 z-scores). the family diet), whereas children with MAM more of their energy needs covered by the pro- receive a food supplement to complement their posed protocol, with a median of 74% of their When comparing children enrolled in pro- family diet. Most SFP protocols provide 500- energy needs covered. In both Africa and Asia, grammes in the three African countries (South 550 kcal/day of ready-to-use supplementary this simplified dosage protocol meets or exceeds Sudan, Chad and Kenya) and children enrolled food (RUSF). e advantage of using one product the vast majority of children’s energy needs in programmes in the two Asian countries is simplicity (currently procurement of RUTF when children have MUAC < 115mm and is (Yemen and Pakistan), a notable difference in and RUSF involves separate UN agencies) and aligned with the current practice of SFP pro- weekly MUAC gain is observed between 111mm physiological appropriateness, considering acute grammes of providing at least 50% of children’s and 123mm MUAC at last visit (1.4 mm vs 0.7 malnutrition on a continuum of severity rather energy needs when children have a MUAC be- mm). New plateaus in MUAC gain might be than as separate SAM/MAM conditions. seen at 115mm and 126mm among children in tween 115-<125mm. When tested in a theoretical comparison Africa, whereas only one new plateau appears Supporting figures and tables for results are (Table 3 online), the protocol performs as de- to form among children in Asia over MUAC at available online at: www.ennonline.net/fex/spe- signed (i.e. meets the total energy needs for last visit, starting at around a MUAC of 110mm cific reference. (see Figure 2 online). >95% of children with a MUAC <115mm, and meets approximately half the energy needs for Conclusion As the rates of MUAC and weight gain slow, >95% of children with a MUAC 115-<125mm) is study considered the rate of weight and proportional energy needs decrease for all major sub-divisions of children (by sex, MUAC gain and energy needs of children with Comparisons of MUAC and proportional weight country, continent, weight and admission type). acute malnutrition as defined by MUAC status. gain to MUAC at last visit indicate that average Of note: Our findings concluded that two 92g sachets of proportional energy needs (that is, energy needed • At 95% of visits, children with MUAC < RUTF (1,000 kcal) meet the total energy require- per kg of weight to achieve observed growth) 115mm in the specified category have 100% ments for >95% of children with a MUAC<115mm, follow a similar step-down pattern (see Figure of their energy needs covered by two sachets and one 92g sachet of RUTF (500 kcal) meets 3 online), although total energy needs increase of RUTF (1,000 kcal) per day. Two categories half the energy requirements for >95% of children due to greater total body weight. Among children of children fall slightly short of this goal: with a MUAC of 115-<125mm, and serves to with MUAC <125mm, the children with the children aged 25 months or more (93%) simplify and streamline the treatment to be greatest energy needs to achieve observed growth and children who weigh 8.0kg or more tested in a combined protocol. are those with the lowest MUACs; approximately (83%). Even in these two groups, only at 5% 150-160 kcal/kg/day would be enough to support of visits do children have less than 96% of e next phase of ComPAS aims to examine the growth observed in 95% of visits among their caloric needs covered by two sachets the effectiveness and cost-effectiveness of this children with the lowest MUAC. In these data, of RUTF per day. simplified protocol. Stage 2 will pilot the com- energy needs never exceed 190 kcal/kg/day (see • At 95% of visits, children with a MUAC of bined protocol in a cluster randomised controlled Figure 3 online). 115mm -< 125mm have 50% or more of non-inferiority trial in two countries to assess their total energy needs met by the provi- the effectiveness of the combined protocol Total energy needs of 95% of all children sion of one RUTF sachet (500 kcal) per day. against the standard protocol (OTP + SFP) in with a MUAC <125mm can be met with In both Asia and Africa, we estimate that terms of recovery (with enrolment and discharge 1,000 kilocalories a day 49% of total energy needs or more are met based on MUAC), coverage, length of stay, and e 95th percentile line indicates the number of at 95% of visits. Children aged 25 months average daily weight gain and weekly MUAC kilocalories that would be sufficient to cover the or over and children who weigh 8.0kg or gains. A comprehensive cost-effectiveness analysis total energy needs of 95% of children with 100mm more again fall short of this goal, but not by will be included as part of the field trial. ≤ MUAC < 115mm, 115mm ≤ MUAC < 125mm, a startling amount: only 5% of children aged For more information, contact: Jeanette Bailey, or 125mm ≤ MUAC ≤ 140mm. Minor differences 25 months or more and children who weigh email: [email protected] were observed between estimated energy needs 8.0kg or more have 40% and 42% respec- for children in Africa and Asia when MUAC was tively (or fewer) of their energy needs below 115mm (909 kcal in Africa vs 731 kcal in covered to achieve observed growth. How- References Asia), and no practical difference when 115mm ever, the provision of RUTF 500kcal per day ≤ MUAC < 125mm (1,013 in Africa, 1,011 in matches the current global MAM manage- Ashworth A. Growth rates in children recovering from Asia) (see Figure 4 online). protein-calorie malnutrition. British Journal of Nutrition. ment practice of providing 500 kcal of (1969), 23,835 RUSF per day, so the same gap exists with MUAC dosage table Goossens S, Bekele Y, Yun O, Harczi G, Ouannes M, e ComPAS expert panel met to review these the existing SFP protocol. e nutrient Shepherd S (2012). Mid-Upper Arm Circumference Based results from January 26-27 2016. ey agreed compositions of RUTF and RUSF are not Nutrition Programming: Evidence for a New Approach in exactly the same (RUTF has more dairy Regions with a High Burden of Acute Malnutrition. PLoS that MUAC was a suitable alternative to weight ONE 7(11). to determine the dosage of RUTF as children and RUSF has a higher content of macro- minerals, important for linear growth), but Cosgrove N, Earland J, James P, Rozet A, Grossiord M, progress through treatment. e Combined Pro- Salpeteur C. Qualitative review of an alternative RUTF has been proven effective in the tocol will admit all children who have a treatment of SAM in Myanmar. F. Exch. [Internet]. treatment of MAM (Maust et al, 2015). MUAC<125mm and/or oedema, and treat them 2012;42:6. Available from: www.ennonline.net/fex/42/qualitative according to the following simplified dosage Overall, 97% of children with MUAC < 115mm Maust A, Koroma A, Abla C, Molokwu N, Ryan K, Singh L, protocol: in the observational data would have their total Manary M. Severe and Moderate Acute Malnutrition Can • Children with a MUAC <115mm or oedema energy requirements to achieve observed growth Be Successfully Managed with an Integrated Protocol in (+) to receive two sachets of RUTF per day met or exceeded by the proposed protocol. e Sierra Leone. Journal of Nutrition. 2015. (1,000 kcal); median percentage of their energy needs covered FAO. Food and Agriculture Organization. Human energy • Children with a MUAC 115mm- <125mm would be 170% (i.e., they would receive 70% requirements: Report of a Joint FAO/WHO/UNU Expert Consultation. FAO Food Nutr. Tech. Rep. Ser. [Internet]. to receive one sachet of RUTF per day (500 more calories than needed to achieve observed 2001;0:96. Available from: kcal). growth), and 95% of children with MUAC < www.fao.org/docrep/007/y5686e/y5686e08.htm ...... 菀菀 Field Article ......

Location: Yemen What we know: Emergency response in fragile state contexts is complex; Yemen is currently in a state of acute crisis against a backdrop of long-term political and nutritional volatility. What this article adds: A three-year Save the Children programme in Yemen was designed to strengthen household resilience and improve infant and young child feeding (IYCF) and care and hygiene practices in an insecure (though stable) context. Two years of programming involved a food-for-assets scheme (vouchers in exchange for community-identified assets development) and mother-to-mother support groups. Community feedback mechanisms and impact monitoring were established. Communities reported high coverage of benefits from roads and water projects (assets). Deterioration to a crisis situation in year three led to needs reassessment and adaptation to an unconditional voucher programme that served almost twice as many Beneficiaries on the beneficiaries compared to the conditional transfers. Household Dietary site of redemption Diversity Score rose and Household Hunger Score fell. The electronic food- voucher programme, established in the community assets scheme, was key to Adapting a the feasibility of scale-up. resilience Context community-level resilience through food-for- In 2013, the United States Agency for Interna- asset (FFA) activities. e second IR focused improvement tional Development (USAID) Office of Food on the adoption of key IYCF, care and hygiene for Peace (FFP) provided three years of funding practices in the community. to Save the Children International (SCI) to e project targeted a part of the country programme implement a programme with the objectives where communities were largely rural and scat- of strengthening household resilience and im- tered across mountain tops and valleys, with in conflict: proving infant and young child feeding (IYCF) limited market access. Most households relied and care and hygiene practices in Dhamar and on various seasonal labour options for income, Sana’a governorates. e original programme supplementing these incomes with the sale of strategy sought to layer and integrate activities small animals and/or support from the govern- Experiences so that the short-term food security needs of ment social protection programme. e project vulnerable households were met with conditional sought to work with 150 communities over three food vouchers, while establishing long-term years. To optimise operations, clusters of villages from Yemen resilience through rehabilitating or improving and households took part in asset-improvement community-level assets and improving IYCF By Mustafa Ghulam and activities for six months, aer which the pro- practices at the community level. Mohammed H Alshama’a gramme would move on to another village. In However, with the outbreak of fighting in its first two years, the FFA programme benefitted Mustafa Ghulam is a March 2015, the project was forced to adapt to 7,350 households and built or rehabilitated 436 Food Security and a rapidly changing context. As a result, the community assets in Dhamar and Sana’a. But in Livelihoods programme adjusted its programme objectives the third year alone, the programme drastically Progamme Manger and activities to meet immediate humanitarian ramped up operations and managed to nearly with Save the needs. is article recounts how a resilience- double the number of households served. Children, based in building programme successfully adapted to a Yemen. He has 20 rapidly emerging humanitarian crisis. IYCF and hygiene-promotion activities were years of experience in programme design expected to continue across all programme areas and implementation in both natural and Programme rationale and for the whole three years of the programme. man-made disasters. design e programme also organised training for Mohammed When the programme was designed in 2013, Ministry of Public Health and Population staff Alshama’a is MEAL Yemen was facing a different set of challenges (MoH) on referral systems and nutrition services Technical Advisor to the one it faces today. While the political at health facilities. With the support of the with Save the and security climate was still volatile and MoH, SCI established 169 mother-to-mother Children, based in pockets of humanitarian need existed in the support groups (MTMSGs) in target villages. Yemen. Mohammed country, development policies were focused ese are groups of women helping new mothers has extensive on resilience-building programmes. e focus care for their children through model-optimal experience in emergency and development of many development agencies and funders breastfeeding practices and sharing information programming in different contexts. He is was on solving issues of dwindling water re- and experiences, and by offering support to experienced in programme design, sources, child health, nutrition and education other women in an atmosphere of trust and re- programme monitoring, research and and seizing opportunities for livelihood security. spect. Group leaders create awareness among assessment in complex emergency In that context, this programme was originally members about exclusive breastfeeding practices responses in fragile state contexts. designed with two immediate results (IR) in and complementary feeding for infants and The authors would like to acknowledge mind. e first IR focused on improvement of young children during regular meetings...... Karl Frey, Save the Children and Brian Kriz, Consultant for their technical input and contributions to this article. 菀菀 Field Article ......

e CRCs were trained on targeting criteria Profile of participants in the and generated lists of beneficiaries that met the Table 1 FFA project criteria developed by SCI (see Box 1). SCI would Description 2014 2015 audit the list by randomly selecting 15% of Governorate Male Female Male Female households on each list to visit and verify eligi- Dhamar 2,862 800 2,918 511 bility. If there was evidence of systematic errors Sana’a 154 34 69 2 in targeting, CRCs were required to start the process again. In addition, beneficiary selection Total 3,016 834 2,987 513 criteria were displayed throughout the village, which also helped make the process transparent. vendors in local markets. ese vendors were vetted and entered into an agreement with SCI Targeting vulnerable households to participate prior to the distribution. In the second and in the FFA project was conducted with the aid third years, the programme took part in a pilot of village poverty-ranking indicators in addition MasterCard e-voucher solution. is provided to SCI-developed criteria. Roughly 80% of house- a chip-enabled card loaded with a token that al- holds were selected from each village. Uncon- lowed beneficiaries to access the same prede- ditional transfers were provided to those who termined food basket as the paper vouchers were very poor and had no labour to enable from local vendors. Vendors were equipped them to participate in the asset-improvement with and trained in the use of tablets and dongles project. About 10% of the total beneficiary list that worked much like a point-of-sale system. Vocational skills trainees was made up of this group. Typically, women Once beneficiaries satisfied their work require- with their kits from female-headed households did not work ments under the FFA programme, a token was on the FFA activities, instead sending male sur- deposited in their account that could later be rogates in their place, or were included in the exchanged with a vendor for their food items at Mobilisation and targeting unconditional food-assistance transfers. In some a time convenient to them. A back-end accounting e mobilisation and targeting process took cases, women assisted in providing food and system reconciled the token exchange, which place in partnership with district-level leaders. water during workdays. is practice was in informed quantity of payment to vendors. e It began by ranking districts based on vulnerability line with local traditions and customs. Roughly system was designed to work on or offline, criteria, including proximity to markets, income 18% of beneficiaries were women (see Table 1). though most of the time data was synched options, access to water and access to previous FFA and skills development offline. is consisted of SCI programme staff assistance. At the sub-district and village level, travelling to vendors to synchronize the trans- Assets built or rehabilitated by the programme another round of mapping, ranking and targeting action history with another device before re- were identified through broad-based community using the same set of criteria was completed turning to the field office to upload. e pilot meetings facilitated by CRCs and SCI staff. Each with local authorities and community leaders. started with 100 households and scaled up to asset-improvement project, which was endorsed e geographic and administrative targeting 6,050 households per month. If necessary, the by a majority of the participants and was in line process not only ensured that vulnerable com- e-voucher programme could add other tokens with the programme’s mandate, was documented munities were targeted, but also enabled com- with different vendors to meet the need of other in a village resolution. munity buy-in before the village and beneficiary programmes. selection process. One family member from each of the 7,350 With the support and guidance of CRCs, households was engaged in the asset-improve- Community Resilience Committees (CRCs) SCI engineers designed asset-rehabilitation spec- ment project. ese family members worked were formed in each village and acted as the ifications. Once the project’s specifications and for ten days a month (four hours a day) to primary interface between the programme and work plan were finalised, a bill of quantity de- receive a monthly food voucher for their family. the community. eir key responsibilities were tailing necessary materials and labour require- Many of the target population were rural, de- to advise on community-specific programme ments was signed with CRCs. While the asset pendent on local, temporary, seasonal incomes; decisions, identify target beneficiary households, project was underway, SCI engineers provided the asset work was another income strategy and communicate programme messages to the technical backstopping to the CRCs, who mon- available to them. e value of the voucher was community (i.e. work and distribution schedules). itored attendance and quality of work performed. designed to provide a food basket to cover ap- A Memorandum of Understanding (MOU) out- proximately 70% of an average-size family’s food lining roles and responsibilities was signed be- Quality monitoring needs and could be exchanged with vendors at tween SCI and CRC before the start of the as- To ensure programme quality, the SCI Moni- the local market at a time of their choosing. For set-improvement project. Village committees toring, Evaluation, Accountability and Learning some difficult-to-reach villages, vendors would included men, women and youth. CRCs were (MEAL) team followed the project and measured hold a market day at a designated distribution less involved with the IYCF activities, but helped progress against pre-identified output indicators. site in the village. e cash value of the voucher communicate the intention of this part of the e use of Indicator Performance Tracking was between US$66 and US$72, depending on programme to the community. Tables (IPTT) and Budget versus Actuals (BVA) the exchange rate and local commodity prices. management tools allowed the programme to Every registered household was entitled to six take corrective action when projects veered transfers, as per the design of the programme. FFA Beneficiary Targeting Criteria from their plans. Box 1 e six-month period of FFA activities coincided with the seasonal lean period, a time when in- Accountability to the beneficiaries was a key 1. Households with two or more children component of the SCI monitoring and quality under the age of two years come-earning activities are limited; therefore assurance system. It involved giving beneficiaries 2. Households with more than seven the effort required of participants to receive as- the opportunity to influence key programme members sistance added to income-earning strategies at 3. Households with no livestock a time when the household had excess time to decisions and highlight problems with pro- 4. Households with no or small parcels participate. gramme activities. In addition to participating (maximum 0.5 acres) of arable land in CRCs, beneficiaries could provide feedback 5. Female-headed households In the first year, the project utilised paper- to SCI on any aspect of the programme through 6. Households with a high number of school based commodity vouchers, which were ex- a complaints mechanism. is initially consisted dropouts changed for a predetermined food basket by of comment boxes, which were promoted during ...... 菀菀 Field Article ......

there was a limited flow of assessment information for decision-making purposes. Finally, field operations were challenged with shortages of fuel and other commodities and destabilisation of the Yemeni currency, the rial. Despite these barriers, rapid assessments were still able to take place in accordance with security advisories. Once gathered, information was compiled and disseminated in Yemen and Redememption of points Amman. Information was regularly shared within the United Nations (UN) cluster system. Field teams were frequently tasked with following up Figure 1 Beneficiary household caseload over three years on information related to their area of operation. Management provided remote technical back- 7,000 stopping and addressed all issues as quickly as Redesign 6,000 Conflict possible to ensure the programme moved forward. escalated operationalised 5,000 It was clear from the assessment information 4,000 that the programme would need to shi its 3,000 focus towards addressing immediate humani- 2,000 tarian needs and away from resilience-building activities. In order to adapt to growing food-as- 1,000 sistance needs and the changing operational 0 context, the community asset projects were dropped. It was determined that continuing the Jul-14 Jul-15 Jan-15 Jan-16 Jun-14 Jun-15 Oct-14 Oct-15 Apr-14 Apr-15 Apr-16 Feb-15 Feb-16 Sep-14 Sep-15 Mar-14 Mar-15 Mar-16 Dec-14 Dec-15 Nov-14 Nov-15 Aug-14 Aug-15 May-14 May-15 May-16 FFA portion of the programme would put staff and beneficiaries at risk. As a result, the programme was redesigned to scale up unconditional the community mobilisation process. In the coalition. As a result, market supplies quickly food assistance to meet the growing need. SCI third year, SCI introduced a national, toll-free dwindled, pushing food prices higher. planned to reach IDPs and local host communities hotline to the complaint mechanism that allowed to address their immediate food needs through beneficiaries another avenue to provide feedback. Aer the conflict began, Dhamar governorate was categorised as Integrated Food Security electronic voucher transfers. e resources saved Each method allowed a person to provide input by dropping the FFA component of the pro- Phase Classification (IPC) level 3 (crisis). Nearly anonymously if they so wished. ese mechanisms gramme allowed the beneficiary caseload to in- half the population in Yemen was food-insecure not only enabled SCI to deliver a quality pro- crease by about 75%; from 3,500 households prior to March, and the situation significantly gramme; they also empowered the communities per year to 6,050 households in the third year worsened as a result of the conflict. At the time to participate and address their concerns with alone. Figure 1 shows the number of households of writing, it is estimated that more than 21.4 the programme at any time. e complaint mech- that were assisted before and aer the decision million people, including three million IDPs, anism produced three key issues: inclusion errors, to change the design of the programme was are in need of humanitarian assistance in Yemen. request of information for date and time of dis- made, in consultation with the donor. tributions, and concerns about food quality. Be- Emergency food assistance became a top priority cause these mechanisms were in place, the SCI in the programme area. Cash transfers were considered, but the programme retained the e-voucher scheme because team could quickly learn about beneficiary com- e deteriorating situation in the second plaints and rapidly find a resolution to the issue. it was considered more appropriate with sharp and third year of the programme posed massive fluctuations in market prices, supply chain dis- In addition to complaint mechanisms, SCI operational challenges. First, the security situation ruptions and depreciation of the rial. To facilitate also conducted Post Distribution Monitoring required senior leadership for most international food assistance in the target programmes, SCI (PDM) surveys for all target villages. e surveys organisations to evacuate to Amman in Jordan, began to negotiate directly with national food inquired about beneficiary’s perception of the which slowed decision-making processes. Yemeni distributors to ensure local vendors were provided distribution process, security concerns, and staff were regularly forced to shelter in place with the required food and timely delivery. e knowledge of complaint mechanisms. Each and unable to visit programme areas due to programme continued to use the MasterCard PDM also measures the Household Dietary Di- safety concerns. With staff periodically immobile, system, which proved to be agile enough to versity Score (HDDS) and Household Hunger Score (HHS). In order to ensure quality in the delivery of programme outputs, SCI developed quality benchmarks that drew on international standards, such as Sphere, as well as the organisation’s global expertise. Regular field visits were conducted to measure the project’s performance against these standards. Adapting to a changing context With the outbreak of fighting in March 2015, Yemen faced large-scale displacement, civil conflict, food insecurity, high food prices, diminishing resources, and an influx of internally displaced persons (IDPs). In addition to airstrikes throughout the country, ports, which are crucial for im- porting key commodities such as wheat, cooking IYCF training - preparation of different types of food oil and petrol, were blockaded by the Saudi-led ...... 菀菀 Field Article ......

Beneficiaries recieving Year three beneficiary mean Boxplot of HDDS baseline vs food vouchers Figure 2 HDDS improvement during Figure 3 endline for year three the course of the beneficiaries unconditional assistance 12 . 12 10 . 10 . 8 8 6 6 HDDS

HDDS 4 4 2 2 0 0 Jul Jan Jun Apr Feb Mar Dec Baseline Endline May meet the demands of a rapid scale-up of benefi- sure and reduced vulnerabilities for the target able to link multiple communities to markets ciaries. In fact, having an established electronic households. and highways. Eighty-six per cent of those who food-voucher programme in place was key to were provided with some type of road asset saw It is important to note that each measurement the programme’s ability to scale up assistance. an improvement in travel time. All those who was taken with a new cross-sectional random received some type of water asset saw improve- sample of the beneficiary population; therefore Impact ments in agricultural and livestock production. some changes in mean HDDS between each rough paper and electronic vouchers, 13,400 Some beneficiaries asserted that working on round of measurements are likely due to sampling households (around 93,800 individuals) were community assets gave them an opportunity to variance. Additionally, the programme was able to receive wheat (50 kg), beans (12 cans), recognise the value of cooperation and that they unable to capture non-beneficiary HDDS scores cooking oil (4 litres) and rice (20 kg) on a monthly can replicate similar activities in the future. to understand the likely impact of the programme. basis for at least six months. Perhaps the most Finally, both hygiene and breastfeeding education Despite those limitations, a Welch approximation interesting insight from the programme endline were mentioned as an intervention with lasting test showed that mean HDDS between the base- survey is how household vulnerability and hunger effects; 77% of the respondents expect the line and endline were not equal: t (1074.4) = changed during the course of the programme. MTMSGs to continue to function1. Endline data showed that the mean HDDS, which 13.285; p = 0.001. e boxplot in Figure 3 shows is used as a proxy measurement of household so- the difference in the HDDS distributions between Conclusions cio-economic status, increased by 31% compared the baseline and endline. It is clear from this In March 2015, the conflict in Yemen forced to the baseline. Using the HHS, households with plot that the central tendency for the endline SCI’s USAID-funded, resilience-strengthening no or little hunger increased by 76%, while severe measurement of HDDS shied upwards and programme in Dhamar and Sana’a governorates hunger fell to zero. ese improvements in food- the variance was reduced. Levene’s test indicated to reassess beneficiary needs and adapt the pro- security outcomes came despite a major conflict the variance was not equal between the two gramme design to meet a growing humanitarian and disruptive markets. groups; p<0.001. crisis and changing operational environment. Key challenges during this period included a In the first two years, prior to the outbreak e mean HDDS trend throughout the third deteriorating security situation for programme of conflict, the community asset-improvement year of the programme clearly illustrates how staff and beneficiaries, rapidly increasing prices, projects contributed to increased access to water the emergency assistance supported beneficiary limited commodity supplies and devalued local assets, improved market access through repaired households during the course of the programme currency. Further, the outbreak in violence re- roads, and improved water harvesting through (see Figure 2). At the time of the baseline, mean quired senior management to evacuate the coun- repair of agriculture and rehabilitation of terraces. HDDS for the beneficiaries in the third year of try and limited field staff movement within op- More than 430 asset projects were successfully the programme was 3.88. While households re- erational areas. implemented (see Table 2). ceived food assistance (January to June 2016), In the face of these challenges, there was still HDDS scores temporarily elevated to between During years one and two of the programme, a window of opportunity to adapt the programme 47% and 51% of the baseline. e endline HDDS 80% of year one beneficiaries and 95% of year to the context and provide much-needed food measurement, which took place one month aer two beneficiaries sampled indicated they benefited assistance. As a result, the community asset- the last distribution in July 2016, fell to 5.07. It from the community assets projects, especially improvement activities were replaced with an is unknown how far the HDDS has fallen since those related to water and road projects. Sur- emergency food-assistance programme that the end of the programme. While there is no prisingly, some beneficiaries from the third year served almost twice as many beneficiaries. Mon- clear cut-off for this measure, the increase in of the programme who were not in villages that itoring data collected throughout this period mean HDDS while households were receiving directly benefited from the FFA activities also showed a measurable increase in HDDS for assistance and some lingering effects of elevated reported that they benefited from the community target beneficiaries and a decrease in the HHS. HDDS aer the assistance stopped indicates asset-improvement projects from previous years. that the food assistance relieved economic pres- is most frequently happened when roads were Key to the programme’s success was the field staff’s willingness to leverage its experience and community network to mobilise and gear up Table 2 Assets improvement projects by year beneficiary selection. e use of MasterCard’s Assets improved Year 1 Year 2 Total electronic food-voucher programme in the first two years also provided the infrastructure that Rehabilitation of terraces (by village) 139 120 259 allowed for new activities to easily scale up to Road linkages established 2 18 20 meet the programme’s need. Water points established and rehabilitated 0 29 29 Road sections rehabilitated 8 73 81 For more information, contact: Mustafa Ghulam, Water-harvesting channels rehabilitated 2 12 14 email: [email protected] Surface water pools rehabilitated 2 31 33 1 While baseline and endline IYCF assessments were made, Total 153 283 436 different methods were used, which has limited comparison...... 菀菀 News ......

President of Turkey Recep Tayyip Erdogan and Secretary-General Ban Ki-moon pose with children during the closing ceremony of the World Humanitarian Summit, Istanbul, Turkey 2016. Location: Global

What we know: Inadequate resources are a severe and increasing constraint on humanitarian action in the face of increasing emergencies due to conflicts, natural disasters and disease. What this article adds: The ‘Grand Bargain’ is a package of reforms to humanitarian funding launched in May 2016 at the World Humanitarian Summit. It comprises 51 ‘commitments’ to make emergency aid finance more efficient and effective, endorsed by 34 agencies. It requires innovation, greater efficiencies, more resources and enhanced collaboration between existing and new partners. It is estimated to produce annual savings of US$1 billion within five years (5% of current spending). Both opportunities and limitations have been raised. ©World Humanitarian Summit ©World Grand Bargain: Reform or business as usual?

Summary of commitments1 and review2

Introduction 1. Greater transparency ments and oversight mechanisms”. There is ten- The ‘Grand Bargain’ is the name given to a pack- The pledge is to “publish timely, transparent, sion between donors wanting their grantees age of reforms to humanitarian funding, harmonised and open high-quality data on hu- to trim costs, and recipient aid agencies blaming launched in May 2016 at the World Humanitarian manitarian funding within two years”. The In- donor bureaucracy for adding to those costs. Summit. A group of 34 representatives of donors ternational Aid Transparency Initiative (IATI) Donors should ‘harmonise’ boilerplate grant and aid agencies (which together provide the data model is likely to be the agreed format. agreements. Aid agencies should commit to ‘lion’s share’ of global emergency aid funding) Several major donors already publish at least being more open about their real costs “by the produced 51 ‘commitments’ to make emergency some of their information in this format, which end of 2017” and meanwhile find savings from aid finance more efficient and effective. The should help accountability both upwards to sharing costs such as transport, logistics, infor- Grand Bargain is presented as a collective action the donor and downwards to aid recipients. mation technology (IT) and insurance. to address the shortcomings of under-resourced 2. More support and funding tools for local 5. Improve joint and impartial needs humanitarian response which requires innova- and national responders assessments tion, greater efficiencies, more resources and Only 0.4% of emergency funding currently goes Significant efforts have been made to strengthen enhanced collaboration between existing and directly to local and national operators, so the the quality and coordination of humanitarian new partners across the humanitarian ‘ecosystem’. target of 25% by 2020 is high. Southern NGOs needs assessments used for strategic decision- It identifies a need to move from the present will likely receive more funding, on better terms, making, but critics claim that aid agencies too supply-driven model dominated by aid providers but will not easily ‘shake off’ the sub-contracting often get to define the scale of the problem, to a demand-driven model more responsive to relationship with the United Nations (UN) agen- pick where they wish to intervene and set their the people being assisted. Commitments are cies and large, international, non-governmental price tag. The Grand Bargain tackles only a part packaged under ten measures/areas for reform. organisations (NGOs). of the problem of overlapping and duplicative It is estimated that the Grand Bargain agreement assessments; donors and aid agencies are to will produce annual savings of US$1 billion 3. Increase the use and coordination of cash- “provide a single, comprehensive, cross-sectoral, within five years, which equates with 5% of based programming methodologically sound and impartial overall current spending. There are no firm targets for the expanded use assessment of needs for each crisis to inform of cash, despite studies saying it is now beyond 3 strategic decisions on how to respond and fund A recent IRIN report suggests the package has 4 question that it works . According to the author, thereby reducing the number of assessments.” had a mixed reception. Some, like Dutch devel- the Grand Bargain text is contradictory: it claims opment minister Lilianne Ploumen, feel the bu- that “using cash helps deliver greater choice reaucracies involved did well to agree on so and empowerment to affected people and 1 much in a few short months, given the com- The Grand Bargain – A Shared Commitment to Better Serve strengthens local markets, but remains under- People in Need. Istanbul, Turkey. 23 May 2016. consultations. plexities of budgeting and contracting emer- utilised”, while at the same time calling for worldhumanitariansummit.org gency aid. Others point to a lack of more specific 2 Is the Grand Bargain a Big Deal? A deal to sort out emergency further research to better understand its risks actions tied into timelines and targets: “It could funding meets with a mixed response. By Ben Parker, Head and benefits. of Enterprise Projects, IRIN. www.irinnews.org/analysis/ be the Grand Bargain for business-as-usual 2016/05/24/grand-bargain-big-deal unless there are more specific actions” (Christina 4. Reduce duplication and management costs 3 Originally the Integrated Regional Information Networks, Bennett, Overseas Development Institute). The with periodic functional reviews IRIN left the United Nations in January 2015 to relaunch as author of the review outlines some opportunities The agreement states that “reducing manage- an independent, non-profit media venture. See www.irinnews.org/ and limitations around the ten key areas of re- ment costs depends upon reducing donors and 4 www.odi.org/projects/2791-humanitarian-cash-cash-trans form, including: aid organisations’ individual reporting require- fers-high-level-panel-humanitarian-cash-transfers ...... 菀菀 News ......

De-linking assessment from response, for ex- rise to US$1 billion a year5. The goal to reduce data in a common open format within two ample by commissioning independent assess- earmarking is worded without much promise years. Major reform on cash-based aid and ments, was proposed in earlier drafts but not of enforceability: “The aim is to achieve a global needs assessments did not materialise. included in the final text. target of 30% of humanitarian contributions The following donors and aid organisations endorse that are non-earmarked or softly earmarked by 6. A participation revolution: include people the Grand Bargain: 2020.” Measurable progress on this will depend receiving aid in making the decisions Australia, Belgium, Bulgaria, Canada, Czech Re- heavily on classifications of earmarking. which affect their lives public, Denmark, European Commission, Germany, The end customers of aid often have little choice 9. Harmonise and simplify reporting Italy, Japan, Luxembourg, The Netherlands, Norway, or influence in the services they get, and feedback requirements Poland, Sweden, Switzerland, United Kingdom, mechanisms so far have had little impact in The text puts more onus on the donors: “simplify United States of America changing programme delivery. The agreement and harmonise reporting requirements by the invokes two different sets of guidelines for this, end of 2018 by reducing [their] volume, jointly Food and Agriculture Organization of the United the Core Humanitarian Standard and the Inter- deciding on common terminology, identifying Nations (FAO), InterAction, International Committee Agency Standing Committee (IASC) Commit- core requirements and developing a common of the Red Cross (ICRC), International Council of ments to Accountability to Affected Populations. report structure”. Voluntary Agencies (ICVA), International Federation Donors will have to agree that programmes of Red Cross and Red Crescent Societies (IFRC), In- 10. Enhance engagement between can change as a result of community feedback, ternational Organization for Migration (IOM), humanitarian and development actors while aid agencies have to show how they in- Steering Committee for Humanitarian Response Combining emergency and development funds corporate it into their programmes. (SCHR), United Nations Children’s Fund (UNICEF), and agendas is a hot topic. The text addresses United Nations Development Programme (UNDP), 7. Increase collaborative, humanitarian, this: ‘it is about working collaboratively across United Nations Entity for Gender Equality and the multi-year planning and funding institutional boundaries on the basis of com- Empowerment of Women (UN Women), United Aid agencies often find themselves presenting parative advantage”. The general intent is broad: Nations High Commissioner for Refugees (UNHCR), similar programmes to donors year after year “use existing resources and capabilities better United Nations Population Fund (UNFPA), United that have no longer-term goals; a process that to shrink humanitarian needs over the long Nations Office for the Coordination of Humani- wastes time and effort. Most humanitarian find- term with the view of contributing to the out- tarian Affairs (OCHA), United Nations Relief and ing is issued on a 12-month cycle. The Grand comes of the Sustainable Development Goals Works Agency for Palestine Refugees in the Near Bargain target is for five countries to trial multi- (SDGs)”. This will need to be the focus not only East (UNRWA), World Bank, World Food Programme year planning and funding by the end of 2017. of aid organisations and donors, but also of na- (WFP) tional governments at all levels and civil society 8. Reduce the earmarking of donor and the private sector. The World Health Organization (WHO) will lead a contributions discussion on the Grand Bargain commitments Donors typically earmark funds to specific proj- Conclusion with its Member States. ects, but this can become wasteful and encour- According to the author, two of the ten areas age micro-management. The Grand Bargain covered – transparency and funding of local suggests that various types of pooled funding and national aid agencies – have gone further 5 mechanisms will expand; e.g. the UN’s Central 2015 CERF funding amounted to US$469,650,008. Source: than others. On transparency, the Grand Bargain www.unocha.org/cerf/cerf-worldwide/funding-sector/fund Emergency Response Fund (CERF) is likely to ‘group’ committed to publish their financial ing-sector-2015

Call for experiences on mothers measuring MUAC

Are you using the mothers measuring shown to cost less to implement than the tra- training of trainers. ALIMA. Available in Eng- mid upper arm circumference (MUAC) ditional CHW-led approach. lish (alima-ngo.org/empowering-mothers- prevent-malnutrition) and French (alima- approach or do you know someone who Since this evidence has been published, mul- ngo.org/fr/les- meres-meilleur-atout-pour- tiple implementers have adopted it world- is? If so, we want to hear from you! prevenir-la-malnutrition). wide. We would like to collect all the experiences to date from diﬀerent contexts: Alé et al (2016). Franck GB Alé, Kevin P.Q. Phe- how the evidence has been implemented, lan, Hassan Issa, Isabelle Defourny, Guillaume Action Against Hunger, in partnership with what works, and the challenges, supported Le Duc, Geza Harczi, Kader Issaley, Sani ALIMA, is compiling a lessons-learned docu- by case studies. This will be used to guide oth- Sayadi, Nassirou Ousmane, Issoufou Yahaya, ment detailing the use of this approach ers on how to implement the approach and Mark Myatt, André Briend, Thierry Allafort- worldwide, building on the existing evidence overcome any associated challenges. Duverger, Susan Shepherd and Nikki Black- (Alé et al, 2016) and guidance (ALIMA, 2016). well/Mothers screening for malnutrition by If you can contribute to this or know any- Evidence from Niger has shown that care- mid-upper arm circumference is non-inferior to one who can, please contact Eleanor Rogers givers are able successfully to measure MUAC community health workers: results from a at [email protected] by and are not inferior to community health large-scale pragmatic trial in rural Niger. November 15 2016. workers (CHW), with children being admitted Archives of Public Health (2016) 74:38. arch- to care earlier and requiring fewer hospitali- ALIMA (2016). Mother-MUAC. Teaching moth- publichealth.biomedcentral.com/articles/10. sations. Additionally, this approach has been ers to screen for malnutrition. Guidelines for 1186/s13690-016-0149-5

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Indonesian researchers involved in the AuthorAID: AuthorAid programme A global network for early career researchers from low and middle- income countries

By Jennifer Chapin

Jennifer Chapin is Programme Manager, Research and Communications at INASP, an international development charity based in Oxford, UK. INASP works with a global network of partners in Africa, Latin America and Asia to support individuals and institutions to produce, share and use research and knowledge. Projects are running in 28 countries. INASP

“…being an AuthorAID mentor goes beyond a conventional The mentoring system helps pair together to conferences are offered twice annually teacher-student relationship – it is experienced mentors with researchers who (www.authoraid.info/en/funding). a really stimulating and need support at any stage of their writing • Over the last year, AuthorAID has focused project. It is easy to make contact with menon supporting women in research to ad- worthwhile learning process for tors or mentees: we have a ‘find a researcher’ dress gender inequalities they face in both mentee and mentor” search facility and our mentoring dashboard progressing in their careers. AuthorAID Dan Korbel, UK will automatically suggest suitable ‘matches’ has recently produced a Gender Main- based on subject and skills – rather like a dat- streaming in Higher Education Toolkit esearchers in the developing world ing website for researchers! (available online soon), which is hoped have long been under-represented will be a valuable resource for universities Fifteen of the most common types of sup- Rin published research. This is not a and institutions tackling gender inequal- port needed by new mentees include: huge surprise. They face many of ity in academia. • Writing the same intense pressures to publish as aca- • AuthorAID also provides training materi- • Article planning demics in the UK, yet they lack access to the als and resources free of charge online. • Proofreading fundamental resources needed to communi- Resources are available in English, Arabic, • Grant proposal development cate their research: information and training, Chinese, French and Spanish • Language editing or proofreading writing support and mentorship. How can (www.authoraid.info/en/resources). support they manage the pressure of publishing rig- • An increasing number of our members • Career mentoring orous scientific research and communicating also provide informal mentoring, advice • Theses and dissertation writing findings in a way that meets publisher expec- and support by replying to questions • Literature reviews tations? about publishing on the Discussion • Study design Group, now numbering over 2,300 • Statistics In order to address some of these issues, the members. AuthorAID programme (www.authoraid.info) • Presentation planning was launched in 2007 by the Oxford-based or- • Responding to peer review Whether you’re an early career researcher in ganisation INASP (www.inasp. info) to support • Publication ethics a developing country who could benefit from researchers in low and middle-income coun- • Technical reports support and mentoring, an established aca- tries to publish and communicate their work. • Dealing with the publishing process demic with a strong track record who wants It also serves as a wider global forum to dis- to give something back to the research com- Over the years, AuthorAID has amplified its cuss and disseminate research. munity, or are just keen to get involved in scope to provide support to researchers in a some stimulating discussions, you can easily number of other ways: One of the cornerstones of AuthorAID is a register now on the AuthorAID website at • One primary aim is to embed research popular online mentoring system (www.au- www.authoraid.info. thoraid. info/en/mentoring) that allows vol- writing skills training in universities and unteer mentors to use their crucial skills and re-search institutes, with the objective of “My experience with AuthorAID experience to guide less experienced re- building local training capacity face-to- searchers through the challenges of publish- face and online. We are currently working has been great! rough the ing and communicating their research. Since with ten partners in four countries: AuthorAID website, I met my the platform was set up in 2008, requests for Ghana, Tanzania, Sri Lanka and Vietnam. mentor, a PhD student at the mentoring assistance have intensified, and • In recent years, AuthorAID has launched University of Michigan. She has mentors are in demand. The platform is open free Massive Open Online Courses been very dedicated in offering to researchers from all subject areas and cur- (MOOCs) in research writing. So far, these rently comprises almost 2,000 active mentors courses have attracted over 2,800 re- me guidance on how to improve and mentees. Support is available in a num- searchers from 76 countries my writing skills” ber of languages, including English, French (www.authoraid.info/en/e-learning). Rhoune Ochako, Kenya and Spanish. • Small grants to host workshops and travel ...... 菀菀 0

News ...... Accelerating the Girls at a clinic in scale-up of Bossaso, Somalia treatment for severe acute malnutrition

By Saul Guerrero, Erin Boyd, Claire Harbron, Diane Holland, Abi Perry and Sophie Whitney

Saul Guerrero is the Director of Nutrition at Action Against Hunger UK (ACF UK). Prior to joining ACF, he worked for Valid International supporting UN agencies, NGOs and national governments in the design, implementation and evaluation of WFP/Laila Ali community-based management of acute malnutrition interventions in over 16 countries in Africa and Asia. In 2012 he co-created the Coverage Monitoring Network he last decade has been one of the most exciting in the global ef- (CMN), an inter-agency initiative to evaluate the reach of forts to treat Severe Acute Malnutrition (SAM) at scale. In that pe- Triod, we have seen a community-based model to treat SAM go nutrition services worldwide. from a small-scale but innovative pilot to a large-scale intervention Erin Boyd is a Nutrition Advisor and in over 70 countries worldwide. We have seen the availability of revolution- instructor with experience in emergency ary, ready-to-use therapeutic foods (RUTF) increase, with reductions in cost nutrition response and covers policy, and a wider range of producers at global, national and regional levels. This programme management, monitoring and has led to a rise in the number of SAM children accessing life-saving treat- evaluation, coordination and operational ment worldwide from just over one million in 2009 to over three million in research. She has worked in nutrition 2014. And all of these changes have occurred against a backdrop of increas- surveillance, emergency nutrition ing political support for addressing malnutrition worldwide, through plat- interventions, and coordinated responses in locations such as forms like the Scaling-Up Nutrition (SUN) movement and the formal inclusion Darfur, Ethiopia, Haiti and Pakistan. She has also worked with of wasting as a key target in both World Health Assembly (WHA) and Sus- donors and at the Friedman School of Nutrition Science and tainable Development Goals (SDG). Policy at Tufts University. When we take stock of these and other achievements, we feel optimistic Claire Harbron is a Manager at the Children’s about the future. But we also know that the job is far from over. Nutrition- Investment Fund Foundation. She oversees sensitive investments and programmes are on the rise, yet the evidence base CIFF’s strategy and programme portfolio on for the prevention of acute malnutrition, in particular, remains limited and the prevention and treatment of severe acute often inconclusive, hampering efforts to effectively link prevention and treat- malnutrition. ment efforts. The number of children accessing treatment has tripled in just five years, but is beginning to stagnate; today only one in every five children suffering from SAM has access to treatment, leaving the large majority of Diane Holland is Senior Nutrition Advisor at those affected at increased risk of mortality from associated illnesses. UNICEF New York and has a focus on scaling up programming to treat severe acute This has to change, and the nutrition community, together with col- malnutrition and addressing nutrition leagues across health and other sectors, needs to do whatever it takes to en- emergencies. She has over ten years’ sure that a higher proportion of children have access to effective treatment. experience in public nutrition, including No single approach or solution will be sufficient and critical challenges across support to nutrition surveillance in Sudan, nutrition programming, policy and financing will need to be addressed. nutrition policy in Afghanistan, and technical support in large- scale emergencies such as Typhoon Haiyan in the Philippines. Programmatically, community-based approaches for treating SAM must continue to be integrated into health systems and basic emergency pack- Abigail Perry is acting Nutrition Team Leader ages. To do so, the specific measures required for these efforts to fully suc- at the Department for International ceed need to be identified. For us, there are five key elements that must be Development, UK. A nutritionist with at the heart of these efforts: extensive experience in development and 1. Ensure that prevention and treatment of wasting is situated in all emergency work, Abi has previously worked child survival packages. As the drive to address childhood illnesses in a variety of technical roles for different together continues, SAM cannot continue to be addressed in isolation. NGOs and as a Research Associate at UCL. Its prevention and treatment must be formally and officially integrated Sophie Whitney is working as a Global in child survival packages once and for all. Nutrition Expert for the European 2. Maintain the focus on home-based models of care. Outpatient Commission Humanitarian Aid and Civil approaches need to be formally integrated into national guidelines in Protection (DG ECHO). She has extensive all countries. The boundaries of service delivery models need to be experience in nutrition, having worked for pushed to ensure that services are accessible and equitable, including over 15 years in both headquarters and field for those living in hard-to-reach areas. positions in programme design, monitoring 3. Modify and expand the ways in which SAM is diagnosed. The way and implementation. In her current role she is monitoring children suffering from SAM are identified must be simplified to innovation and informing the nutrition policy to ensure aid enable a wider range of individuals (starting with the caretakers them efficiency in humanitarian crises. selves) to find them and do so early...... 菀菀 News ......

4. Optimise the specifications and dosage of is gathering pace, the issue of SAM is often lost including (but not limited to) health financing. specialised nutritious foods. To make sig- in policy debates at a global level and fails to be It will also require a gradual but sustained com- nificant improvements in the cost-effective- included in national nutrition targets. To make mitment from national governments to include ness of treatment, efficiencies and im- SAM a political and public health priority, the SAM treatment costs into multi-year health provements in the way these products are nutrition community must do what we have budgets. Business, private sector companies made, what they contain and how much of recognised for years: get out of the echo cham- and foundations also have a critical role to play, it is used in the treatment of SAM must ber and start engaging consistently and actively but in different ways to national governments continue to be pursued. with the wider public health community. Doing and bilateral donors. Determining the added 5. SAM information must be consolidated that will require us to be clear about what we value of each in covering different components and made widely available. Today, critical want to see happen, in concrete terms, and to of treatment services (e.g. commodities, re- information about the context-specific fac- ensure that the benefits of putting SAM into search & development and health system-re- tors that lead to acute malnutrition, the child survival policy and practice are made ex- lated costs) will be the key to optimising the scale of the problem and the performance plicit. This conversation is particularly critical at contributions of each actor and getting us of the services dealing with acute malnutri- national level, for it is there that the impact of closer to the mark. tion is either missing or inaccessible. As the scaling-up SAM treatment will ultimately be And when all is said and done, that is our Global Nutrition Report has high-lighted, most profound. Repositioning SAM as a key as- lasting answer: to unlock the global and na- greater investments in SAM information, pect of accelerating child survival will be about tional challenges we will need to bring our dif- and the right platforms to make this infor- high-level dialogue, but it will ultimately be ferent skills, knowledge, geographical reach mation easily accessible to those who need about translating dialogue into action and and diverse networks to bear on this very press- it, are urgently needed. measurable commitments. ing problem. Only if efforts are coordinated Addressing these and other questions will re- Delivering SAM treatment at scale will come and dialogue sustained on the opportunities quire investment in innovative and bold ideas, at a cost. The recent projections made by the and challenges we face, will we maximise the and the capacity to generate evidence and World Bank, Results for Development, 1,000 influence and impact we can leverage, and identify what works in a timely manner, so that Days and others, have generated valuable in- bring others on board to drive change. In this, innovations can be mainstreamed in years, not sights into exactly how much will be needed to the UN-designated Decade of Nutrition, we decades. deliver SAM treatment at scale ($1.8 billion a need to ramp up and coordinate our collective year) and how much is currently being made efforts to tackle severe acute malnutrition, The challenge of SAM treatment scale-up available ($450 million in 2014). Addressing the thereby unlocking the wider benefits for child might often be defined in programmatic terms, deficit will require a step-change and the ca- health and global development. but the solutions are, more often than not, po- pacity to integrate SAM treatment into non- litical. At a time when the nutrition movement emergency, long-term funding streams Watch this space…www.nowastedlives.org

Global School Feeding Sourcebook: Lessons from 14 countries

he Global School Feeding Sourcebook: Lessons from 14 countries was produced in response to demand from gov- Ternments and development partners for guidance on designing and implementing large-scale, sustainable, WFP/Aditya AryaWFP/Aditya national school-feeding programmes that can meet globally approved standards. The Sourcebook documents and analyses government-led school-feeding programmes to provide decision-makers and practitioners worldwide with the knowledge, evidence and good practice they need to strengthen their national school-feeding efforts. Based on high-level collaboration with government teams from 14 countries (Botswana, Brazil, Cabo Verde, Chile, Côte D’Ivoire, Ecuador, Ghana, India, Kenya, Mali, Mexico, Namibia, Nigeria and South Africa), the Sourcebook includes a compilation of concise and comprehensive country case studies. Programmes are examined in terms of Five Quality Standards that are needed for school-feeding programmes to be sustainable and effective. These standards include: design and implementation; policy and legal frameworks; institutional arrangements; funding and budgeting; and community participation. The review highlights the trade-offs associated with alternative school-feeding models and analyses the overarching themes, trends and challenges that run across them. School feeding The Sourcebook is free to download at www.hgsf-global.org and programme in www.wfp.org Odisha, India ...... 菀菀 News ...... The missing ingredients: Are policy-makers doing enough on water, sanitation and hygiene to end malnutrition?

Introduction although national nutrition policies were also Continuum approach. Working together Evidence shows that scaling up interventions reviewed for a comprehensive picture. Pre-de- should be considered along a continuum, with that tackle the immediate causes of malnutri- fined criteria used for reviewing action plans in- different degrees or approaches to collaboration. tion is insufficient to overcome the challenge. cluded: is may range from simply sharing information A more comprehensive ‘recipe’ requiring a mix • Is WASH recognised as an underlying and and targeting different programmes to the same of ‘ingredients’ from multiple sectors is critical important factor in nutrition? populations to a more integrated programme, to address both the immediate and underlying • Are all three components of WASH involving the same staff and a single budget. mentioned? causes of malnutrition. Challenges in working together. Inherent • Is there a budget outlined for WASH differences in the objectives, outcomes of in- A report from SHARE (Sanitation and Hy- activities? giene Applied Research for Equity) and Wat- terest and people involved in delivering nutri- erAid highlights why water, sanitation and In addition, a keyword search of nutrition tion and WASH programmes present a number hygiene (WASH) are essential for nutrition. An terms in the national WASH plans and policies of challenges to working together. Unlike estimated 50% of undernutrition is associated of the 13 countries was conducted to allow for those responsible for nutrition, the WASH sec- with infections caused by poor WASH, con- a basic assessment of whether the plans in- tor is not dependent on nutrition action for tributing to 860,000 preventable annual clude nutrition considerations. achieving its primary objectives. However, deaths in children under five years of age. Evi- both nutrition and WASH policy-makers share Key findings a common vision and goal of improving dence from a number of trials and observa- WASH into nutrition varies widely. All the nu- health, and evidence shows that public health tional studies has identified three biological trition plans and policies that were analysed aims have been a key driver of investments in mechanisms linking WASH to undernutrition, recognise the importance of WASH; however, WASH, particularly sanitation. Working to- including repeated bouts of diarrhea, intes- the degree to which WASH is embedded gether can also leverage investments across tinal parasitic infections and environmental within plans varies significantly across coun- the two sectors to maximise health impact and enteric dysfunction (EED). There may be other tries in terms of objectives, targets, interven- improve cost-effectiveness. Plans and policies important WASH-related social and economic tions and indicators (Nepal and Timor-Leste pathways. have the strongest plans in terms of embed- are a core part of the process of outlining the ding WASH components). mechanisms and systems required to allow Growing evidence of the links between nu- more cohesive working to advance nutrition trition and WASH has contributed to building Nutrition into WASH is limited. Very few and WASH goals. momentum for better coordination, collabo- WASH plans reference nutrition or identify op- ration and integration. However, the defini- portunities to integrate with nutrition and The report uses findings from the analysis, tions that different sectors, individuals and health programmes and campaigns (with the along with existing evidence and lessons organisations use for ‘integration’ vary consid- exception of Liberia). learned to date, to provide insights into the erably along a continuum. This ranges from different ways of working to enhance nutrition very minimal coordination and collaboration Limited budget information and WASH coordination and collaboration on one side through to a more closely inte- Of the plans analysed, a detailed budget for across different stages of the policy cycle. grated and jointly delivered programme on activities was not generally included in the the other. same document, limiting the ability to capture Recommendations the budget for WASH activities. Where budget According to the report, comprehensive na- Through an analysis of both nutrition and was available, this was provided at the level of tional nutrition plans are a critical first step to- WASH plans and policies in 13 Scaling Up Nu- the objectives or priority areas and not by ac- ward ending malnutrition by 2030, but they trition (SUN) countries (Bangladesh, Kenya, tivity; thus a detailed costing analysis was not must include all three WASH ‘ingredients’. Liberia, Madagascar, Malawi, Mozambique, possible within the scope of this research. Moreover, these plans should be underpinned Nepal, Rwanda, Sierra Leone, Tanzania, Timor- by sufficient financing, effective coordination, Leste, Uganda and Zambia), the report evalu- One size does not fit all. There is no single timely tracking of results and stronger institu- ates the degree to which national strategies in blueprint for how WASH should be embedded tions. The report makes specific recommenda- both ‘sectors’ are integrated. It identifies gaps in nutrition plans, nor for how WASH pro- tions on how partners – governments, UN in coordination and ways of working, and grammes can be made more nutrition-sensi- agencies, donors, technical agencies and inter- where and how improvements must be made. tive. However, consideration of some key national NGOs and academics – can play their principles and approaches could help drive part to ensure an integrated approach to end- Method progress. For example, designing WASH pro- ing malnutrition. Countries selected for analysis were based on grammes to target populations most vulnera- SHARE’s focus countries and WaterAid’s country ble to nutrition and/or identifying opport- An infographic on how well water, sanitation programmes, for which national, multi-sector unities to integrate activities such as those re- and hygiene are integrated into national pro- nutrition action plans or strategies were freely lated to behaviours (e.g. personal and food hy- grammes is available at: www.wateraid.org/ available online. National, multi-sector nutrition giene and breastfeeding) could result in more uk/what-we-do/policy-practice-and-advo- action plans were the primary focus of analysis, joined-up approaches. cacy/research-and-publications ...... 菀菀 News ...... Nutrition funding: The missing piece of the puzzle

recent report by Generation Nutri- The 2016 N4G summit in Rio de Janeiro did that programmes include objectives on, tion, a coalition of 85 civil society or- not turn out to be a pledging summit, as had and intended outcomes for, nutrition and Aganisations, describes both why originally been envisaged. The Generation Nu- that aid is targeted towards those most at funding matters to nutrition and trition campaign is calling for the next high- risk of undernutrition. the current situation with regard to donor fund- level nutrition funding summit to be For southern countries ing and domestic resources. The report calcu- announced immediately and for all stakehold- • To support the inclusion of dedicated lates that, at the current rate of progress, ers to step up and pledge ambitious and budget lines for nutrition within national countries will miss the 2025 World Health As- SMART (Specific, Measurable, Achievable, Rele- health budgets. sembly (WHA) targets on stunting and acute vant and Time-bound) financial commitments. • To raise the level of government expendi- malnutrition by a significant margin (see Table At this next summit, they want donors to agree ture in key nutrition-sensitive sectors, such 1), let alone the more ambitious Sustainable De- to a doubling of global aid to nutrition by 2020, as health, education, agriculture, water and velopment Goals (SDGs). Increasing funding is and for southern governments to agree to in- sanitation, and social protection, and con- essential if these and the other global nutrition crease their budget allocated to nutrition, start- tinue developing systems that can guaran- targets are to be met on time. Progress in meeting with (but not restricted to) the health sector. tee a minimum level of investment in nutri- ing the WHA stunting and wasting targets are tion (3% of national budgets). respectively 20 and five years behind schedule. Recommendations Recommendations made in the report are in For all stakeholders In 2013, the UK hosted the Nutrition for line with priorities from states and other donors • To announce measures to strengthen inter- Growth (N4G) event, a high-level summit result- who are part of the N4G initiative. They relate national, innovative, financing mechanisms ing in over US$23 billion pledged to improve to measures which, if implemented, would help and funds for nutrition. One example is nutrition up to 2020. This was a substantial either to increase nutrition funding or to im- UNITLIFE, an initiative for combating un- commitment, but ultimately not enough to end prove the impact of existing programmes. dernutrition, based on small-scale levies in malnutrition in all its forms, as promised by the extractives sector (www.unitlife.org). world leaders. The report by Generation Nutri- All international donors The initiative is expected to generate tion describes the ‘London Legacy’ as present- • To identify quickly a date and occasion for US$115 million a year in its initial phase. ing challenges in relation to the a new, high-level, pledging summit on nu- Mali was the first country to contribute, implementation of the deal; for example, of the trition, working together with southern with a levy of 10% per gram of gold sold. eight donors who supplied data on nutrition- countries. Another example is the Power of Nutrition specific and nutrition-sensitive aid spending in • To ensure that the promises made at N4G 1 (www.powerofnutrition.org); allocations 2013, only 64% of the aid pledged for that year are fulfilled by keeping spending up to totalling US$200 million have been made. was actually disbursed. Moreover, the 2015 2020 ‘on track’. • To ensure that any new financial pledges Global Nutrition Report, which tracks N4G com- • To go further and commit to a doubling of are developed in a way that is SMART and mitments, revealed that 13 donors were spend- global aid for nutrition, to be achieved by makes their delivery easy to assess. For in ing either less than US$1 million per annum or 2020 and based on a verifiable baseline fig- stance, all the money committed should nothing at all on nutrition-specific pro- ure (for instance, 2014 spending). A signifi- represent additional spending. grammes. Furthermore, only a relatively small cant share of the increase should be for share of donor budgets in supposedly nutri- life-saving, nutrition-specific interventions. • To improve the nutritional impacts of aid tion-sensitive sectors is being targeted directly 1 channelled to agriculture, education, Nutrition Funding: the missing piece of the puzzle. at improving nutrition – 3% out of 21% spend A Generation Nutrition briefing paper. June 2016. on health agriculture, WASH (water, sanitation health, water and sanitation, and social www.generation-nutrition.org/sites/default/files/editorial/ and hygiene) and education. protection. This can be done by ensuring missing_piece_of_the_puzzle.pdf

Breastfeeding advice session, Ethiopia ©Ashley Gilbertson/IMC

...... 菀菀 News ...... Biofortification: Vitamin A fortiﬁed maize Helping meet nutrition needs worldwide

By Dr Erick Boy, Nutrition Head, HarvestPlus

Dr Erick Boy is a public health practitioner and has a doctoral degree in nutrition from University of California, Davis. He currently heads the HarvestPlus nutrition programme, overseeing dietary intake and nutritional status surveys, as well as food science and epidemiologic research required to assess the nutritional merits of biofortiﬁcation in Sub-Saharan Africa and South Asia. Before joining HarvestPlus he worked as chief scientiﬁc adviser at the Micronutrient Initiative (1999-2008). Content for this article was secured by Charulatha Banerjee, ENN Regional Knowledge Management Specialist (Asia).

Eliab Simpungwe, Harvest Plus, 2012

Location: Global, India output of mainly cereal grains such as rice, What we know: maize, and wheat. However, research by Dr Micronutrient deficiency is common in populations that rely Howarth Bouis, an economist at IFPRI and primarily on staple foods; poor, rural communities are particularly affected. founder of HarvestPlus, found that vitamin and mineral intake in non-staple foods and animal What this article adds: Biofortification is the process of increasing the density of products is more highly correlated with health vitamins and minerals in a crop through plant breeding and agronomic practices, so outcomes. Making staple foods – on which that when consumed regularly the crops will generate measurable improvement in poorer, rural communities were so dependent vitamin and mineral nutritional status. HarvestPlus is a global partnership – more nutrient-rich could therefore contribute programme that leads the global development and promotion of biofortified crops, to addressing so-called ‘hidden’ hunger. This in- involving crop development, work with policy-makers and engagement with tersection between nutrition and agriculture communities. Biofortified crops can provide 30% to 80% of a woman’s or child’s daily led to biofortification, a movement that has needs of vitamin A, zinc and iron (key focus nutrients). Evidence is emerging on brought ministries of health and agriculture nutrition and health impact. Developments in India are promising for biofortification under one roof (although it took two decades to achieve this). In many HarvestPlus target at scale. Biofortification now reaches more than 15 million people in Africa and Asia; countries, these two ministries are coordinating new crop varieties are available/pending release in 55 countries. closely to enable biofortification. Biofortification in practice icronutrient deficiency is usually fied food consumed regularly. Biofortification Conventional plant breeding is not new. Early the result of consumption of mo- targets in particular the rural poor, who are farmers chose the best-looking plants and seeds Mnotonous plant-based diets com- more vulnerable to the underlying causes of and saved them for next year’s planting. As the posed predominantly of a starchy undernutrition and consume large quantities of science of genetics became better understood, plant breeders were able to select certain desir- staple food (cereal, roots/tubers), which results staple foods, often with little else. in a lack of essential minerals and vitamins required for proper growth and development of HarvestPlus is a global partnership pro- the body. When large segments of a population gramme that leads the global development Box 1 About Harvest Plus are affected by micronutrient deficiency, their and promotion of biofortified crops (see Box 1). health and economic development are curtailed. Together with local farmers and researchers, HarvestPlus began as a research (‘challenge’) HarvestPlus develops and promotes staple programme of the global research partnership Biofortified staple crops rich in micronutri- crops that are climate-smart, high-yield and CGIAR (www.cgiar.org). It is coordinated by two ents are most beneficial to groups who are vul- members of the consortium, the International packed with micronutrients. HarvestPlus also Food Policy Research Institute (IFPRI) and the nerable to micronutrient deficiencies, especially works with policy-makers to develop pro- International Centre for Tropical Agriculture infants, young children and pregnant and grammes to promote the crops, and with com- (CIAT). In addition to IFPRI and CIAT, HarvestPlus breastfeeding women. Deficiencies in micronu- munities to take the crops ‘from fields to meals’. works with more than 200 scientists, researchers trients such as zinc, iron and vitamin A can and other experts around the world, working cause profound and irreparable damage to the closely with scientists from International Maize Origins of biofortification: and Wheat Improvement Centre (CIMMYT), body, including blindness, growth stunting, Intersection between nutrition International Institute of Tropical Agriculture mental retardation, learning disabilities, low and agriculture (IITA), International Crops Research Institute for work capacity and even premature death. Traditionally, economists believed that energy the Semi-Arid Tropics (ICRISAT), and the International Potato Centre (CIP) to select and Biofortification can help in the prevention of intake was the primary dietary factor constrain- breed biofortified crops. HarvestPlus nutrition micronutrient deficiencies. Biofortified crop va- ing better nutrition outcomes in developing generates the research required to consolidate rieties will eventually provide from 30% to 80% countries. This was the underlying premise of the case for single-nutrient crops and extend its of a woman’s or child’s daily needs, depending the ‘Green Revolution’ which, in the late 1960s, proof-of-concept approach to traditional combinations of biofortified crops. on the nutrient and the amount of the bioforti- allowed farmers to increase their agricultural ...... 菀菀 News ......

Box 2 Developments in India in from the farming communities. Studies are conducted to ensure that these new crops have In India, HarvestPlus and its partners are iron pearl millet seed in 2015. That included over sufficient amounts of the nutrient needed to im- developing new varieties of rice and wheat with 340 metric tons of the open-pollinated variety prove nutrition. The national government then increased amounts of zinc (and iron) and pearl Dhanashakti and 13 metric tons of the hybrid officially releases the best-performing varieties millet with increased iron (and zinc) using variety Shakti-1201. Cumulatively, more than one of micronutrient-rich crops for farming commu- conventional breeding. While there is a one-time million people across four states (Maharashtra, cost fixed to developing these nutrient-rich Rajasthan, Uttar Pradesh and Haryana) have nities to grow, eat and sell in local markets. varieties, which are also high-yielding, they can be accessed iron pearl millet in the three years since grown by farmers and consumed year after year the first variety was released. For wheat-producing Experiences from India alongside other traditional foods. states, four zinc-rich varieties have been The future of biofortification in India looks distributed to 35,000 farming households, thanks promising (see Box 2). The 2013-2014 budget in Pearl millet is eaten daily by more than 50 million to partnerships with various seed companies. people in the semi-arid regions of India. The iron- India allocated funds equivalent to 40 million US Farmers in the states of Uttar Pradesh and Bihar dollars to develop farms growing micronutrient- rich pearl millet variety was developed in received and planted 350 metric tons of zinc wheat partnership with the ICRISAT in India. Through seed produced through Astha Beej Co, Sood Foods, rich crops, reflecting India’s plan to develop partners Nirmal Seeds and Shakti Vardhak, some Said Seeds and Shakti Vardhak. ‘nutri-farms’ where iron-rich pearl millet, zinc- 140,000 farming households were reached with rich rice and wheat, and protein-rich maize will be grown. India’s strong scientific infrastructure able traits in a plant to create improved varieties. from stem and root cuttings. Many crops, such is an asset in developing biofortified crops, while All the nutritious crops released or in the near as sweet potato, cassava, pearl millet and beans, there are sophisticated marketing networks of pipeline through the efforts of HarvestPlus and can be replanted every year from plant cuttings seed companies that are essential to dissemi- its partners were or are being developed using or seed that the farmer has saved. In the case of nate these crops. Policy-makers and other stake- conventional plant breeding. hybrids, farmers usually purchase fresh seed for holders are key targets of evidence generated each planting season in order to maintain high on the nutritional benefits of biofortified crops Farmers do not have to make changes to productivity. Biofortified nutritious crops are and how this food-based approach can be effec- grow biofortified crops. After the initial outlay being made available as public goods to native in improving nutrition on a large scale. of funds for development of the biofortified tional governments. Wherever these seeds are There are also ongoing efforts to leverage pri- crops, the recurrent costs are minimal. Advan- typically sold in markets, they are competitively vate and public sector partners and work out tages are many: biofortification is built on what priced so that subsistence and smallholder ways to mainstream biofortified crops in India. poor households, who likely have no access to farmers can afford them. In the long run, the or cannot afford commercially marketed forti- Evidence of nutrition impact cost difference between these seeds and non- fied foods grow and eat (staple); there is a one- With more people and countries adopting bio- biofortified varieties should be negligible. time-only investment to develop seeds that fortified crops globally, evidence is emerging on fortify themselves (which keeps recurrent costs HarvestPlus approach the nutritional and health impact of these crops. low); the germplasm (the living tissue from HarvestPlus focuses on three crucial micronu- Over the last few years, leading scientific journals which plants can be grown) can be shared glob- trients that are most limited in the diets of the have published studies that demonstrate the ef- ally; and biofortification produces higher yields poor: vitamin A, zinc and iron, and breed these ficacy of biofortified crops (see Box 3). Nutrition in an environmentally friendly way. into key staple crops. Thousands of different data demonstrates that biofortified foods can re- types of crop seeds stored in seed banks that verse iron deficiency and reduce the incidence In most cases, farmers will be able to save and duration of diarrhoea, one of the leading their seed and replant it, or grow new plants have naturally higher amounts of iron, zinc and vitamin A are screened. Nutritional genomicists causes of preventable death in children under use tools such as marker-assisted selection to five years old. A small daily ration of orange Selection of published evidence sweet potato is enough to provide a young child Box 3 of nutrition impact help speed up the breeding process. Harvest- Plus uses these more nutritious seeds to breed with his/her daily vitamin A requirement. A 2015 study found that vitamin A-rich orange new crop varieties with higher micronutrient Cost sweet potato (OSP) reduced both the prevalence content that are also high-yielding and have The 2008 Copenhagen Consensus, comprising and duration of diarrhea in young children in other traits farmers want. Mozambique (Hotz et al, 2012). the world’s leading economists, estimated the health benefit-to-cost ratio of biofortified nutri- In India, pearl millet bred to be richer in iron was These new varieties are tested in the target able to reverse iron deficiency in school-aged region, partnering with farmers to ensure buy- tious crops as US$17 of benefits for every dollar Indian children (Finkelstein et al, 2015). Previously, the same iron-rich pearl millet had been shown to provide iron-deficient Indian children under the age of three with enough iron to meet their daily needs, and to provide adult women in Benin with more than 70 per cent of their daily needs (Kodkany et al, 2013). A study from Rwanda found that daily consumption of meals with beans bred to be richer in iron helped prevent and reverse iron deficiency in women in just four and a half months (Haass et al, 2016). In Zambia, switching to orange maize, which is rich in beta-carotene, provided maize-dependent populations with up to half their daily vitamin A

needs. In a controlled efficacy study, children who Plus, 2012 Harvest Nigeria, ate vitamin A maize showed significant increases in their total body stores of vitamin A (Gannon et al, 2014). There is also evidence that maize that has been bred to have higher zinc content can Vitamin A cassava provide enough zinc for a growing child in their compared with a less formative years (Chomba et al, 2015). nutritious white version ...... 菀菀 News ...... invested. Once a particular micronutrient is wheat varieties for South Asia, which will be avail- reach 100 million people with biofortified nu- bred into a crop line, the trait remains. This able year after year without much investment. tritious foods by 2020 and one billion people makes the process of biofortification, over time, with biofortified foods by 2030. sustainable and cost-effective. Conclusions Biofortification is an approach to preventing It is a nutrition-smart agricultural interven- A very simple cost comparison between micronutrient deficiency that is sustainable and tion supported by robust scientific evidence supplementation, fortification and biofortifica- scalable: it now reaches more than 15 million demonstrating that regular consumption of tra- tion was done by HarvestPlus researchers. They people in initial focus countries in Africa and ditionally cooked biofortified food crops im- found that one year of vitamin A supplementa- Asia. Cumulatively, more than 100 biofortified proves the nutritional status of the most tion for 37.5 million pre-school children in varieties across ten crops have been released in vulnerable groups: rural and marginal-urban, Bangladesh, India and Pakistan can be bought 30 countries, where second and third waves of poor women of child bearing age (pregnant or for US$75 million. The same amount can buy even higher nutrient lines are being tested for not) and children aged 0 to 24 months. enough iron fortification for one year for the future release. Candidate biofortified varieties For more information, visit: same populations. It is also the cost of developing across 12 crops are being evaluated for release www.harvestplus.org/ and disseminating iron and zinc-rich rice and in an additional 25 countries. The goal is to

References Gannon B, Kaliwile C, Arscott SA, Schmaelzle S, Chileshe J, Hotz C, Loechl C, Lubowa A, Tumwine JK, Ndeezi G, Kalungwana N, Mosonda M, Pixley K, Masi C, Nandutu Masawi A, Baingana R, Carriquiry A, de Brauw A, Chomba, Westcott CM, Westcott JE, Mpabalwani EM, Tanumihardjo SA. Biofortified orange maize is as efficacious Meenakshi JV, Gilligan DO Introduction of β-carotene-rich Krebs NF, Patinkin ZW, Palacios N and Hambidge KM. Zinc as a vitamin A supplement in Zambian children even in the orange sweet potato in rural Uganda resulted in increased Absorption from Biofortified Maize Meets the Requirements presence of high liver reserves of vitamin A: a community- vitamin A intakes among children and women and improved of Young Rural Zambian Children. J. Nutr. January 21, 2015, based, randomized placebo-controlled trial. Am J Clin Nutr. vitamin A status among children. J Nutr. 2012 doi: 10.3945/jn.114.204933. 2014 Dec;100(6):1541-50. doi: 10.3945/ajcn.114.087379. Oct;142(10):1871-80 jn.nutrition.org/content/142/10/1871 jn.nutrition.org/content/early/2015/01/21/jn.114.204933.f ajcn.nutrition.org/content/100/6/1541.long Kodkany BS, Bellad RM, Mahantshetti NS, Westcott JE, ull.pdf+html. Haas JD, Luna SV, Lung’aho MG, Wenger MJ, Murray-Kolb Krebs NF, Kemp JF and Hambidge KM. Biofortification of Finkelstein JL, Mehta S, Udipi SA, Ghugre PS, Luna SV, LE, Beebe S, Gahutu J-B and Egli, IM. Consuming Iron pearl millet with iron and zinc in a randomised controlled Wenger MJ, Murray-Kolb LE, Przybyszewski EM, Haas JD. A Biofortified Beans Increases Iron Status in Rwandan Women trial increased absorption of these minerals about Randomized Trial of Iron-Biofortified Pearl Millet in School after 128 Days in a Randomized Controlled Feeding Trial. J. physiologic requirements in young children. J. Nutr. July 10, Children in India. J Nutr. 2015 Jul;145(7):1576-81. doi: Nutr. June 29, 2016, doi: 10.3945/jn.115.224741. 2013, doi: 10.3945/jn.113.176677 10.3945/jn.114.208009. jn.nutrition.org/content/145/7/ jn.nutrition.org/content/early/2016/06/28/jn.115.224741.f jn.nutrition.org/content/early/2013/07/10/jn.113.176677 1576.long ull.pdf+html Erna Mentesnot Erna Hintz/HelpAge International, Ethiopia, 2011 75-year-old Elema during the East-Africa Minimum Standards drought crisis in 2011 for Age and Disability Inclusion in Humanitarian Action

he Minimum Standards for Age and Nutrition Standard 1 This is a pilot document and feedback is wel- Disability Inclusion in Humanitarian • The nutritional status of older people and come, contact Diana Hiscock, email: diana.his- T people with disabilities is systematically Action have been developed for use [email protected] or [email protected] by all practitioners involved in hu- assessed and monitored; manitarian response, including staff and volun- • Nutritional assessments are used to trigger The Minimum Standards have been devel- teers of local, national and international and inform emergency nutrition responses oped as part of the Age and Disability Capacity humanitarian agencies. The Standards are in- that include or target older people and programme (ADCAP), which is funded by the tended to inform the design, implementation, people with disabilities. UK Department for International Development (DFID) and the United States Agency for Inter- monitoring and evaluation of humanitarian Actions to Meet the Standard – a sample of points programmes; to strengthen accountability to that are included in the Minimum Standards: national Development (USAID). people with disabilities and older people; and • Use sex-, age- and disability-disaggregated www.helpage.org/what-we-do/emergen- to support advocacy, capacity-building and data to assess the nutritional status of cies/adcap-age-and-disability-capacity- preparedness measures on age and disability adults and children with disabilities and building-programme/ across the humanitarian system. older people; To learn more, download the Minimum Stan- • Use outreach programmes to identify and The Sector Standards on Food Security and include those who cannot reach registration dards for Age and Disability Inclusion in Hu- Nutrition have a set of Sector Specific Standards points; manitarian Action from and Action Points which can be selected to ad- • Ensure nutrition assessments are informed www.helpage.org/download/56421daeb4eff dress the specific context of the humanitarian by food security assessments in order to To access the webinar on Health and Nutrition response, based on the initial assessments. identify and address factors affecting the in Humanitarian settings, please go to the Dis- The following is an example of how the Mini- nutritional status of people with disabilities mum Standards can guide your response to in- and older people. Include these groups in aster Ready website disasterready.csod.com. clude older people and older people with strategies for the prevention of micronutri- Register for free to access the webinar and disability in a comprehensive response: ent deficiency. other content...... 菀菀 News ...... Regional humanitarian challenges in

the Sahel WFP/Jane Howard, 2012 Mali,

1 Summary of report A family in their tent in Mali, displaced from their homes due to conﬂict

Location: The Sahel • The weakness of governance across the region. What we know: The Sahel is currently in complex crisis fuelled by conflict, climate change and weak governance. This report, based on field visits to Mali, Niger and Senegal, describes how these issues are What this article adds: A recent case study of regional humanitarian challenges playing out across the Sahel and discusses the in the Sahel, informed by visits to Mali, Niger and Senegal, identifies major implications for humanitarian action. It raises shortcomings in the humanitarian system as currently organised. Competition rather important questions for the future of humanitarian action in the Sahel and beyond. The au- than collaboration characterises the humanitarian/development relationship. thors introduce the history of the region and Humanitarian architecture is complex, duplicative and bogged down in coordination. nature of the current crisis, with details on Conflict is the dominant view of the region by donors; increased security measures major stakeholders – an array of the state and pose challenges to operations. Large aid agencies are increasingly not operational, non-state actors, including conflict actors and with energies diverted to reporting and accountability to donors, rather than transnational criminal networks. The largest beneficiaries. National agencies are operationally significant but lack power within multilateral donors to the Sahel are the United the aid dynamic. Solutions are available, but political will is currently lacking. States and the European Union, with the 2012 drought marking a sudden increase in humanitarian funding for the region. espite impressive growth and insti- changers affecting humanitarian action in re- Major findings, themes and tutionalisation, the humanitarian cent crises. This study focuses on the Sahel and lessons learned Dsystem is facing a crisis. According to is one of four case studies developed for the Findings are organised around the concept of a recent report on humanitarian Planning from the Future study, conducted in “game changers” (factors that emerged from challenges in the Sahel region, the humanitar- collaboration with Kings College, London and the crisis or were relatively new, and for which ian system risks being outpaced by new threats the Humanitarian Policy Group at the Overseas the humanitarian community is ill-prepared to and vulnerabilities linked to conflict, technol- Development Institute (ODI). deal with), and “blockages” (either things that ogy and natural disasters. The authors assert are blocking humanitarian action in a given that the system is struggling to adapt to the so- The Sahel context, including long-standing problems); cial and political changes spawned by globali- Until the early 2000s, the Sahel was on the mar- some findings contain elements of both. sation, constrained by the way the gins of geopolitical interest and humanitarian humanitarian system is organised with a frame- action and debate. The African region stretches The main findings focus on the Sahel (and more generally, West Africa) as a relatively neg- work for decision-making that risks becoming in a 4,000km band from Senegal on the west lected and peripheral region of intervention for obsolete. coast to Chad in the east, encompassing Sene- gal, the Gambia, Mauritania, Mali, Burkina Faso, aid, compared to other global crises. This is re- Recent crises in Afghanistan, Somalia, Haiti, Sri Niger, Chad and Cameroon. The Sahel countries flected in smaller budgets and observed differ- Lanka and Pakistan as well as current emergen- share a French colonial heritage (apart from the ences in professionalisation of humanitarian cies – Syria, South Sudan, Central African Re- Gambia) and features of a common currency staff (the region is considered a “less presti- public, among other less visible crises – raise and lingua franca. gious” posting with limited circulation of staff questions about the very foundations of hu- outside the Francophone “pocket”). manitarianism. The authors argue that unless Today, the Sahel is centre stage because of a Problems have tended to be viewed in de- urgent steps are taken, humanitarian action will complex crisis that has potential ramifications far beyond the region. The situation is due to a velopmental rather than humanitarian terms, lose its relevance as a global system for saving with the chronic crisis perceived as a “failure” in and protecting the lives of at-risk populations. set of interconnected factors, including: • The emergence of conflicts, strong non- development, thus lacking humanitarian own- The report identifies areas where, given the po- ership and innovation as seen in other regions. state armed and non-armed actors, litical will, immediate improvements could be This fuels the uncomfortable coexistence be- transnational criminal networks, and a introduced in order to make the humanitarian tween development and humanitarian action, counter-terrorism agenda; system more effective in responding to current whereby the Sahel’s main problems (food secu- crises and disasters. • The tense relationship between humanitarian action and development, which has As part of its analysis of the current human- fostered a competitive rather than collabo- 1 Donini, Antonio and Scalettaris, Giulia. 2016. Case Study: itarian system and its strengths and weak- rative environment among organisations Regional Humanitarian Challenges in the Sahel. Planning from nesses, the Feinstein International Center (FIC) the Future, Component 2. The Contemporary Humanitarian operating in the region; Landscape: Malaise, Blockages and Game Changers. Feinstein at Tufts University has produced a series of case • The impact of climate change on liveli International Center. Medford: Tufts University. studies that analyse blockages and game hoods; and fic.tufts.edu/assets/Sahel-case-study-Final-09-05-16.pdf ...... 菀菀 News ...... rity, malnutrition and epidemics) can be framed since inter-agency dynamics absorb large alignment with external political/military in both terms. amounts of human and financial resources. Of- agendas; ficial coordination mechanisms involve the UN • The humanitarian aid system has still not The chronic nature of the situation makes it Office for the Coordination of Humanitarian Af- found its footing and is struggling to deal a complex humanitarian environment. The hu- fairs (OCHA), Inter-Agency Standing Committee with the complexity and tensions sur- manitarian situation is understood to be in con- (IASC)-mediated clusters, UNHCR (refugees) rounding the Sahel crisis; stant expansion and polarisation, with local and a parallel ECHO (European Civil Protection • The appointment of a regional humanitarian actors only playing a minimal role. Local non- and Humanitarian Aid Operations) coordination coordinator has been an innovation but it governmental organisations (NGOs) are used to system; sub-groups/fora/working groups are is unclear if it has made the system any access insecure areas but not treated as “equals”. While international players raise issues of ac- proliferating partly in response to inadequacies more effective; and countability and capability of local agencies, na- in existing systems. • The humanitarian architecture is complex, duplicative and bogged down in tional NGOs voice frustrations regarding Key lessons include: coordination. bureaucracy and challenges in accessing inter- • The Sahel is rapidly changing, with conflict national humanitarian funds. becoming a key lens through which the The report concludes that solutions are available Large aid agencies are losing their “field region is viewed by donors. The escalation to make the system more effective, but political craft” as they are increasingly not operational, in security measures will pose increasing will is lacking. The humanitarian system in the with energies diverted to reporting and ac- challenges to humanitarian agencies; Sahel, as elsewhere, is becoming more remote countability to donors, rather than beneficiar- • There are implications for humanitarian and functional to the needs of the main players, ies. Coordination and transaction costs are high, principles and staff security in the perceived rather than the populations it purports to serve.

A boy having undergone rehabilitative surgery during the surgical camp, organised The incidence of NOMA among children is in collaboration between HUG (Hôpitaux Universitaires Genevois) and Sentinelles, estimated at 140,000 per year and the preva- in Ouagadougou, Burkina Faso, 2013. lence at 770,000 cases worldwide (2, 3). Lower estimates are 100,000 children per year who are affected by NOMA, of whom 20,000 survive (www.nonoma.org). However these figures are likely gross underestimates; NOMA is underre- ported since it occurs in remote areas, people are not eager to let the world know there is a disfigured member of the family, and the disease progresses rapidly to death. Most cases of NOMA (80%) occur in countries in the SAHEL belt, such as Chad, Nigeria, Niger, but also in Asia and South America. In the past, NOMA oc-

NOMA: Zizzo,Mylène 2013 curred in Europe too, where it was associated with poverty and the presence of other infec- A neglected disease! tious diseases such as measles or tuberculosis. The precise causes of NOMA are unknown, but the disease is thought to be related to immune By GESNOMA, Winds of Hope, Sentinelles, and Médecins sans Frontières dysfunction. Reduced immune function is in turn associated with poverty, the presence of other diseases (measles, malaria, pneumonia and HIV/AIDS (4)), malnutrition (5), poor hygiene and sanitation (no clean water, contact with animal waste), as well as lack of primary health care and health promoting activities like vaccination. Lack of oral hygiene is also a risk factor for OMA (cancrum oris and fusospiro- management. Two posters are included with the NOMA; one of the early stages of NOMA is gin- chetal gangrene or Necrotising Ulcer- print edition of Field Exchange, one for an out-pa- givitis and other infections in the mouth. Native Stomatitis), disfigures children tient and one for an inpatient consulting room rapidly, if they survive. It is one of the setting, in both English and French. most devastating and disfiguring human diseases worldwide and was designated a health What is NOMA? Screening for gingivitis: priority by the WHO in 1994 (1). NOMA is still a NOMA is a gangrene in the orofacial area. The neglected disease, and there is not much known course of the disease is very aggressive and fast. • Gums: redness, pain, bleeding about its causes, prevention and optimal treat- It starts as a gingivitis that develops into a gin- • Hyper salivation, drooling ment. Fortunately, with simple interventions, gival ulcer and/or necrotising gingivitis, spread- • Bad breath ing rapidly throughout the tissues of the mouth NOMA can be addressed and contained and peo- • Anorexia ple with NOMA can be cared for. Thus, this dis- and face. The infection can result in necrosis of • Gingival ulceration ease deserves more attention from healthcare tissue and bone in the face which, combined workers, nutritionists, researchers and policy- with sepsis, is fatal in most patients. NOMA not • Facial swelling / oedema. makers. In this article, we explain NOMA, explore only disfigures the patient but also causes dys- • Dry necrosis, loss of tissue, the relationship between NOMA and nutrition function in eating and speaking, resulting in possible bone sequestrum and suggest how health workers in nutrition pro- malnutrition and social isolation (2). If NOMA is grammes can be involved in its identification and untreated, 70-90% of patients will die...... 菀菀 News ......

once the scarring process is over and no earlier NOMA in an area. Activities to include in a than one year after the acute NOMA. Treatment feeding centre are: to improve function, counselling and actions to • Systematic screening of patients on maintain dignity of the patient must always be admission for gingivitis present from the beginning of the lesion. • Nutritional rehabilitation • Vaccination Simple gingivitis can be treated in an ambu- • Systematic HIV counselling and testing latory therapeutic feeding centre (ATFC), the • Screening of siblings and mothers, clinic and at home by rinsing with salted water • Improvement of water quality, sanitation for 14 days. In inpatient settings, such as an in- and hygiene patient therapeutic feeding centre (ITFC) or • Education of patients and caretakers on hospital, mouth washes with 0.5% Betadine 4 mouth hygiene and NOMA times per day for 5 days (maximum) can also be • Reporting of cases of NOMA in the village used. Then, application of a solution consisting by caretakers of 2 parts 1.4% bicarbonates at to 1 part nysta- • Referral of NOMA patients to specialised tine 4 times per day for at least 10 days, or pos- institutes (where available) sibly over the total duration of the hospitalisation, can be applied with the aid of a Accessing guidance and compress rolled up on a tongue compressor support (the caregiver can be taught to do this). In the Sentinelles, Winds of Hope, GESNOMA (all case of necrotising gingivitis, the above local members of the International NoNoma Federa- treatment should be completed with antibi- tion) and Médecins Sans Frontières (MSF) have otics (amoxicillin-clavulanate combination or created a working group to collaboratively de- amoxicillin plus metronidazole). velop several kinds of support: The treatment should be complemented by • Posters for the consultation room in French active nutrition support (e.g. supplementation and English for inpatient (hospital, ITFC) with lipid nutrition supplements (LNS) or ther- and outpatient facilities (outpatient apeutic foods where severely malnourished), medical clinic and outpatient/ambulatory treatment of any other existing infections, and therapeutic feeding centres (ATFC)) updating of vaccination status. Prompt recog- (included in this edition of Field Exchange) nition of the early stage of NOMA (gingivitis) • Guidelines on treatment of NOMA and treatment at this stage can prevent subse- • Support to specialised centers for surgery quent tissue destruction and disﬁgurement. • Background information This implies early recognition and active screen- • Guidelines on management of moderate ing for NOMA. and severe acute malnutrition • Research Malnutrition and NOMA Nonoma (FR): www.nonoma.org Malnutrition (moderate and severe) is the most Winds of hope (EN, FR, GE): www.windsofhope.org important risk factor for NOMA (5). Therefore Sentinelles (FR, EN): www.sentinelles.org prevention of malnutrition (along with treating underlying diseases, improving vaccination Study of the Human Rights Council Advisory coverage and HIV testing) is an important step Committee on severe malnutrition and child- in the prevention of NOMA. This means that all hood diseases with children aﬀected by noma moderately or severely malnourished individu- as an example. UN General Assembly. 24th Feb- als should be screened for signs of gingivitis. In ruary 2012. Human Rights Council Nineteenth addition, every patient in inpatient and outpa- session Agenda item 5. tient nutrition treatment centres should be www.righttofood.org/wp-content/uploads/ screened for gingivitis (simple and severe) and 2012/09/A-HRC-19-73.pdf Treatment of NOMA other mouth abnormalities. Once the NOMA in- www.righttofood.org/work-of-jean-ziegler- The early stages, such as simple gingivitis, fection is treated, many patients still have se- at-the-un/noma/ should be treated with mouth washes of salted vere lesions in the mouth and face that can water and general oral hygiene. A complicated hamper eating, chewing, swallowing, talking, References gingivitis (with necrosis, spontaneous gingival and sometimes even vision or breathing. Good bleeding and pain) requires professional dental 1. Bourgeois DM, Leclercq MH. The World Health nutritional support and guidance, with possible Organization initiative on noma. Oral Dis. 1999; 5:172-74 hygiene and follow up (if available). If dental hy- physiotherapy, can help to return to an accept- giene and follow up cannot be achieved, antibi- 2. Ashok N, Tarakji B, Darwish S, Rodrigues JC, Altamimi able nutritional status. Prior to any surgery, the MA; A Review on Noma: A Recent Update. Global otics are needed. When there is a necrotising lesion must no longer be active and the patient Journal of Health Science. 2016;4 (53-59) gingivitis/stomatitis with oedema of the corre- should be well nourished; close monitoring of 3. Baratti-Mayer D, Pittet B, Montandon D, Bolivar I, sponding facial region, antibiotics are manda- their nutrient status and supplementary feed- Bornand JE, Hugonnet S, Jaquinet A, Schrenzel J, Pittet tory. The later stages should be managed by an ing is often necessary before surgery can be D; Noma: an “infectious” disease of unknown aetiology. intense antibiotic regime in order to stop the performed. Lancet infect Dis. 2003; 3: 419–31 spread of the infection and to avoid the deadly 4. Masipa JN, Baloyi AM, Khammissa RAG, Altini M, complications (such as septicaemia). Once the Active screening in feeding Lemmer J, Feller L; Noma (Cancrum Oris): A Report of a Case in a Young AIDS Patient with a Review of the infection is over, and depending on the localisa- programme Pathogenesis; Head and Neck Pathol. 2013;7:188–192 tion of the NOMA, physiotherapy aimed to avoid Feeding programmes treating moderate and 5. Baratti-Mayer D, Gayet-Ageron A, Hugonnet S, François complete trismus (jaws constriction) must be severe malnutrition have a concentration of P, Pittet-Cuénod B, Huyghe A, Bornand J, Gervaix A, started for those patients developing this com- children at risk for NOMA and are therefore Montandon D, Schrenzel J, Mombelli A, Pittet D. Risk plication. In many cases, specialist reconstruc- excellent places to target these children; they factors for NOMA disease: a 6-year, prospective, matched case-control study in Niger. Lancet Global tive surgery is needed and can only be planned can play an important role in controlling Health 2013; 1: e87-96 ...... 菀菀 Research ...... Improving care of people with NCDs in humanitarian settings MSF, Jordan Treating non-communicable By Emily Mates, ENN Technical Director (meeting attendee) diseases in Jordan

here is an increasing burden of non- problems associated with NCDs in humanitar- humanitarian systems do not currently communicable diseases (NCDs) ian settings include: cater well for assessment of NCD needs. Tamong people displaced and other- • Varying burdens, depending on the context • Lessons can be applied from other chronic wise affected by humanitarian crises. • Impact on health care infrastructure of host disease programmes such as HIV/AIDS. Humanitarian organisations are facing new nations; there are additional problems • Standardised guidelines, tools and training challenges when confronting them as there are when host nations have largely private are needed on how to deal with NCDs in many uncertainties regarding the best strate- health care systems emergency settings. gies to implement NCD care in these crisis-af- • There are currently multiple protocols and • Cohort monitoring is required to identify fected settings. guidelines in existence, depending on the gaps in service provision and evaluate A recent (2nd September 2016) one-day context services. symposium on the topic was hosted by the Lon- • Insufficient mental health services • Service must be patient centred, with don School of Hygiene and Tropical Medicine • As in non-crisis situations, people generally trained and incentivised health workers. (LSHTM) Centre for NCDs and Centre for Health prefer medication to lifestyle change. • Institutional structures and resources sup- and Social Change (ECOHOST) and Médecins Some lessons can be drawn from the global re- portive of integration for chronic disease Sans Frontières (MSF). It brought together sponse to the HIV pandemic, although with HIV management alongside traditional human- speakers from academic, development and hu- there is a single cause with high burden, which itarian response are required. manitarian organisations to address some key makes it easier for researchers and practitioners • Recognising the mortality consequences of issues faced when working to improve the care to activate around it. The situation with NCDs is treatment interruptions, it was suggested of patients with NCDs. Presenting agencies in- more complex, as it involves a heterogenous that a matrix is needed for use at organisa- cluded MSF, International Medical Corps, group of diseases with no single cause and vari- tional level regarding what problems exist LSHTM, NCD Alliance, United Nations High able burden, depending on context. A key con- and how acute they are, to ensure contin- Commissioner for Refugees (UNHCR), United siderations is the mortality risk when treatment ued treatment. Nations Relief and Works Agency for Palestine is interrupted. For example with CVD and statin • More research is needed: two systematic (UNRWA), International Rescue Committee, In- treatment, if treatment is interrupted the results reviews on effectiveness of NCD interven- ternational Committee of the Red Cross and the are not too serious; with type 1 diabetes, mor- tions and integration of HIV/NCDs pre University of Geneva. tality risk is extremely high with treatment in- sented at the meeting were inconclusive The burden of NCDs in the Middle East re- terruptions. due to lack of evidence. gion is increasing, particularly cardiovascular Regarding nutrition, obesity was raised as a Video recordings of all presentations are avail- disease (CVD), respiratory disease, diabetes and causal factor but further nutrition considerations able at: www.msf.org.uk/event/symposium-im- cancers, with an estimated 1.7 million deaths regarding NCDs (prevention or management) in proving-care-of-people-with-non-communicab per year; diabetes rates are amongst the high- humanitarian settings were not discussed. le-diseases-in-humanitarian-settings est in the world. It is very difficult to get people to change behaviour even in the developed Main summary points included: This symposium is linked to a thematic series world; in crisis situations, this becomes ever • We must improve our understanding of the on NCDs in humanitarian crises being pub- more difficult. Mental health issues are often an needs, which will vary by context, to respond lished in the journal ‘Conflict and Health’. See: acute problem amongst refugees. Particular to the challenges effectively – traditional www.conflictandhealth.biomedcentral.com eLearning module on improving nutrition through agriculture and food systems

he new eLearning module ‘Improving global and regional initiatives and commit- Other related e-learning modules are: Nutrition through Agriculture and ments related to nutrition on which learners can Nutrition, Food Security and Livelihoods: Basic TFood Systems’ is now online. It is de- build to integrate nutrition in their work. concepts. A short course on the basics of nutri- signed to assist professionals from any tion. www.fao.org/elearning/#/elc/en/course ﬁelds related to food security, agriculture and This module was developed by FAO’s Nutri- /NFSLBC food systems that are involved in designing and tion and Food Systems Division and Partner- implementing nutrition-sensitive programmes, ships, Advocacy and Capacity Development Agreeing on causes of malnutrition for joint ac- investments and policies. The module uses a Division, in collaboration with the World Bank tion. A key resource to improve the under- scenario-based and experiential learning ap- and European Union, and with technical inputs standing of the multi-sectoral causes of proach to illustrate the linkages between agri- from many partners. malnutrition and support integrated nutrition culture, food systems and nutrition. It provides a series of examples of nutrition-sensitive poli- It is available in the FAO e-learning page: planning. www.fao.org/elearning/#/elc/en/ cies and interventions and gives an overview of www.fao.org/elearning/#/elc/en/course/NFS course/ACMJA ...... 菀菀 News ...... FANTA’s Body Mass Index (BMI) Wheel

etermining BMI is a way for health workers to identify malnutrition in children over 5 years of age, adolescents, and non-preg- Dnant, non-lactating adults. BMI is calculated as body mass divided by the square of the body height(kg/m2). In 2014, FANTA and the Boston Children’s Hospital created the BMI Wheel for health care workers in developing countries to quickly calculate BMI and BMI-for-age, as well as determine a client’s nutritional status using a single time-saving tool. The FANTA Project is pleased to announce that the BMI Wheel is now available. The design ﬁles for the BMI wheel are available in English, Spanish, and Portuguese for organisations interested in printing the wheel for their own use. For details on how to print and use the tool, including an informational video, visit: www.fantaproject.org/tools/body-mass-index-bmi-wheel Any questions or experiences on using the tool should be sent to: [email protected]

Launch of BabyWASH Coalition

he newly launched BabyWASH Coali- Coalition will create a toolkit for programme tion is a five-year initiative comprising implementers on how to successfully inte- Torganisations across civil society, grate BabyWASH interventions into their United Nations (UN) organisations, programming and work collabo ratively funders, academics and the private sector. It is with other sectors and organisations. focused on increasing essential integration between programming, policy-making and fund- 2) Define integration metrics ing in the areas of water, sanitation and hygiene The Coalition will use current research and (WASH); early childhood development (ECD); success stories to define the key compo- nutrition; and maternal newborn and child nents and metrics of beneficial integration. health MNCH), to improve child well-being in Where appropriate, the Coalition will assist the first 1000 days. in planning pilot programmes to validate metrics. It is built on the premise that half a million children and 30,000 mothers annually could 3) Advocate for stronger focus on integrated survive and thrive through better and more in- care in the first 1,000 days of life tegrated approaches to maternal and young The Coalition will use case studies and child health. WASH is often missing from nutri- evidence to advocate for more integration tion, ECD, and MNCH programming, despite a between sectors. Funders and policy- growing evidence base on the need for link- makers will be targeted to minimise ages. There are many policy, attitudinal, and current barriers to integration. funding barriers to integration. The coalition Who can be involved? aims to leverage its collective strengths to break The Coalition is open to all organisations inter- BabyWASH news, and being an advocate for in- down these barriers. The coalition is a direct re- ested in promoting improved maternal, new- tegration in their circles of influence. They will sponse to the Sustainable Development Goals born and young child health outcomes through also be asked to review materials created by (SDGs) call for increased partnerships and inter- increased sector integration. The Coalition is es- each of the workstreams. Organisations in- sectoral collaborations, and is in support of the pecially interested in finding national champi- volved in one of the workstreams will meet Every Woman Every Children Global Strategy, ons who can advocate for or implement monthly to move Coalition deliverables forward which has a newly enhanced focus on multi- BabyWASH interventions at a local level. and work in a dedicated team on advocacy, pro- sector actions. gramme guidance, and metrics for integration. Interested organisations can join the Coali- Main coalition objectives tion as a Community of Practice (CoP) member For more information, or to join the Coali- 1) Develop and disseminate lessons and or as a dedicated member of one of the work- tion, visit www.babywashcoalition.org or con- guidance for programme integration streams. CoP members commit to providing in- tact Peter Hynes, BabyWASH Coalition Besides being a source of information and formation and case studies for the monthly Coordinator, email: admin@babywashcoali- case studies of successful integration, the resource newsletter, staying up to date on tion.org or follow: #BabyWASH ...... 菀菀 News ......

En-net update By Tamsin Walters, en-net moderator

ver the past four months (1st July to of Parliamentarians in all provinces and at Fed- Adaptation for Food Security Assembly which 31st October), 88 questions have eral level to engage them to play an important is a Pan African institution, and thereby encour- been posted on en-net, generating role in implementation of Inter-sectoral Nutri- aging other nutrition activists to include cli- O228 responses. Forty-two vacancy tion Strategies and enactment/ enforcement of mate change issues in their nutrition activities. announcements have been posted, which have relevant legislation, such as Protection and Pro- Follow the discussion and add your contribu- accumulated almost 12,000 views on the web- motion of Breastfeeding laws, mandatory food tion at www.en-net.org/question/2700.aspx site; and eight upcoming trainings. fortification laws, etc. Parliamentarians can also help increase budgetary allocations for nutri- Finally, there have been several calls on en- en-net has increasingly seen posts alerting tion specific and nutrition sensitive interven- net for access to more nutrition materials in readers to new research and guidance in areas tions. They found key messages that work well French, Spanish, Russian and Portuguese. This that have received much attention on the site, are: ranges from translated guidelines to SMART such as coverage assessment www.en-net.org/ (1) The current malnutrition crisis in Pakistan survey reports. The dearth of available literature forum/16.aspx and WHO updates on HIV and has been estimated to cost the economy in languages other than English is a significant infant feeding www.en-net.org/question/ 2-3% of Gross Domestic Product (GDP) per issue. If you have links or materials to share, 2579.aspx which is a welcome development, year; Pakistan cannot afford to sustain this please do so, here www.en-net.org/question/ assisting people to access research and evi- drain on the economy. 2583.aspx or www.en-net.org/question/2705 dence-based information. In addition, there (2) If prioritised, malnutrition can be ended in .aspx or contact [email protected]. en-net has a have been several posts recently to encourage a generation in Pakistan! Addressing mal- mirror French site, launched earlier this year, readers to engage in online consultations and nutrition is one of the best investments www.fr.en-net.org. We very much welcome experience-sharing by researchers and those Pakistan can make in its future. feedback on the quality of translations on this developing guidelines. These include Sphere (3) Improving nutrition is transformational - site and suggestions to make it increasingly ac- Handbook consultation, updated guidance on families become healthier, wealthier and cessible and useful to French speakers. All feed- Infant feeding, and contributions to research on better educated, because back is welcome to [email protected]. “Understanding the contextual factors enabling • Children who are malnourished learn less evidence-based decision making in disasters: at school, and earn less when they grow To join any discussion on en-net, share your ex- Organisational contexts and other disaster re- up. perience or post a question, visit www.en- lated contexts”. The latter is still open for inputs • Iron and iodine deficiency in childhood net.org.uk here, www.en-net.org/question/2697.aspx reduces IQ by up to 25 and 13 points Contributions In the Scaling Up Nutrition (SUN) forum area respectively. Nahas Angula, Muhammad Irshad Danish, Has- there has been a call for experiences on engag- • Malnutrition makes children more likely sane, Edward Jusu, Dr. Bonnix Kayabu, Regine ing nutrition champions for a new guide to be to acquire communicable diseases like Kopplow, Scaling Up Nutrition/Transform Nutri- published by the Institute of Development measles and also develop complications. tion Moderator. Studies (IDS) and the SUN Movement Secre- Malnutrition also reduces the effectiveness tariat. Contributions have been shared by indi- of certain vaccinations. vidual practitioners, SUN Focal Points, The SUN CSA, Pak is now developing policy government ministers and civil society alliance briefs and provincial scorecards to equip them conveners. Findings so far include: with ready to reference information required for The Prime Minister galvanised Namibia into ac- policy making and planning. tion after a review illustrated that the country was facing a major challenge in reducing ma- The Sierra Leone Alliance Against Hunger ternal deaths and infant mortality and making and Malnutrition is a civil society advocacy non- slow progress towards its Millennium Develop- governmental organisation and an alliance of ment Goals (MDGs). A survey was then con- over 150 networks. They came together as an ducted which clearly showed the links between alliance after persistent reports identifying mal- the high rates of anaemia in pregnant women nutrition as one of the major causes for the high and stunting in children and these poor out- maternal and infant mortality in the country, comes. It was against this background that the one of the key issues responsible for Sierra Namibia Alliance for Improved Nutrition Leone’s low position in the Human Develop- (NAFIN) was born. NAFIN is multi-sectoral and ment Index. multi-stakeholder. Its mission is to provide evidence-based information to policymakers on To enhance government commitment to the state of nutrition in Namibia; promote social nutrition, the alliance is currently leading the ef- mobilisation in favour of balanced diets; pro- forts to include nutrition and food security is- mote breastfeeding; build awareness among sues in the National Constitution in the current pregnant mothers about the need to visit ante- constitutional review process. The effort has al- natal clinics; promote public hygiene such as ready yielded fruit: under Protection of Socio- good sanitation and hand washing. economic Rights, to be free from hunger and to have food of acceptable quality, has been in- The SUN Civil Society Alliance Pakistan cluded. The alliance is currently hosting, on be- A child awaits her check-up at a community clinic (SUNCSA, Pak) organised sensitisation sessions half of Sierra Leone, the Ecosystem Based in Nyankpala in the Northern Region of Ghana WFP/Nyani Quarmyne ...... 菀菀 Field Article ...... Open Data Kit Software to Location: Kenya conduct What we know: Manual survey data collection and analysis is resource- nutrition intensive, with risk of errors. What this article adds: A free, open-source mobile data collection package (Open Data Kit) (ODK) was successfully used by World Vision Kenya to surveys: conduct a SMART survey. Compared to manual data collection, it proved cheaper (less staff), quicker (instant data upload ready for analysis), less prone to error (immediate data checks possible) and abuse (GPS checks on Field random sampling) and more environmentally friendly (printed questionnaires not needed). Data aggregation (hosted on cloud server or internal servers) allows for further future analysis. Electricity/power packs experiences (for charging), mobile internet (for data upload) and smartphones are needed but were not a barrier. Minor suggestions are made to the developers to from Northern improve usability.

Kenya Background (see Box 1). Its core developers are researchers Nutrition programmes require high quality at the University of Washington’s (UW) De- By Daniel Muhinja, Sisay Sinamo, Lydia and timely data for appropriate decision- partment of Computer Science and Engi- Ndungu and Cynthia Nyakwama making. In the past, nutrition programmes neering and active members of Change, a used time-consuming manual processes for multi-disciplinary group at UW exploring Daniel Muhinja is National data collection and analysis. Open Data Kit how technology can improve the lives of Nutrition Specialist with (ODK) is a free and open-source set of tools under-served populations around the world. World Vision (WV) Kenya, which helps organisations author, field and WV is using ODK extensively for nutrition providing technical manage mobile data collection solutions and health surveys across Asia and Africa; leadership to nutrition programming. He has over ten years’ experience in the About ODK design, management, monitoring and Box 1 documentation of nutrition programmes. Open Data Kit is an open-source set of tools that enables online generation of forms/questionnaires, data collection on mobile phones and submission to a central Dr Sisay Sinamo MPH, MD is server which is downloaded during analysis. ODK is made of up of three platforms: currently Nutrition Advisor for WV International East ODK Build: Enables users to create questionnaires using a drag-and-drop form designer Africa Region, supporting or an Excel spreadsheet; nine countries. He has ODK Collect: Phone-based replacement for paper forms for data collection; worked in developmental ODK Aggregate: Provides a ready to deploy online repository to store, view and export and emergency nutrition collected data. programming for the past 16 years. Data collected using ODK may be stored by Google servers or organisational servers. The Lydia Ndungu is Nutrition server is a safe repository for data collected (cloud), and can be used for future analysis by Programme Oﬃcer with WV other internal parties, such as WV-support oﬃces. Kenya and provides nutrition technical capacity-building, mentoring, resource mobilisation, nutrition advocacy, research, documentation, programme design, monitoring and evaluation.

Cynthia Nyakwama is Health Programme Oﬃcer with WV Kenya. She has over 10 years’ experience in developing and managing national programmes and projects for health on malaria and HIV/AIDS with international non-governmental organisations.

The authors acknowledge the Ministry of Health, International Rescue Committee, Save the Children and Islamic Relief. The project was funded by the Department for International Development (UKaid),...... World Vision UK and World Vision Canada. Thanks also to Colleen Emary, Senior Emergency Nutrition Advisor, World Vision International, for 菀菀 assistance in the development of this article. Field Article ......

Survey SMART phone charging data quality by using a Geographic Information form accepting that the smartphone was in their System to verify randomness of the data collected custody, that they would take care of it and be in the clusters (Figure 1) and by using skip responsible in case of loss. logic, which ensures all questions are answered. Plausibility checks were done on a daily basis Data collected is easily accessed and is stored in and data analysis for anthropometry was done a server, hence it cannot be manipulated; WV easily on downloading the data. e field survey Kenya used Google servers to store data and teams uploaded survey data daily. e survey did not encounter any challenges. Use of smart- manager would download the data and conduct phones in two surveys saved approximately plausibility checks, relaying any data quality US$8,352 compared to paper-based surveys. issues to the team supervisors to ensure subse- One survey of 25-35 clusters requires one set of quent data was of better quality. six smartphones, which cost about US$3,180, and which are used for subsequent surveys. Global Positioning System (GPS) improves Lessons learned the quality of data by locating the sampled to date, 19 countries have been trained on ODK. household. Collection of GPS information enables Developing the survey tool using Microso World Vision Kenya introduced the concept of mapping of data during the data collection Excel is more user-friendly, easier and faster ODK for nutrition surveys conducted in Kenya; process to show randomness of the data. is than using online ODK build function. Since this article shares their experiences around this. protects against the risk that a data collection Excel is offline, it is easier to work with; e.g. team could falsely complete the questionnaires. Methodology changes can be made that are then uploaded. Recommendations to the developers are to World Vision conducted a three-day LQAS (Lot Power conservation, internet connectivity increase the cloud size to accommodate more Quality Assurance Sampling) survey training and mobile network coverage influence the time data sets, especially for organisations conducting using ODK for 12 staff from a consortium of to upload survey data. To enable the smartphones many surveys, without charging fees for cloud four non-governmental organisations (NGOs) to keep power longer, ‘app lock’ is used to lock storage. In addition, it is difficult set up questions and equipped them with skills to create a survey some applications, which reduces power wastage. normally in tabular format where each column tool, upload data and download it for analysis. Back-up power banks of about 5,200mAH were requires different types of ODK responses. For is training led to the development of a Stan- purchased by World Vision to address the chal- example, for questions on utilise “add group”, dardised Monitoring Assessment for Relief and lenge of some smartphones being drained of the ODK output is normally a link that requires Transition (SMART) survey generic tool by the power during data collection. ese power banks additional publication; hence more time is nutrition sector in Kenya. Sixty enumerators are able to charge a smartphone twice in a day. needed to organise the data before it is transferred and 20 team leaders in Turkana County and 30 It is also essential to map out availability of to another soware program for analysis. enumerators and ten team leaders in Wajir were mobile network or internet so that the survey trained for four days to conduct SMART surveys. teams can upload data daily. Survey teams were During the fourth day, the survey teams com- Conclusion provided with data bundles to allow data upload ODK has proved to be a good platform for pleted a pilot exercise using smartphones. is while in the field; bulk 300MB costs about faster, cost-saving collection and aggregation of was followed by six days of data collection in US$10 and is shared among teams. nutrition survey data. World Vision’s experience the field. Use of smartphones is not a substitute for with ODK has been shared with other partners; Table 1 compares manual survey requirements survey team supervision, which is key during the Nutrition Information Working Group in against using ODK. Use of ODK saves on printing data collection to provide support and ensure Kenya has embraced the platform and supports or photocopying bulky questionnaires and trans- survey protocols are followed. its use. e positive Kenya experience reflects porting them during data collection to central World Vision’s positive experiences in other data entry centre. It reduces the number of staff Making survey supervisors accountable for countries. needed to collect data, as no data entry staff are smartphones and consistent use of one smart- For more information, contact Daniel Muhinja. required (data is collected using the smartphones phone per team reduces loss and mismanagement Email: [email protected] in the field), and it saves on time needed to of smartphones. To ensure responsibility and access data that has been collected. ODK improves care for the equipment, supervisors signed a Access ODK at: opendatakit.org

Geographic information system mapping of data Table 1 Comparison of traditional vs ODK surveys Figure 1 points for a survey in Turkana county Survey aspect Manual With ODK Data clerks Required Not required Printing and Required Not required photocopying questionnaires Questionnaire Required Not required since data is uploaded on transportation servers Time taken to 40-60 minutes (depending 15-25 minutes complete on size of questionnaire) questionnaire Data access Up to several days to Immediately uploaded complete entry Data quality Compromised at times Improved – GPS tracking, no omissions and use of skip mode. Pictures taken in real time (for example, oedema checks) Environment Excessive paper waste Environmentally friendly Data Can be manipulated Secure and cannot be manipulated Number of Minimum of four Two is suﬃcient people per team Mobile Does not require mobile or Requires mobile or internet to send connection internet data to central servers Electricity Not required (questionnaire Requires electricity to charge is photocopied in advance) smartphones as survey progresses ...... Source: World Vision Kenya 菀菀 Field Article ......

Location: South Sudan What we know: Management of SAM children with medical complications is critical; communicable disease burden can rise in emergencies, increasing caseload and adding strain to existing health services, including key medicines supply and management. What this article adds: Throughout the heightened emergency phase in South Sudan from 2014 to 2016, WHO intensified support to nutrition programmes with increasing focus on inpatient management of medically WHO emergency complicated severe acute malnutrition (SAM). A SAM-specific medicines kit was devised and introduced in June 2016, along with a comprehensive nutrition capacity-building package and consistent M&E tools, in line with existing WHO Global Guidelines and national information systems of the health and nutrition sectors. Kits were distributed to one third of functioning response in stabilisation centres before the latest escalation in violence disrupted services and monitoring. This initiative reflects WHO’s operational role in South Sudan nutrition programming in emergencies.

By Marina Adrianopoli and Allan Mpairwe Context el Ghazal, one of the 10 former states of South Sudan before reorganisation in 2015, Marina Adrianopoli has been Current crisis South Sudan, the world’s newest nation, has hit the catastrophic level of 33.3%, in- supporting WHO in South Sudan dicating that one in every three children as Emergency Nutrition Focal has chronic vulnerabilities and is faced with multiple crises alongside historical aged 6 to 59 months is acutely malnourished. Point since 2014. She has over 10 In Western Bahr el Ghazal, GAM prevalence years’ experience in advising on marginalisation, acute insecurity, economic decline, disease and lack of access to services, is now 20.6%, a nearly two and a half-fold and implementing nutrition increase in malnutrition in the last six emergency response, policy- infrastructure and food. e armed conflict in South Sudan has caused a major public months (8.5%, Dec 2015). Food insecurity making processes and country-level programmes is at critical levels in Northern Bahr el focusing on public health nutrition and food and health crisis since December 2013, disrupting essential primary and secondary healthcare Ghazal, Warrap, Western Bahr el Ghazal, nutrition security in different emergency and 1 services and infrastructure. Since then, de- Upper Nile, and Lakes Region . development contexts in East Africa, Central Asia and spite diminishing intensity of the armed Eastern Europe. WHO role in South Sudan violence and increased humanitarian access Less than 40 per cent of the population has in the most-affected areas, the conflict has Dr Allan Mpairwe is the access to basic health and humanitarian spread to new areas that were previously Programme Manager for Health services, and more than one third is in stable, causing further displacement and Security and Emergencies for the urgent need of food, agriculture and nutri- damage to livelihoods. In July 2016, the WHO Country Office in South tion assistance. e WHO Country Office country was already facing rising food in- Sudan. He has over 15 years’ (WCO) in South Sudan provides basic security (due to deepening economic crisis, experience in implementing healthcare in line with the WHO/AFRO unresolved tensions and depleted food emergency health services in transformation agenda2 and Universal Health stocks from limited household production) resource-limited settings and has supported Coverage principles. Adequate and timely and critical malnutrition levels, when re- emergency response operations in South Sudan for health humanitarian response and surveil- newed and severe conflict broke out. is the last seven years. He was instrumental in the lance are effected through coordination has sparked a new wave of mass displace- initiation and introduction of the new kit for with partners, addressing inequality in the ment and has been devastating for civilians; management of children with SAM with medical delivery of priority health services across health and nutrition facilities have been complications in South Sudan. the country by targeting the most under- attacked, damaged and looted. served populations. As Health Cluster lead The authors gratefully acknowledge Dr Usman Prior to the July 2016 crisis, 4.42 million agency, WHO works to ensure a functioning Abdulmumini, WHO Representative in South Sudan, people were estimated to be in need of health sector coordinating mechanism in- and colleagues from the Country Office in Juba, emergency healthcare; an estimated 4.7 volving UN agencies, partners, health au- Magda Armah, Health Cluster coordinator, and Sylvain million people are now in need of health thorities, donors and community members, Denaire, Operation Officer, for playing a crucial role in assistance. e conflict has compounded and provides up-to-date information on supporting the implementation process at the an already dire health situation, documented country health situation and needs, including national level. Thanks also to Havaskhon by appalling health indicators, including regular situation reports and bulletins3. Abdulatipova, Henry Lagu and the staff of the WHO the following mortality rates: maternal Under the Health Security and Emer- Juba Logistics Unit, who provided logistics support. (2,054/100,000 live births); neonatal Deep appreciation is expressed to Dr Adelheid gencies operations, emergency nutrition is (43/1,000); infant (83/1,000); and under- a strategic sector for WHO in South Sudan. Onyango, WHO AFRO Regional Advisor for Nutrition, fives (106/1,000). Sophie Laroche, WHO HQ Essential Medicines, and Since the onset of the crisis in early 2014, colleagues at WHO Headquarters Department of e current prevalence of acute malnu- WHO has provided technical and strategic Nutrition for Health and Development for their trition in South Sudan is unprecedented. guidance to the nutrition humanitarian technical guidance, advice and continued support. Global acute malnutrition (GAM) rates now exceed emergency thresholds of 15% 1 IPC analysis 2016. A poster sharing these experiences was presented at in all states except Central Equatorial and 2 www.afro.who.int/en/rdo/transformation-agenda. the World Nutrition Congress, Cape Town, South Lakes. An estimated 5.1 million people are html Africa, in September 2016. Improving strategies for 3 The work of WHO in South Sudan, 2015. Working classified as severely food and nutritionally towards better health outcomes for the people of inpatient management of severe acute malnutrition and insecure. e GAM level in Northern Bahr South Sudan...... medical complications in children: A new WHO medical module distributed in South Sudan as innovative WHO Emergency Response on Nutrition. Marina Adrianopoli, 菀菀 Allan Mpairwe and Sophie Laroche. Field Article ...... community and Ministry of Health (MoH) during common causes of death are malaria, followed and reinforce the capacity of medical teams man- the level 3 emergency. It has effectively supported by ARIs, and acute watery diarrhoea. Commu- aging patients with SAM with medical conditions. review of strategic plans, policies, guidelines and nicable diseases remain a concern throughout In this challenging context, WHO South Sudan criteria, and provided operational guidance on the country due to poor sanitation, shortage of has identified the provision of a medical kit for nutrition, through close collaboration with the safe drinking water, crowded living conditions, SCs and the related capacity-building package MoH and partners. WHO is also actively engaged malnutrition, and poor immunity. ere has and guidelines as a comprehensive strategy to in intensifying timely sharing of nutrition infor- been a notable upsurge in the scale and frequency support SCs managing SAM children with medical mation to better plan the response, as well as of outbreaks of epidemic-prone diseases, especially complications (MSAM/MC). strengthening linkages and integration between in displacement sites where malnutrition and e innovative procurement strategy shaped health and nutrition. poor immunity render young children and preg- by WHO in South Sudan entails: nant women particularly vulnerable. A major is article documents WHO-led developments • Design and technical development of an inov- cholera outbreak was reported in the second and progress around the treatment of complicated ative kit (see Box 1), which has been distrib- quarter of 2016 and is ongoing. SAM in South Sudan. uted in South Sudan and has been available in As of September 2015, some 55% of the health the online WHO catalogue since April 2016. Identified gap: Challenges in facilities in Unity State, Upper Nile State and South Sudan was the first country in the world management of complicated Jonglei were no longer functioning. Stock-outs of to introduce the medical kit in June 2016; SAM essential medicines exacerbate the critical situation7. • Standardisation of the set of medicines needed According to Nutrition Cluster (NC) projections, e conflict hampers access to and delivery of in SCs, aligned to South Sudan national med- in 2016 nearly 690,000 children under five years humanitarian assistance and has already increased icine usage and taking into consideration of age are expected to be acutely malnourished, the operational costs of implementing the hu- quality, safety and efficacy of medicines of whom more than 230,000 will be severely manitarian response. is is exacerbated by the supplied; malnourished. e burden of SAM children with very fragile health systems (lack of skilled staff, • Fast track procurement, involving supply of medical complications is significant and estimated supplies and equipment, leadership, functioning standard, pre-packed kits ready to meet priori- at up to 10% of the total SAM caseload (approx- facilities, etc.) at all levels. Most of the health ty health needs in an emergency, agile supply imately 6% in 2015)4. Figure 1 reflects the ad- facilities in Juba and affected states are almost chain management and strategic sourcing of missions trend of malnourished children with non-functional, as health personnel fail to report SC drugs to support positioning of supplies; medical complications at a stabilisation centre for duty due to the prevailing insecurity8. • e inpatient care component of the Integrated (SC) through 2015. Medical complications of Management of Acute Malnutrition (IMAM) SCs are usually set up in hospitals or in Primary SAM include: severe oedema; poor appetite in- national guidelines will be updated, aligned Health Care Centres (PHCCs), which are normally cluding inability to suckle breastmilk effectively; with the Hospital Care of Children Pocket situated at Payam headquarters. ey provide re- and one or more Integrated Management of Book 2013 (reference guidelines in SCs); ferral services as well as laboratory services for Childhood Illness (IMCI) danger signs5. Children • Quality assurance, as all drugs are obtained diagnosis, maternity and inpatient care. Each presenting these conditions should be treated as from reliable sources; and PHCC is expected to serve a catchment area of inpatients in SCs, where clinical and nutrition • Integrated feedback mechanism (report), so around 50,000 people. Drugs used in the SC are care is provided. However, the lack of basic that the service can be continuously im- part of the hospital or PHCC package; therefore medical supplies drastically reduces the capacity proved in response to feedback on delivery. SCs rely on hospital and PHCC stock and use to deliver effective and immediate response. medicines that are also administered to sick non- is strategy enables MoH and partners operating e most common morbidities amongst in- SAM children who present. As a result of service SCs to be autonomous in providing timely treat- ternally displaced persons (IDPs) in South Sudan integration, procurement and budgeting exclusively ment. It also provides a stopgap measure, offering are acute respiratory infection (ARI), acute bloody for SCs’ stock of medicines is not common practice. relief for hospital stocks of medicines, which diarrhoea, and malaria (see Table 1); the most Since they are embedded in static health facilities, currently are not procured and managed specifi- SCs are also more exposed to closure in times of cally for children with SAM/MC. Top causes of morbidity insecurity and displacement compared to outreach Table 1 among IDPs6 and outpatient mobile nutrition services. Training To provide guidance on medicine usage and sup- No Disease Cumulative Cases as % of total cases 2015 consultations WHO response port partners in delivering refresher training to 1 Malaria 276,913 28% An improved inpatient care component of CMAM staff working in SCs, WCO South Sudan has de- 2 Acute respiratory 187,673 19% in South Sudan called for measures to address veloped a context-specific, capacity-building pack- infection (ARI) critical drugs shortage through timely procurement age on inpatient management of SAM focused 3 Watery diarrhoea 82,747 9% of essential medicines, ensuring coverage coun- on medical conditions. Building on the WHO 4 Acute bloody 10,386 1% trywide including conflict-affected areas and in Guidelines and training for the inpatient treatment diarrhoea terms of protection of civilians (PoC). Additional of severely malnourished children9, the package 5 Measles 598 0.002% actions such as training were required to develop has been developed by WHO Emergency Nutrition South Sudan, with the support of implementing Admissions trend of malnourished children with medical complications at a partners and WHO AFRO Regional Office, and Figure 1 stabilisation centre (SC) in Bentiu Protection of Civilians site, 2015 cleared by MoH, Republic of South Sudan. 60 4 South Sudan Humanitarian Response Plan 2016. 5 www.who.int/maternal_child_adolescent/documents/IMCI 50 50 48 _ chartbooklet/en/ 46 6 WHO South Sudan (EWARN) Early warning and disease 42 42 38 surveillance bulletin. www.who.int/hac/crises/ssd/epi/en/ 40 37 37 7 WHO/MOH Situation Reports on Cholera in South Sudan, 34 34 35 32 August 2016. 28 29 2930 29 30 27 28 8 Humanitarian Needs Overview, 2016. 2424 24 9 Based on WHO Guidelines for the inpatient treatment of 19 17 19 18 severely malnourished children, available at www.who.int/ 20 16 15 15 13 nutrition/publications/severemalnutrition/9241546093/en/, 11 1711 13 1112 10 9 7 9 7 8 78 and WHO Paediatric emergency triage, assessment and 5 5 6 5 6 treatment: care of critically-ill children Updated guideline 0 2016 www.who.int/maternal_child_adolescent/documents/ 0 paediatric-emergency-triage-update/en/ 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 10 WHO Pocket book of hospital care for children: Second No . of SamNo cases with medical admitted complications Weeks edition www.who.int/maternal_child_adolescent/documents /child_hospital_care/en/ ...... 菀菀 Field Article ......

e package consists of four tools: Box 1 Content of WHO SAM kit 1) A comprehensive refresher training of 70 slides covering key steps of the Management The objective of the new WHO kit Second line drugs for the medical management of Severe Acute SAM/MC, addressing both clinical and sup- Malnutrition with medical complications is to provide essential drugs for the inpatient management of portive care for conditions to be treated with severe acute malnutrition with medical complications in children (MSAM/MC). the medicines provided. Most slides can be The content is organised into four modules which constitute one kit, sufficient to treat 50 children with used as stand-alone handouts or posters. It is SAM/MC. The kit contains 33 medicines and 11 health commodities. The modules are: not a substitute for full training on appropriate Routine drugs module Contains routine drugs also used in outpatient nutrition programmes management of SAM with medical complica- (anthelminthic, antibiotics, retinol and resomal). tions, designed for health-care providers. Basic module (analgesic, antifungal, antibiotics, solutions for treatment of hypoglycaemia, 2) A pictorial manual illustrating medical con dermatological preparations, ophthalmological preparations, health commodities and renewable). ditions associated with SAM in children, Supplementary module (medicines used in heart failure, antibiotics, ophthalmological preparations). accompanied by detailed explanations. Malaria module (Coartem tablets, artesunate, malaria rapid diagnostic tests and lancets), incorporated 3) Pocket book of hospital care for children: in the kit to address one of the top priority diseases reported in the context under consideration. Second Edition – Guidelines for the man- The kit does not contain nutritional commodities as it has been designed to complement existing kits, agement of common childhood illnesses. equipment and supplies already provided by UNICEF and WFP. The provision of kits complements the is includes a full chapter on the inpatient collective NC response in South Sudan, largely focused on outpatient and preventive care of SAM. management of SAM, web link to the Pocket The kit was established in line with the recommendations of the 1999 WHO ‘Management of severe book10 and links to free applications for malnutrition: a manual for physicians and other senior health workers’ and the ‘Course Director Guide of android phones and iphones. the related WHO Training Course, 2002’. The list of drugs, initially developed in 2011, was reviewed by 4) WHO video – Emergency Treatment, which SAM management experts, the WHO Expert Committee on Essential Medicines, and with advice from illustrates urgent actions required and stan- colleagues from relevant WHO departments (HAC, CAH), and revised accordingly. dard emergency procedures on giving oxygen, glucose, fluid and antibiotics to help improv- mation, together with several field-mission find- (16 facilities out of a total 5811), ranging from ing the quality of inpatient care for the man- ings, was instrumental in better identifying hospitals to PHCCs in host communities, IDP agement of SAM/MC in children. capacity needs, information gaps, stock capacity and PoC sites. Supplies are calculated to treat e capacity-building package was illustrated to and skills in management of supplies. is laid 1,000 children over three months. e distribution the nutrition and health community in South the foundations for developing the capacity- strategy took into account the different levels of Sudan during the ‘kick off’ meeting and distributed building and monitoring packages. vulnerability across the country and aimed at re- to all nutrition and health cluster partners running sponding to the high needs in urban contexts inpatient care programmes. Technical orientation Implementation and PoC sites, where the SCs integrated in the on the package has been provided by WHO Procurement of the first 20 kits by WHO South main hospitals of the capital Juba and clinics in during ad hoc orientation sessions conducted Sudan began in November 2015. e process of PoC sites required increased support. collectively and on a one-to-one basis with all procurement for these initial kits was long (six Sadly, as soon as the distribution was completed, interested partners and the MoH. months) as it involved medicine procurement from different suppliers, MoH clearance and as- a renewed and terrible wave of violence erupted Monitoring sembly of the kits in Juba. (Now that the kit again, drastically reducing the capacity of partners Five monitoring components have been developed features in the WHO online catalogue, the shipment to respond to the emergency. Most of the staff by WHO South Sudan aimed at collecting, man- takes approximately one month from the purchase were relocated (WHO and other nutrition/health aging, analysing and reporting on key indicators order). e first recipient, MoH, and partners’ cluster implementing partners’ personnel worked to track progress, plan response and prioritise facilities were selected based on average monthly remotely from the region in July, August and actions to improve service delivery (see Box 2). caseload, prevalence of GAM (and associated September) and the monitoring system has been SAM) in the catchment area, population figures interrupted. Preparatory work including number of children under five as per A consultative process began in November 2015 the official statistics, documented gaps in stock Conclusions led by WCO Emergency Unit/Nutrition, involving of medicines, and confirmed presence of medical The overall response reflects an active imple- the MoH, NC, Health Cluster and implementing officers operating in the SC (given the nature of menting role of WHO in an emergency, specifically partners, and technically supported by WHO the kit and skillset required). e selection process in the context of the CMAM approach. WHO’s HQ. Key steps of the process have included tech- was coordinated by WHO Emergency Nutrition, role has been to strengthen complicated case nical consultations with MoH Pharmaceutical supported by the Health and Nutrition Cluster management, which tends not to attract the same Department, Nutrition Unit and Primary Director coordination team and guided by the MoH. attention as the prevention, outreach and outpatient General; verification and review of the list of services for MAM and SAM children. e expe- medicines to ensure consistency with the List of e strategy was launched in June 2016 in rience in South Sudan reflects efforts to strengthen Essential Medicines of South Sudan; and meetings conjunction with the distribution of kits. e coordination and synergies between clusters and with partners at different levels to corroborate distribution covered nearly one-third of the total other key actors at national and field levels in the the effectiveness of drugs utilisation. is infor- functioning SCs across all ten (former) states context of CMAM. e development of a standardised module of medicines for SAM/MC brought a unique opportunity for WHO South Box 2 Monitoring tool Sudan to increase effectiveness and sustainability of life-saving nutrition interventions and to boost WHO strategy shaped around improved inpatient Tool 1: Stock inventory form, to track the quantity of medicines dispensed and the balance in each facility. management of SAM/MC, which encompasses Tool 2: The Inpatient Therapeutic Programme (ITP) SC data collection form, employed by the current provision of medical supplies, capacity-building Nutrition Information System (NIS) of the NC in South Sudan, is integrated as the second tool. Partners and review of national guidelines. are required to continue reporting to the NC on a monthly basis, as per the established mechanism; WHO has supported the NC in advocating for an increased reporting performance. For more information, contact: Tool 3: Additional information on the medical conditions diagnosed and treated, including eye Marina Adrianopoli, email: Marina.adrianopo- problems, severe anaemia, SAM with oedema, malaria, suspected/confirmed HIV infection and ARI [email protected], tel: +393497507123 or Dr Allan (including TB and pneumonia). Mpairwe, email: [email protected] ; ampair- Tool 4: Final feedback form, to assess the appropriateness of medicines and material provided [email protected], tel: +256772510026 (quantity, suitability) and suggestions for improvements. Tool 5: Challenges and strengths, for submission at least once and any time during implementation. 11 Nutrition Cluster, March 2016...... 菀菀 Agency profile......

Name: WaterAid Address: WaterAid, 47-49 Durham Street, London, SE11 5JD, UK Email: [email protected] Website: www.wateraid.org/uk Year founded: 1981 Chief executive: Barbara Frost No. of HQ staff: 289 No of staff worldwide: 1151 WaterAid/ Ernest Randriarimalala, Madagascar, 2016

NN interviewed Dan Jones and Megan sustainable water, sanitation and hygiene (WASH) Dan explained that the organisation still sees Wilson-Jones from WaterAid for the services for the whole population. is new itself very much as a development agency with a Field Exchange agency profile slot. Megan strategy is much more about advocacy and exer- focus on long-term sustainable programming, is the Policy Analyst for health and hy- cising influence; WaterAid still supports on-the- although emergencies do occur where they operate gieneE in the global policy team, while Dan (no ground programmes, but increasingly uses them in fragile contexts. For example, in Nepal recently, relation) is Advocacy Coordinator for Healthy to demonstrate what can be done to local, district WaterAid found itself working as part of the Start, WaterAid’s current global advocacy priority and national decision-makers in order to provide WASH cluster, contributing hygiene expertise to to improve child health and nutrition by integrating evidence and support the government in scaling programming. e organisation has also been water, sanitation and hygiene into health policies up and ‘owning’ the provision of national services. involved in the Ebola crisis in West Africa, as and programmes worldwide. Both used to work WaterAid also invests in work to enable citizens well as engaging in policy dialogues on anti-mi- for RESULTS UK (which advocates for building to claim their rights. As it looks to influence crobial resistance. Megan described how these the public and political will to end poverty) and, governments on how much and how they spend experiences reinforced the vital importance and since they are relatively new to the organisation, on WASH, it supports them in budget planning major gaps in provision of clean water, sanitation checked in with some longer-serving colleagues and tracking. It also looks at international insti- and good hygiene in hospitals and health clinics. to answer some of our questions. e answers tutions and donor agencies and how WASH needs (WHO estimates that, for example, 38% of health- were very interesting. to be integrated into health, nutrition and edu- care facilities in low and middle-income countries cation, because WASH underpins many of the lack access to clean water, making preventing WaterAid was set up in 1981 by the UK water Sustainable Development Goals – as Megan puts and controlling infections impossible). industry following a irsty ird World con- it simply: “ey all need WASH for success”. e WaterAid is increasingly collaborating with ference, which was prompted by the industry’s ultimate aim is national-led plans that donors the SUN Movement at global and national levels. desire to respond to the UN Decade on Water. coordinate and harmonise funding streams behind; e SUN Movement Secretariat has contributed e UK water industry raised £25,000 and Wat- an ambition that explains WaterAid’s engagement greatly to WASH policy development at national erAid was born, starting with projects in Zambia with mechanisms such as the Sanitation and level, with country staff becoming members of and Sri Lanka. Fast forward to 2016 and WaterAid Water for All global partnership (SWA)1; similar the national Civil Society Alliance. WaterAid has has just celebrated its 35th anniversary. Its growth to the SUN Movement in the WASH world. has been truly phenomenal: in the six years from also recently become part of the new BabyWASH 2009 to 2015, it provided 9.6 million people with Megan explained that nutrition is a relatively coalition, working closely with World Vision clean water and a further 13 million with sanitation new area of interest for WaterAid, as part of its ex- (lead) and others. is coalition is bringing to- facilities. It also expanded its country programmes panding work on health. e growing evidence of gether actors from Early Childhood Development, in that time from 22 to 37, including countries links between WASH and nutrition, as well as Nutrition, Health and WASH, and was launched in Asia, Africa and the Americas. is year, Wa- critical work on environmental enteric dysfunction at this year’s UN General Assembly. (EED), has helped promote greater focus on nutrition terAid India became the first country programme WaterAid believes that multi-sector program- within the organisation. e World Health Organ- to become a member of the WaterAid International ming is essential to ending malnutrition. However, isation (WHO) estimates that half of all undernu- Federation. e secretariat for the Federation is its recent Missing Ingredients report (summarised trition is linked to infections caused by unsafe based in the UK and all members (Australia, in this edition of Field Exchange), which analysed water, lack of sanitation and poor hygiene. Most Canada, India, Japan, Sweden, United Kingdom national nutrition action plans, found that apart member countries now have health advisors that and United States of America) are involved in from Timor Leste and Nepal, very few countries cover nutrition, and country programmes are in- advocacy and fund-raising in respective countries. are comprehensively embedding and integrating creasingly employing health and nutrition staff. WASH into these plans. Furthermore, very few Dan explained that WaterAid’s general oper- Megan mentioned two recent WaterAid nutrition- WASH plans make reference to nutrition. Megan ational model is to work with local partners to sensitive WASH programmes. One is in Bangladesh, reflected that designing WASH programmes target the most marginalised communities. It is where the WASH programme has an element through a nutrition or health lens can lead to best known for its ‘taps and toilets’ programmes; specifically to improve access to water for food better quality programmes; for example by targeting a reflection of its founding by a group of water production. e second, in Nepal, is collaboration programmes based on nutrition vulnerability. engineers. Over the years, the organisation has with the Ministry of Health and builds hygiene and With regard to behaviour change, there is a real evolved into using a ‘transformation and sus- nutrition behaviour-change into the routine im- opportunity to come together and combine efforts tainability advocacy-based model’, working closely munisation of rotavirus. WaterAid has just developed with national governments, who are encouraged internal guidance material on how to improve the to take ownership of scaling up and delivering nutrition-sensitivity of WASH programmes. 1 sanitationandwaterforall.org/ ...... 菀菀 Agency Profile ...... grammes can also be problematic, as they are – taking breastfeeding and food hygiene as ex- between WASH and nutrition), it is likely that, oen too short to report nutrition impact unless amples, both involve changing behaviours, which given the increasing evidence of overlapping followed for a number of years. Finally, stake- is challenging. However, through utilising multiple pathways for wasting and stunting, the attention holders need to stop thinking in silos. Dan sug- delivery channels and delivering joint messaging, of WASH actors like WaterAid may start to gested that this occurs on multiple levels – pro- especially if one reinforces the other, this could include a focus on wasting. gramme silos, sector silos, divided ministerial lead to more effective and sustained behaviour Our last question concerned the major chal- responsibility in governments, and even silos change. lenges for scaling up nutrition-sensitive WASH within donors (humanitarian and development). WaterAid is not a research-organisation and programming. Dan reflected that, in order for is, he argues, needs to change. does not engage in randomised controlled trials, WASH services to lead to nutrition outcomes, WaterAid is a large and highly respected however it is well placed to contribute to the the services must be utilised, and changing be- WASH agency that is starting to look at how learning and evidence around delivering coordi- haviours is very challenging. It requires under- policy and programming can best support nutri- nated and integrated programmes, oen described standing the specific context (knowing what motion. ENN greatly looks forward to including as operational research. Although the nutrition tivates behaviours and what the barriers are), WaterAid learning in this relatively new area in focus of its work has so far been on stunting which is informed through rigorous, formative future issues of Field Exchange. (where there is the strongest evidence of a link research. e typical time-frame of WASH pro-

Views......

ditional contributing factors to malnutrition in the worse-off counties are sub-optimal Infant and South Sudan nutrition: Young Children Feeding (IYCF) practices and poor water, sanitation and hygiene (WASH) facilities and practices. Child-feeding practices, such as Overcoming the challenges of untimely introduction of complementary foods or poor quality and inadequate quantity of these nutrition information systems foods, contribute substantially to the high levels of malnutrition. Additionally, low exclusive breastfeeding practices are a key contributing factor. e health sector in South Sudan, the youngest nation in Africa, has been growing In the upcoming season (September to De- from strength to strength amid insecurity and emergencies that have affected the cember 2016), the nutrition situation is expected general nutrition situation. e Ministry of Health and partners are implementing to improve slightly in most counties due to the various nutrition programmes and coordinating efforts to put in place a sustainable expected harvest, pasture and availability of milk. nutrition information system. In an interview with Titus Mung'ou, ENN Regional Admission trends to nutrition centres are also Knowledge Management Coordinator (SUN), Rebecca Alum William, the Director of expected to decrease in most counties in the Nutrition in South Sudan, and Shishay Tsadik, the Nutrition Technical Advisor country during this season. However, taking into seconded to the Ministry of Health by Save the Children International, discuss progress consideration the current existing burden of made. acute malnutrition, market price trends and the existing high level of conflict, the nutrition situation in Northern Bahr el Ghazal and Unity Q: How would you summarise South Sudan’s with recent assessments4, and ‘Critical’ (15% to states are not likely to see significant changes current nutrition situation? 29.9% prevalence) in Akobo, Twic East, Uror, and will likely remain in ‘Critical’ phase (GAM A: Overall, the nutrition situation in South Sudan Abiemnhom, Guit, Mayom, Mayendit, Panyinjar, prevalence currently 15% and 29.9% respectively). is worrying, with global acute malnutrition Rubkona, Bentiu POC, Pariang, Longetchuk, Q: Since joining the Scaling Up Nutrition (GAM) persistently above the emergency threshold Nasir, Maiwut, Ulang, Wau, Gogrial West and (SUN) Movement in June 2013, what in the Greater Upper Nile, Northern Bahr el Gogrial East. Counties classified as ‘Serious’ (10% important steps have been taken and Ghazal, Warrap states and Eastern Equatoria to 14.9% prevalence) were Kapoeta North, Melut, milestones achieved in South Sudan as a result states (FSNMS, Dec 20161). According to the Maban and Tonj North, while Kapoeta South is of joining the Movement? most recent national data, nearly one third of in ‘Alert’ (5% to 9.9% prevalence). A: e Republic of South Sudan officially joined children under five years old are stunted, 23 per e deterioration in the nutrition situation is the global SUN Movement in 2013 aer a letter cent wasted, and 28 per cent underweight (SSHHS primarily due to physical insecurity (which partly 2010)2. e prevalence of GAM varies seasonally hinders the humanitarian response), the effects and substantially across states, with peaks of up 1 World Food Programme South Sudan, Food Security and of the economic crisis, and depleted stocks from to 30 per cent in some locations. Nutrition Monitoring Report (FSNMS) bulletin 18 July 2016. the last harvest. In the Greater Upper Nile, while 2 South Sudan Household Health Survey 2010 Final Report, From April to August 2016, a total of 26 conflict subsided in most areas, it persists in some published August 2013. 3 Proxy GAM is a term used to denote findings from rapid county-level assessments were conducted; 81% pocket areas. Furthermore, the economic crisis nutrition assessments where conditions often involving of these assessments showed GAM rates above (partly due to devaluation of the South Sudanese insecurity have prevented standard ENA SMART methodolo- the 15% WHO emergency threshold. Based on pound and exponential increase in food prices in gies being used. 4 August 2016 Aweil North and Aweil West exhaustive MUCA 3 the analysis, the GAM/Proxy GAM was ‘Extreme 2016), coupled with persistent violence, notably screening result. Critical’ (>=30% prevalence) in Aweil North and in Wau and some parts of the Greater Equatoria, 5 World Food Programme South Sudan, Food Security and Aweil West, which were the only two counties aggravate the malnutrition situation5. Major ad- Nutrition Monitoring Report (FSNMS) bulletin 18 July 2016...... 菀菀 Views ...... of commitment was signed by H.E the Vice Pres- Security and Nutrition Monitoring System). Have helps nutrition stakeholders in resource mobili- ident. e letter expressed the political commit- these improvements been maintained and what sation, planning and decision-making. However, ment from the Government of the Republic of steps are being taken or are needed to strengthen most nutrition assessments focus on emergencies South Sudan to scaling up nutrition in the country. NIS in South Sudan? and the results don’t influence stakeholders in A: Yes, improvements have been made and main- addressing longer-term nutrition resilience and e SUN Movement was launched in the tained. ere are efforts to integrate the NIS into protection responses. country with commitment to include nutrition the District Health Information System (DHIS) in the Food Security Council so that it became and Health Management information system Q: e need for advocacy by Nutrition Cluster ‘the Food and Nutrition Security Council (FSNC)’ (HMIS). Currently, nutrition information reporting partners to build MoH understanding of the im- in in 2013, the same year of the launch of SUN formats, registration books and other tools are portance of information systems in relation to Movement. e FNSC is a high-level, multi- being developed and finalised in consultation preparedness and response planning was identified sector policy coordination platform chaired by with the Nutrition Information Working Group in 2013. Has it been addressed? How? H.E the President. SUN Movement activities (NIWG). Nutrition information is then shared A: e MoH has started emphasising the critical have been slow since the launch, with limited with the M&E Department of the MoH. importance of NIS. ere are moves to integrate progress in establishing the country’s SUN Sec- systems, as outlined earlier; NIS tools and indi- retariat and SUN networks, developing the Na- Together with the nutrition coverage network cators have been identified; and the MoH is tional SUN Work Plan and other activities. is , the MoH and Nutrition Cluster facilitated a les- looking for resources to train and build the partly reflects the crisis which erupted in 2013, son-learning workshop on how to maintain the capacity of health and nutrition service providers resulting in a refocus on humanitarian activities. capacity of partners and government actors to and personnel involved in data collection, reporting However, revitalisation of the SUN Movement conduct coverage assessments for the treatment and analysis on how to use these nutrition infor- started again in April 2016. A six-month detailed of SAM and MAM and maximise the use of cov- mation tools (mainly the reporting formats, reg- work plan for revitalisation of the country’s SUN erage assessment results. istration books, monitoring and supervision Movement was developed with a focus on con- Beyond the traditional SMART assessments, checklists). e integration/harmonisation will ducting social mobilisation and advocacy, estab- there are initiatives to consider other monitoring critically allow for a central database within gov- lishment of different SUN Networks, development mechanisms like the Integrated Food Security ernment that can be used for planning, deci- of work plans for the networks, and development and Nutrition Causal Analysis (IFANCA), sion-making and further research. of a national SUN work plan. Factors that con- strengthening the FSNMS and IPC system for tributed to this revitalisation included nutrition Q: How has MoH addressed the challenge of its South Sudan which helps MoH to make informed being prioritised in Ministry of Agriculture and capacity to lead and implement NIS and engage decisions. Health policies, strengthening of the Nutrition technically in NIWG? What progress has the Directorate by the Ministry of Health (MoH), Q: How is the MoH undertaking its functions as MoH made in enhancing its capacity in infor- and United Nations (UN) agencies supporting a the Secretariat of NIWG? What key lessons and mation management? ‘rebooting’ of the SUN Movement in the country. challenges have MoH noted in coordinating ac- A: e developments outlined so far reflect actions tivities with NIWG members? and progress made in this regard, such as moves e South Sudan SUN Movement Steering A: In April 2015, the MoH assigned two national to harmonise NIS within DHIS and HMIS, inte- committee was established in late 2015 with a technical staff, together with the Nutrition Advisor grate the NIWG within the MoH’s M&E Depart- responsibility to provide technical support to seconded from Save the Children (SCI) working ment, and transition the Nutrition Cluster NIS SUN networks and advise the SUN Focal Point, with the NIWG, to lead the overall coordination to DHIS and HMIS. In terms of enhanced capacity, the Under-secretary in the MoH. is position is of the group. Moreover, there is an initiative to SCI seconded a Nutrition Technical Advisor to temporarily located in the MoH with its permanent integrate NIWG’s Technical Working Group build capacity of the NIWG and NIS and the location still under discussion. e steering com- (TWG) into the MoH’s M&E Department, where MoH has assigned two technical staff responsible mittee is composed of UN agencies (UNICEF, all health and nutrition information activities to the NIWG who are receiving training supported WFP, WHO and FAO) and government line min- are coordinated, to ensure sustainability of the by partners. e MoH has taken a leadership istries chaired by the MOH Nutrition Director. function of NIWG. However, due to competing role as chair and co-chair of the NIWG and the e Steering committee conducts weekly meetings. priorities, this may take time. MoH Nutrition department is working closely Media advocacy has been identified as one of with the Nutrition Cluster team and partners. Q: In South Sudan, the NIWG officially reports the key strategies for advancing the SUN Move- to the Nutrition Cluster. How has this arrangement Q: Overall, to what extent has strengthening of ment in South Sudan. rough advocacy, it is improved coordination of nutrition information? the NIS (helped by the Nutrition Cluster and hoped to reach out to the many stakeholders A: e NIWG is still reporting to Nutrition largely driven by emergency programming needs) that can have an impact on nutrition in South Cluster, which is one of the limitations, since the contributed to the aims and objectives of the Sudan, as well as inform them about SUN activities. MoH is unable to access, utilise and review the SUN Movement and how could the existing NIS e establishment of multi-stakeholder net- working group’s performance. However, the move in South Sudan be strengthened to further enable works including UN agencies, Donor, Civil Society, to integrate within the MoH’s M&E Department SUN Movement aims and objectives? Academia/Research, and Business/Private Sector will address this and provide a comprehensive A: e current NIS provides a means to understand has begun. database of assessment proposals and results. the levels of malnutrition in South Sudan, the investments on nutrition, the gaps, priorities and Government SUN Focal Point and SUN rep- Q: What is the role of the Government and key the need for national and local government lead- resentatives from MoH and Ministries of Agri- actors in sustaining the NIWG? How have SUN ership to tackle the situation. However, in order culture and Finance have attended global and Movement actors/networks connected with NIS? to strengthen the contribution of NIS to the ob- regional meetings and workshops for experi- Have SUN actors’ activities been influenced by jectives of the SUN Movement, NIS should move ence-sharing and learning exchange. NIS? beyond SMART, FSNMS and IPC to include as- A: e Government and partners sustain the Q: In 2013, South Sudan nutrition actors noted sessments which involve a causal analysis of mal- NIWG. Once the SUN networks are established, challenges of nutrition information during emer- nutrition. ere is also a need for harmonised it is hoped that the NIS will help inform their gencies and the need for a coordinated, validated and standardised national SMART and coverage planning and activities. Nutrition Information System (NIS). Significant survey guidelines, in line with the international and important changes were then made to vali- Q: How has the NIS helped shape policies and guidelines. Furthermore, the most recent national dation of SMART surveys, OTP/SFP (Outpatient programmes in relation to country and global household survey (Demographic Health Survey) erapeutic Programme/Supplementary Feeding nutrition targets? was conducted in 2010. is urgently needs up- Programme) reporting harmonisation, IPC (In- A: e available information from SMART surveys, dating, as there has been substantial change in tegrated Phase Classification) and FSMNS (Food IPC, FSNMS and programme reports significantly the nutrition landscape over the past six years...... 菀菀 Field Article ...... Sampling in insecure environments: Field experiences from coverage assessments

MUAC screening in in Afghanistan Hazrat-e-Sultan District By Marina Adrianopoli and Allan Mpairwe

Ben Allen has been Global Coverage Advisor for Action Location: Afghanistan Against Hunger UK for the past What we know: Afghanistan is a challenging place to implement two years. He has now left to community-based management of acute malnutrition (CMAM) and pursue further study in public coverage assessments, due to persistent insecurity. health. From 2010 Ben worked with ACF-UK in evaluation, What this article adds: Coverage assessments are important but not life- learning and, more recently, on methodologies to saving interventions; exposure to risk should be managed and minimised assess the coverage of CMAM programmes. He has for staff. Insecurity typically affects spatial representation of villages and directly supported two SQUEAC assessments in achieving minimum samples. Including only safe and accessible villages is Afghanistan and provided remote support to many likely to inflate coverage estimates; bias introduced due to adaptations others. should be clearly reported. Qualitative information from identified cases Mark Myatt is a consultant and additional qualitative studies can also valuably inform programme epidemiologist and senior reform and, to some extent, compensate for the limitations to the survey fellow at University College sample. A number of steps can help achieve the basic principles of data London. His areas of expertise collection while ensuring the safety of staff and informants. These include include infectious diseases, balancing risks, triangulation and monitoring of security information, use nutrition and survey design. of local staff, additional context-specific staff training, strong communication protocols and documentation of challenges for wider Nikki Williamson is Senior lesson learning. Project Officer at Action Against Hunger UK, specialising in the coverage assessment of CMAM hen evaluating access and e assessments faced two broad cate- programmes. Previously she coverage of CMAM serv- gories of conflict related to insecurity. First, was SLEAC Programme ices in insecure environ- hostile environments largely caused by conflict Manager in Afghanistan, managing the ments, restrictions on data between government forces and armed op- implementation of the five SLEACs addressed in this Wcollection limit assessments. is article position groups (AOGs) or inter-ethnic and article. Nikki has also conducted a regional SLEAC describes the challenges faced in sampling tribal conflict. Specifically, this entails un- and district SQUEAC in Uganda. during coverage assessments of severe predictable fighting with a risk of crossfire Danka Pantchova is Nutrition acute malnutrition (SAM) treatment serv- incidents, checkpoints and kidnap. Second, Surveillance and Prevention ices across Afghanistan and provides some direct hostility towards staff and users by Advisor with Action Contre la methodological guidance for obtaining armed groups known to be hostile towards Faim France. Previously she the most reliable information while main- government, United Nations (UN) agencies, technically supported all ACF taining staff safety. e article draws on and staff of national and international non- nutrition programmes in experiences from five different SLEAC1 governmental organisations (NGOs) was Afghanistan, including assessments (in Laghman, Badakshan, also experienced. Health workers may be coverage assessments. Jawzjan, Bamyan and Badghis) and three perceived to be part of government and SQUEAC2 assessments (in Samangan, data collection activities are viewed with Hassan Ali Ahmed is the Paktya and Kunar) supported by Action Nutrition Surveillance Head of Against Hunger (ACF) and the Coverage 1 Department with Action Simplified LQAS (lot quality assurance sampling) Monitoring Network3 (CMN) in Afghan- evaluation of access and coverage. Contre la Faim Afghanistan. He 2 istan4. Details on these coverage methods Semi-quantitative evaluation of access and coverage. has worked on nutrition 3 are available at: www.coverage-monitor- See www.coverage-monitoring.org/ surveillance projects in Kenya, 4 See www.coverage-monitoring.org/country/ ing.org/training-centre/ Somalia and Afghanistan for afghanistan/to access the reports. the last seven years and has wide experience of ...... conducting nutrition assessments, including SQUEACs, SLEACs, SMART and Rapid SMART surveys. 菀菀 Field Article Patterns of insecurity: ...... Box 1a Topography further suspicion (considered as intelligence centre staff and locals) strengthened this appraisal. A number of the assessments took place in gathering). e possibility that family planning During each assessment, at least three informants mountainous areas where security challenges tended to be found in more remote areas, activities are being implemented attracts even were openly asked to identify villages that they away from larger towns and roads. This map of wider suspicion (i.e. not just from armed groups) knew to be unsafe, to give the reasons why, and Laghman province shows secure (blue) and of local and/or international NGO activity. to identify other potentially unsafe/inaccessible insecure (red) villages. The secure villages are villages. Unsafe villages were monitored. generally along the main roads at the bottoms In Afghanistan, war and insecurity are a bar- of the valleys and the insecure villages in the rier to accessing healthcare services (MSF, 2014) Villages identified as unsafe and inaccessible more remote mountain areas. in terms of both demand (users seeking care) from all sources were considered dangerous; and supply (partners providing care). For example, where lists did not concur, further data/informant one in two people are said to be concerned discussion clarified the situation. e end result about making dangerous journeys to receive was a full list of villages with security status and healthcare (MSF, 2014), and implementing part- reasons for insecure classification. Insecure vil- ners are under great strain to provide reliable lages were not visited and the security situation supplies of commodities (ACF, 2016; see this for selected villages was monitored for change. report for more details on the nature of insecurity If there was any doubt, case finding in that and how it impacts CMAM service delivery). village was postponed until the security situation Awareness of insecurity patterns can help with had improved (if within the survey period) or planning and implementing assessments (see was abandoned. Table 1 shows the number of Box 1 for examples). villages that were removed (during the initial security review) and then abandoned (due to a A key guiding principle is that, whilst coverage change in the situation) for each SLEAC assess- assessment is key to improving programme per- Patterns of insecurity: ment undertaken in Afghanistan. A rigorous, Box 1b Localisation formance, assessment should not expose survey open and participatory process in the security teams or informants to unacceptable risk: review and on-going monitoring was important In Jawzjan, villages along the international to ensure staff trust in the final security decisions, border and along roads accessing areas in the Handling insecurity in SLEAC north were more insecure. In the areas whilst benefiting from the team’s local knowledge remaining, along roads and around the two and SQUEAC assessments and experience. main towns, the security status of villages was In order to achieve a reliable classification or mixed, with secure and insecure villages being estimation of coverage in a given area, a minimum Stage 2: Case finding at village in close proximity to each other. sample size of SAM children is required, from a level spatially representative selection of villages. To Once villages had been selected, it was necessary achieve this, both SLEAC and SQUEAC stage 3 first to identify an appropriate survey team to (wide-area surveys) use a two-stage process, go to each village, and second to identify safe sampling and case finding. e impact of inse- routes into and out of villages. To increase ac- curity in Afghanistan on both processes is shown ceptance, local survey staff were employed who below. knew local customs (e.g. dress codes, the need for chaperones for female staff), were aware of Stage 1: Sampling villages whether communities accepted non-local women, Two sampling methods are commonly used to and were familiar with local perceptions of data select villages: the ‘list method’ and CSAS collection activities. Survey team members for (grid/quadrat) method. For both, engagement each village were then carefully considered to with security advisors and informants familiar ensure familiarity. If at least one member of a with the area (e.g. programme and survey staff) survey team was already known to local au- was essential to assess the level of insecurity in thorities (e.g. governors, police commanders, each village. Some subjective interpretation (in- paramilitary commanders) and local leaders, cluding understanding of unacceptable risk and then activities at village level were facilitated. assessment of the reliability of information re- Teams and individuals unfamiliar with an area Patterns of insecurity: quired) was required, but triangulation by source or different ethnicity could be at higher risk of Box 1c Volatility (e.g. use survey staff, programme staff, health being threatened, told to leave or kidnapped. In In most provinces, an initial indication of the security conditions was useful but likely to Villages considered insecure initially and subsequently abandoned due change over the duration of the assessment. In Table 1 to insecurity the case of Badghis, the initial reports a few Province Total # Proportion # Villages # Villages % of Reasons for abandoning villages months before the assessment indicated that, Villages remaining sampled visited sampled despite a generally challenging security after initial villages environment, three whole districts could be security abandoned sampled. By the time of assessment, the review sampling frame was reduced to around half Badakhshan 1,692 53% 91 85 7% Clashes broke out in some villages and the villages in just two of seven districts. elsewhere, the team were advised on arrival to turn back. One small town selected became a strategic checkpoint for AOG and was therefore considered too dangerous to visit. Badghis 985 13% 28 25 11% Recent escalation in conflict from nearby villages. Bamyan 1,882 100% 141 133 6% Abandoned due to snow and flooding. Jawzjan 395 23% 25 23 8% A local conflict broke out amongst two communities. Laghman 621 60% 45 33 27% Half of these were in Alingar district where IMAM activities were ceased. Others were in mountainous areas where conflicts escalated and teams were told to turn back by community elders...... 菀菀 Field Article ......

numbers of children screened, houses visited, cases found, and households refusing entry in each village. During fieldwork, communication was also enhanced. Mobile telephone or radio contact was sustained during village visits for assistance and remote supervision. In the earlier stages, teams oen called the survey leader on arrival and on concluding case finding to crosscheck the course of action decided. When possible, end-of-day debriefings, in person or by phone, were conducted and information gathered (in-

Mohameed Mohameed Yousaf Shoor, Afghanistan cluding challenges faced and solutions to overcome them) was shared amongst the entire team for collective learning. Consequences of adapted sampling e insecure environment in Afghanistan challenges spatial representation of villages and achieving a minimum sample of children – two key aims of SLEAC surveys and stage 3 (wide- MUAC screening in Hazrat-e-Sultan District area survey) of SQUEAC surveys. e sample of villages that are both accessible order to identify safe routes into and out of vil- local informants to find suspected cases and as- and safe is unlikely to be spatially representative lages, a risk assessment was undertaken, again sumes a level of social cohesion) and door-to- of the entire intended programme catchment triangulating various sources of information. door case finding (going to every house) were area; identified insecure villages will tend to be Security on roads is oen subject to rapid change used to identify SAM children. Once a suspected isolated. If spatial representivity is likely to be (e.g. due to the use of roadside bombs or check- case was found, the child was screened using badly affected, alternative villages (or contingency points) and required close monitoring. mid-upper arm circumference (MUAC) and for clusters) could be selected as close to the original On the day of visiting the village, a security bilateral pitting oedema. e caregiver was asked village as possible. In the Afghanistan assessments, assessment was conducted using available sources whether the child was in treatment and all cases alternative villages were not used due to time (programme staff, drivers and friends) and, were interviewed in order to identify boosters restraints, resulting in a smaller sample size when possible, village leaders were called in ad- and barriers to access. than planned and therefore less accurate and vance to confirm safe access. If no village-level precise coverage classification or estimates. e Due to the security risk, assessment leaders, contact was available but all available information removed villages are typically places where who were oen international staff, were not indicated safety, then teams proceeded and con- service delivery and access are more affected, permitted to travel to villages to supervise data tacted village leaders upon arrival. When infor- and where coverage is likely to be lower. Including mation at base was not available, survey teams collection, and field training was not possible. only safe and accessible villages is likely to inflate assessed the security situation while travelling To compensate, training included extra practical coverage estimates. e sampling method and to the village and upon arrival. In Afghanistan, classroom-based exercises, including role-play. any potential bias should be clearly noted when village leaders would advise survey teams to A tailored form ensured that teams recorded reporting the assessment. leave if hostile forces were present in the village or nearby. Teams should and would abort field MUAC measurement at an OTP site activities if there is anything above a low level of risk. Once the team and routes had been identified, the following considerations were made to ensure ongoing monitoring of the security situation: • Work with survey teams and teams from other programmes to monitor the on-going security situation; • Liaise with local security services and paramilitary organisations; • Monitor local radio traffic covering UN, NGO, police and paramilitary frequencies and in some settings, local broadcast radio stations; and • Maintain a radio or telephone network to monitor the locations and status of teams in the field. Nicki Nicki Williamson, Afghanistan Depending on the existing staff capacity, additional resources (for example, a specialist in radio and security) may be needed to ensure this level of communication is maintained. In each village, active and adaptive case finding (which involves local knowledge and ...... 菀菀 Field Article ......

Table 1 Villages considered insecure initially and subsequently abandoned due to insecurity

Introduction Themes investigated checkpoints and threats on the way. During the SLEAC assessment in Jawzjan, large Interview guides were developed to support • Women were not able to travel alone, and areas of the province and entire districts were surveyors in collecting useful information on therefore without a male chaperone (who deemed to be inaccessible for the survey team. challenges to access and service delivery. Different was not always available) were not able to In order to understand more about coverage guides were developed for caregivers and for staff access services. and access of SAM treatment in these areas, a to collect the following information: • More than half of the informants (five out of small study was designed. nine) spoke of clashes between AOG and Caregivers at the health facility: government security forces (Afghan National Methodology • Information about their journey: means of Security Forces (ANSF)) as a factor Qualitative data was collected through transport, duration, cost, whether there were preventing them from making the journey structured interviews with programme obstacles, whether insecurity affects the to the health facility. management staff, health facility staff and journey and how the decision is made to visit • Instead of making a journey, they either use patients. Three health facilities where the facility. alternative treatments (such as buying surrounding villages were deemed insecure • Information about available alternatives when medicine from shops or using fortified milk) were visited. In each health facility, interviews the decision is made not to visit the health or simply must wait until security is better were conducted with at least two staff facility, such as use of CHW (community health before travelling to the health facility. members (engaged with CMAM) and two to worker) or traditional medicine. four patients (visiting for CMAM treatment). Impact on provision of services: Staff at the health facility: • Insecurity inhibits activities required for The following considerations were made to • Information about the running of the operating the SAM sites, specifically those maintain the safety of the surveyor: programme: details of any past closures due to involving movement within the district, • Locally known survey team members were insecurity, and whether insecurity affects the such as monitoring, training, supervision sent and local community members and logistical running of the programme, for and supply of RUTF. health staff should be informed in advance. example in ready-to-use therapeutic food • Delivery of RUTF was managed through • Advise that the study is about the CMAM (RUTF) supply. relationships with local shura, who had programme – do not say it is a study on • Information about activities away from the strong links with armed groups, which security since this may raise unnecessary health facility such as alternative strategies to enabled the continuation of treatment concerns. reach SAM cases, e.g. use of CHWs, outreach services. • When meeting people, do not ask for activities and training and supervision visits. • Many areas in the province are too insecure interviews (which are often seen as Findings for any monitoring or supervision to be interrogatory), just explain that you are conducted safely. For example, in Qush Tepa These investigations provided information about there to talk about the CMAM programme. and Darzab, which are long-term insecure, types of insecurity, as well as the impact of • Ensure the conversation is conducted in a the last support visit to the health facilities insecurity on community access and on the secure and relaxed environment where the was possible in 2010. provision of services. informant can speak openly and in a free • In Darzab, the health facility (a sub-centre) manner. Impact on community access: has now closed because the staff did not • People are not able to take the road because of feel safe to work there.

In order to compensate for loss in survey collected from the cases found during the survey village leader prior to travelling to the coverage and to access information in inaccessible remains useful and can provide evidence for village; areas, additional quantitative and qualitative programme reform. 7. Allow for extra time training and super- studies can be conducted. Quantitative analysis vising survey teams and include role play A number of steps can ensure the most can compare numbers of admissions or defaulting activities; reliable and comprehensive information regarding rates from insecure areas with those from secure 8. Ensure regular communication with survey coverage and access, achieving the basic principles areas to look for differences and provide some teams to monitor their safety and provide of data collection while ensuring the safety of indication of coverage levels. close supervision, including daily debriefings; staff and informants. e following ten points 9. Develop context-specific qualitative and Interviews can be conducted in nearby health should be considered by practitioners undertaking quantitative studies to investigate factors centres with residents that have travelled from coverage surveys in insecure environments: affecting access in the inaccessible areas; inaccessible areas, and with health staff that 1. Adhere to the basic principle that CMAM and cover those areas. Alternatively, specific survey programmes are child-survival pro- 10.Document all limitations, challenges and staff members for whom the risk is deemed ac- grammes, therefore performance must be adaptations to the methodology in the final ceptable may be able to visit an otherwise inac- assessed and coverage assessments them- report. cessible area. In these circumstances, the staff selves are not life-saving activities through member should be carefully prepared and con- out the assessment; 2. Ensure triangulation of security informa- For more information, contact: Nikki Williamson, sulted, together with security advisors. Box 2 email: [email protected] outlines details of a qualitative study on insecurity tion with survey team members and other conducted in Jawzjan. local sources related to the accessibility of villages; References Guidance for practitioners 3. Use a rigorous and participatory process MSF, 2014 Afghanistan: Between rhetoric and reality – the It is possible to undertake SQUEAC and SLEAC to review the security status of villages; ongoing struggle to access healthcare. Médecins Sans assessments in insecure environments, but this 4. Ensure constant assessment of the security Frontières. www.msf.org.uk/article/afghanistan-between- may affect the quality and reliability of the in- situation, especially in sampled villages and rhetoric-and-reality-%E2%80%93-ongoing-struggle-acces formation. e bias introduced by the removal access routes; s-healthcare. of villages from the sampling frame must be 5. Use local survey staff who both know the ACF, 2016 A review of SAM management in Afghanistan: recognised and clearly reported. However, the Lessons from 2013-2016. ACF International. area and are known in the area; www.cmamforum.org/Pool/Resources/Afghanistan- qualitative information (on barriers and boosters) 6. Where possible make contact with the Review-of-SAM-management-2016.pdf ...... 菀菀 Field Article ......

A young caregiver with an infant in her charge

By Samson Desie

Intergenerational cycle Samson Desie is a nutrition specialist who has worked in the of acute malnutrition sector for more than a decade and currently works as Nutrition Cluster among IDPs in Somalia Coordinator with UNICEF Somalia.

Location: Somalia nutrition causality study outlines socio-cultural practices as one of the major underlying causes What we know: High levels of acute malnutrition persist among internally displaced and highlights certain socio-cultural beliefs and children in Somalia; socio-cultural practices that impact women, including teenage practices in particular that have a major impact, pregnancy, are a major underlying cause. including female genital mutilation (FGM), early marriage and premature, repeated child bearing What this article adds: A Nutrition Cluster (NC) visit to an outpatient therapeutic by girls (13+ years) (SNS Consortium, 2015). programme in Garowe, Somalia, found only one third of children were accompanied Infant and young child feeding (IYCF) practices by their mother; over half of mothers were less than 18 years of age. The remaining are weak and adversely aﬀected by heavy women’s admissions presented with a sibling, usually less than ten years of age; mothers were workloads, increased shis to cash economies absent in search of work. The NC considers school nutrition a key strategy to break and absent fathers (due to divorce and khat the intergenerational cycle of malnutrition in the Somalia context; it invests in use). nutrition development and fosters humanitarian-development connections. To e Nutrition Cluster (NC) visited a Garowe address the circumstances witnessed in Garowe, the NC has developed a pilot IDP site on 24 February 2016. At the time, 37 comprehensive school-nutrition programme in collaboration with the Education children were admitted in the outpatient thera- Cluster to build evidence with a view to scale-up. peutic programme (OTP). During the visit, only 14 (36%) children arrived with their mothers; eight (57%) of the mothers were aged 18 years Background for the last five seasons), as well as among or under. e remaining children came to the Children in internally displaced persons (IDP) Bossaso IDPs (12.5 % to 16.8 %). e results centre with their siblings, who are mostly children sites in Somalia remain at increased risk of call for urgent action in this protracted crisis, under the age of ten themselves. On further acute malnutrition. e validated and endorsed and the critical need to scale up multi-sector discussion with these children, it was understood Deyr (short rainy season) 2015 nutrition survey programmes in an integrated manner, including that most mothers were away in town, looking conducted by Somalia Food Security and Nu- at IDP site level. for casual labour (e.g. cleaning, cooking, carrying and domestic service). Leaving children to be trition Analysis Unit (FSNAU) indicates a dete- “When a 13-year-old girl gets married and attended by older siblings is a significant factor rioration in the nutrition situation in five IDP has a baby, there is oen stress between her and limiting the care children require, especially sites (Dhobley, Baidoa, Dolow, Garowe and her husband, which can lead to divorce… Aer a those suﬀering from malnutrition. e fact that Galkayo) among the 13 sites surveyed in Sep- divorce, the girl is le to provide for the children, many mothers are under 18 years old is also an tember 2015; these are areas of critical concern but most oen they are not able to due to lack of underlying cause of the sustained level of acute (see Figure 1). Furthermore, the latest Gu (main resources” (Mothers focus group discussion). rainy season) 2015 findings show little improve- malnutrition. ment in the median global acute malnutrition The underlying causes of e story of Sabri and her daughter (see Box (GAM) rate, with IDPs in Dolow having the sustained malnutrition 1) is typical of the phenomenon of the inter- worst rates of malnutrition (sustained critical Sustained levels of acute malnutrition in IDP generational cycle of malnutrition which sees GAM rates of 25% and severe acute malnutrition sites have always been a challenge in Somalia; teenage mothers give birth to an intrauterine (SAM) prevalence of 6.1%). Further deterioration studies and surveys have been conducted to growth-restricted infant and/or a low-birth- was also observed, moving from Serious to Crit- understand the underlying causes of its persis- weight (LBW) baby (a baby born weighing less ical in Garowe and Galkayo (sustained hot spots tance despite ongoing interventions. A recent than 2.5 kg). e intergenerational cycle of ...... 菀菀 Field Article ......

Figure 1 Prevalence of GAM among IDPs in Somalia (Post-Gu, 2016) Very Critical (>30%) 30

Critical (15-30%) 20

Serious (10-<14.9%) 10 Alert (5-<9.9%)

Acceptable (0-<5%) 0

Sabri Abdiaziz Ali Burao IDPs Burao Dolow IDPs Dolow Baidoa IDPs Qardho IDPs IDPs Qardho

Garowe IDPs Garowe with her daughter, Bossaso IDPs Galkayo IDPs Galkayo Dhobley IDPs Dhobley Kismayo IDPs Kismayo Hargeisa IDPs Hargeisa

Mogadishu IDPs Palestine Mohamed Dhusamreeb IDPs Dhusamreeb

Box 1: Sabri’s story growth failure, first described in 1992 in the to control micronutrient deficiencies in ado- In Garowe IDP site, Sabri Abdiaziz Ali is the 16- Second Report on the World Nutrition Situ- lescent girls. e nutrition programme in year-old mother of an 11-month-old girl, ation (UNSCN,1992) and illustrated in Figure Somalia has never carried out such activities Palestine Mohamed. Sabri has lived almost her 2, explains how growth failure is transmitted and should be piloted in selected IDP sites entire life as an IDP, living here since 2001, when across generations through the mother. e with a view to scale-up. Districts with high she was treated for malnutrition at the age of theory is that small adult women are more burdens of sustained acute malnutrition could one. She was married at 14 and divorced by the likely to have LBW babies, and LBW children also be targeted with similar actions; lessons time her daughter was just two months old. Since then she has been living with her mother, are more likely to have growth failure during from the experiences would help to scale up who is also an IDP. She often goes to the town childhood. us, in turn, girls born with a such approaches. e strategy should also seeking work to help provide for her daughter. LBW are more likely to become small adult attempt to link with livelihoods and other women. e cycle is accentuated by high social protection and safety-net programmes. Sabri hopes to be able to educate her daughter rates of teenage pregnancy. is situation, and not remain in the IDP camp for the rest of Teenage pregnancy is a probable significant coupled with early marriage and early divorce her life. She breastfed her daughter for two cause of malnutrition in most parts of Ethiopia, in Somalia, is becoming a major problem months only, until the time of her divorce, and including IDP sites. It is well recognised that has not breastfed since as she is busy earning but is not fully appreciated by all stakeholders. the size and body composition of the mother survival income. Her daughter often suffers Actions to take in Somalia at the start of pregnancy is one of the strongest from diarrhoea and cough and was recently diagnosed, at ten months old, as severely e authors of the UNSCN Nutrition Policy influences on foetal growth (Kramer, 1987). malnourished. Her daughter’s condition has Paper No 18 on LBW (Pojda & Kelley, 2000) Studies in the USA have shown that there is maternal and foetal competition for nutrients significantly improved since she was admitted found that many questions about reducing to the UNICEF-supported OTP four weeks ago. in adolescent mothers, and birth weight of LBW rates remain unanswered. e paper Now at 11 months, she is improving and highlights the urgent need to find sustainable infants of adolescent mothers are around gaining weight with regular treatment and practices that will improve women’s nutritional 200g lower compared to non-adolescent therapeutic feeding. During the visit, she had a status prior to pregnancy and weight gain mothers (Scholl et al, 1997). Given this, good appetite and was active. The OTP service during pregnancy. Many actions can be taken efforts should be directed towards developing is implemented by Save the Children in the Somalia IDP context. Efforts to improve community-based adolescent girls’ clubs in International (SCI) and fully funded and adolescent nutrition are needed, especially order to help with the early detection of supported by UNICEF and USAID.

Figure 2 Intergenerational cycle of growth failure

Child growth failure

Early Low-birth- Low weight weight and height baby pregnancy in teens

An adolescent mother Small adult with her baby women ...... 菀菀 Young mothers and caregivers attending the OTP teenage pregnancies in communities and educate and the risk of delivering a LBW baby seems to sation of WASH practices; and girls on improved life skills for teenage pregnancy be determined very early in pregnancy (Smith 4. Support the involvement of women groups prevention. et al, 2002). In addition, evidence from Asia in nutrition-sensitive agriculture and liveli- (Mason et al, 2002), rural India (Rao et al, hood programmes and ensure access to Actions to take: Adolescent 2001), Indonesia (Semba et al, 2008) and refugee time and labour-saving technologies. interventions camps in Nepal (Shrimpton et al, 2009) suggests 1. Establish a system to provide comprehensive that consumption of micronutrient-rich foods Nutrition and Education and routine nutrition assessment and coun- (milk, green leafy vegetables, fruit and parboiled Clusters join forces selling services for adolescents at commu- rice) and iodized salt during early pregnancy is eir experience of the horrifying reality prompted nity, school (Ministry of Education, 2012) associated with increased birth weight and action by the NC to come up with a concrete and health-facility level; weight-for-age in young children. e following option to reach adolescent girls. e NC considers 2. Develop key action-oriented, nutrition interventions are therefore recommended for school nutrition a key strategy to break the in- behavior-change communication messages inclusion in existing services, in particular for tergenerational cycle of malnutrition in Somalia. for adolescents, especially for girls, and pregnant and lactating women (PLWs): A school-nutrition initiative also offers strategic promote and demonstrate these messages 1. Establish a system to provide comprehen- engagement for a long-term resilience perspective, through different communication channels, sive and routine nutrition assessment, is in the interests of developmental nutrition and community and facility contact points; counselling and support services, including helps bridge the humanitarian-development nexus. 3. Ensure adolescents have access to micronu- pregnancy weight-gain monitoring; promo- In collaboration with the Education Cluster, a trient services; tion of maternal nutrition (including ade- comprehensive school-nutrition programme has 4. Ensure access to reproductive health services quate food intake); provision of supple been developed which will be implemented in a for boys and girls (delaying early marriage mentary food to malnourished PLWs; and few selected schools to generate further evidence and early pregnancy, family planning, pre- ensure early identification and treatment of with a view to possible scale-up. e project will vention of harmful traditional practices); acute malnutrition among PLWs; follow a continuous learning and adoptive ap- 5. Ensure access to and utilisation of water, 2. Ensure PLW access to micronutrient services, proach and will start with an adaptation of the sanitation and hygiene (WASH) practices in including provision of routine iron folic World Bank FRESH (Focusing Resources on households, communities and schools; acid or multiple micronutrient supplemen- Effective School Health, Hygiene, and Nutrition 6. Conduct regular monitoring of nutritional tation; promotion of the use of iodised salt; Programmes) framework. Funded by the Somalia status of school-age children/students; and and deworming during the second and Humanitarian Funding (SHF) as a pilot, it will 7. Promote girls’ education and economic third trimesters of pregnancy; be implemented by SCI in Baidou. We look empowerment of out-of-school adolescents. 3. Develop key action-oriented nutrition mes- forward to sharing learning from our ongoing implementation of comprehensive school nutrition Actions to take: Nutritional status of women sages to increase the involvement of fathers, among IDPs as well as host communities. e influence of maternal nutritional status on grandparents and faith-based/traditional pregnancy outcomes seems equally important community organisations in supporting For more information, contact: Samson Desie, in early and late pregnancy (Neufeld et al, 2004) PLWs, including ensuring access and utili- email: [email protected]

References Kramer, 1987 – Kramer, MS. Determinants of low birth Pojda & Kelley, 2000 – Pojda J and Kelley L, Low Birthweight Indonesia. Am J ClinNutr. 2008 87(2):438-44. weight: methodological assessment and meta-analysis. − Nutrition policy discussion paper No. 18. United Nations Shrimpton et al, 2009 – Shrimpton R, Thorne-Lyman A, Administrative Committee on Coordination Sub-Committee Bulletin of the World Health Organization. 1987; 65(5): Tripp K, and Tomkins A 2009.Trends in low birthweight 663–737. on Nutrition. 18 September 2000. www.unscn.org/layout/ among the Bhutanese refugee population in Nepal. Food modules/resources/files/Policy_paper_No_18.pdf www.ncbi.nlm.nih.gov/pmc/articles/PMC2491072/ and Nutrition Bulletin 30 (2) S197-206. Mason et al, 2002 ¬– Mason JB, Deitchler M, Gilman A, Rao et al, 2001 – Rao S, Yajnik CS, Kanade A, Fall CH, Smith et al 2002 ¬– Smith GCS, Stenhouse EJ, Crossley JA, Gillenwater K, Shuaib M, Hotchkiss D, Mason K, Mock N, Margetts BM, Jackson AA, Shier R, Joshi S, Rege S, Lubree Aitken DA, Cameron AD, Connort JM. Early-pregnancy Sethuraman K. 2002 Iodine fortification is related to H, Desai B. Intake of micronutrient-rich foods in rural Indian origins of low birth weight. Nature 2002;417:916. increased weight-for-age and birthweight in children in Asia. mothers is associated with the size of their babies at birth: Food Nutr Bull. 23:292-308 Pune Maternal Nutrition Study. J Nutr 2001;131:1217-24. SNS Consortium 2015 – Nutrition Causal Analysis Study – South and Central Somalia November 2015. Ministry of Education, 2012 – National School Health and Scholl et al 1997 – Scholl TO, Hediger ML, Bendich A, reliefweb.int/report/somalia/nutritional-causal-analysis- Nutrition Strategy. Government of Ethiopia October 2012. Schall JI, Smith WK, Krueger PM. Use of multivitamin/ study-south-and-central-somalia-november-2015 mineral prenatal supplements: Influence on the outcome of Neufeld et al, 2004 – Neufeld LM, Haas JD, Grajeda R, pregnancy. Am J Epidemiol 1997;146:134–41. UNSCN, 1992 – United Nations System Standing Martorell R. Changes in maternal weight from the first to Committee on Nutrition 2nd Report on the World Nutrition second trimester of pregnancy are associated with fetal Semba et al, 2008 – Semba R, de Pee S, Hess SY, Sun K, Situation − Volume I: Global and regional results. ACC/SCN, growth and infant length at birth. Am J ClinNutr. 2004 Sari M and Bloem M. Child malnutrition and mortality October 1992. www.unscn.org/layout/modules/ 79(4):646-52 among families not utilizing adequately iodized salt in resources/ files/rwns2_1.pdf ...... 菀菀 ...... People in aid INASP Evidence Aid, 2013 Aid, Evidence

e research team investigating men and household food security in an internally displaced persons Participants in the Evidence Aid priority setting meeting, 2013 camp in Kenya (see research in this edition) (see research in this edition) Kamal Singh, Kenya, Kamal Singh, Kenya,

Participants in an INASP AuthorAid training held in Guinea (see news article in this edition)

...... 菀菀 ......

Editorial team Office Support About ENN Jeremy Shoham, Claire Reynolds, ENN is a UK registered charity, international in reach, focused on supporting populations at high risk of Marie McGrath, Clara Ramsay, malnutrition. ENN aims to enhance the effectiveness of nutrition policy and programming by improving Judith Hodge, Peter Tevret, knowledge, stimulating learning, building evidence, and providing support and encouragement to Chloe Angood, Judith Fitzgerald, Nick Mickshick. Viktorija Nesterovaite. practitioners and decision-makers involved in nutrition and related interventions. Design ENN is both a core team of experienced and academically able nutritionists and a wider network of nutrition Orna O’Reilly/Big Cheese Design.com practitioners, academics and decision-makers who share their knowledge and experience and use ENN’s products to inform policies, guidance and programmes in the contexts where they work. Website Phil Wilks ENN implements activities according to three major workstreams: Workstream 1: Experience sharing, knowledge management and learning. This includes ENN’s core Contributors for this issue: products: Field Exchange, Nutrition Exchange and en-net, as well as embedded knowledge management Mercy Laker within two key global nutrition fora (the Scaling Up Nutrition Movement (SUN) and the Global Nutrition Joy Toose Cluster (GNC)). Leni Martinez Del Campo Emily Sylvia Workstream 2: Information and evidence on under-researched nutrition issues. This comprises ENN’s Concern Burundi Team research and review work on filling gaps in the evidence base for improved nutrition policy and programming. Jeanette Bailey Rachel Chase Workstream 3: Discussion, cooperation and agreement. This includes a range of activities for discussing and Marko Kerac building agreement and consensus on key nutrition issues. It includes ENN’s participation in and hosting of André Briend meetings, its activities as facilitator of the IFE Core Group and its participation in the development of training Mark Manary materials and guidance, including normative guidance. Charles Opondo Maureen Gallagher ENNs activities are governed by a five year strategy (2016-2020), visit www.ennonline.net Anna Kim Mustafa Ghulam Mohammed H Alshama’a The Team Daniel Muhinja Jeremy Shoham and Carmel Dolan and Sisay Sinamo Marie McGrath are Field Emily Mates are Exchange Co-Editors and Lydia Ndungu Technical Directors. Technical Directors. Cynthia Nyakwama Marina Adrianopoli Allan Mpairwe Samson Desie Chloe Angood is a Tui Swinnen is ENN’s Claire Reynolds is Alexandra Rutishauser-Perera nutritionist working Global Knowledge ENNs Senior Erin Homiak part-time with ENN on Management Operations Manager, Mike Clarke a number of projects. Coordinator (SUN based in Oxford Jeroen Jansen Movement) Claire Allen Claudia Rodriguez Viktorija Nesterovaite is Peter Tevret is ENN’s Clara Ramsay is the Iris Emanuelly Segura ENN's Project Assistant Senior Finance ENN’s Finance Assistant, Ana Paula Cantarino Frasão de Carmo based in Oxford. Manager, based in based in Oxford. Daniela Bicalho Oxford. Vanessa Manfre Garcia Souza Flavia Schwartzman Betzabeth Slater Rebecca Alum William Judith Fitzgerald, is the Orna O’ Reilly designs Phil Wilks Shishay Tsadik Operations and Mailing and produces all of (www.fruitysolutions.com) Assistant at the ENN. ENN’s publications. manages ENN’s website. Titus Mung'ou Jennifer Chapin GESNOMA Winds of Hope Sentinelles Médecins sans Frontières Field Exchange supported by: Saul Guerrero Erin Boyd Claire Harbron Diane Holland Abi Perry Sophie Whitney Erick Boy Dan Jones Megan Wilson-Jones

Charulatha Banerjee Emily Mates Peter Hynes Thanks to all who contributed or helped source pictures for this issue. Front cover Pupils from the Catholic school in Ampahadimy Fokontany running in front of their sanitation block. Ankazobe The Emergency Nutrition Network (ENN) is a registered charity in the UK (charity registration no: 1115156) and a district, Madagascar; WaterAid/ Ernest company limited by guarantee and not having a share capital in the UK (company registration no: 4889844). Randriarimalala, Madagascar, 2016 Registered address: 32, Leopold Street, Oxford, OX4 1TW, UK. ENN Directors/ Trustees: Marie McGrath, Jeremy Shoham, Bruce Laurence, Nigel Milway, Victoria Lack and Anna Taylor...... 菀菀 ENN 32, Leopold Street, Oxford, OX4 1TW, UK Tel: +44 (0)1 865 324996 Fax: +44 (0)1 865 597669 Email: [email protected] www.ennonline.net