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...............................................................

1 EditorialField Articles2 Nutrition programming in conflict

settings: Lessons from South Sudan

5 Pilot micronutrient powder distribution in Burundi: Acting on lessons learned

44 Combined protocol for SAM/MAMtreatment: The ComPAS study

47 Adapting a resilience improvement programme in conflict: Experiences from Yemen

67 Open Data Kit Software to conduct nutrition surveys: Field experiences from Northern Kenya

69 WHO emergency nutrition response in South Sudan

75 Sampling in insecure environments: Field experiences from coverage assessments in Afghanistan

79 Intergenerational cycle of acute malnutrition among IDPs in Somalia

Research8 Research Snapshots

8 Factors influencing pastoral and agropastoral household vulnerability to food insecurity inKenya

8 Determinants and trends of socioeconomic inequality in child malnutrition in Mozambique

8 The migrant camp that doctors built

9 Trends in adult body-mass index in 200 countries from 1975 to 2014: A pooled analysis

9 Effect of lipid-based nutrient supplements on morbidity in rural Malawian children

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

10 Decline in the prevalence of anaemia among children through wheat flour fortification in Jordan

10 Making progress towards food security in rural Rwanda

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

11 Meta-analysis of associations between stunting and child development

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

12 Tackling the double burden of malnutrition in low and middle-income countries: response of the international community

14 Ethiopia’s Productive Safety Net Programme: Power, Politics and Practice

15 Admission profile and discharge outcomes for infants aged less than six months admitted to inpatient therapeutic care in ten countries

17 Chronic disease outcomes after SAM in Malawian children (ChroSAM): A cohort study

19 Adolescent nutrition in Mozambique:putting policy into practice

21 Robust evidence for an evidence-based approach to humanitarian action

22 Evidence in humanitarian emergencies: What does it look like?

23 Recovery rate of children with moderateacute malnutrition treated with ready-to-use supplementary food (RUSF) or improved corn-soya blend (CSB+)

25 Impact of child support grant in South Africa on child nutrition

26 Public health nutrition capacity: The quality of workforce for scaling up nutrition programmes

28 Research priorities on the relationship between wasting and stunting

29 Co-trimoxazole prophylaxis to prevent mortality in children with complicated severe acute malnutrition

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

32 Direct procurement from family farms for national school feeding programme in Brazil

33 Relationships between wasting and stunting and their concurrent occurrence in Ghanaian pre-school children

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

36 Carbohydrate malabsorption in acutely malnourished children and infants: A systematic review

37 Nutrition among men and household food security in an internally displaced persons camp in Kenya

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

40 An investment framework for nutrition: Reaching the global targetsfor stunting, anaemia, breastfeeding and wasting

41 Advancing Early Childhood Development: From Science to Scale

43 Role of nutrition in integrated early child development

News51 Grand Bargain: Reform or business as

usual?

52 Call for experiences on mothers measuring MUAC

53 AuthorAID: A global network for earlycareer researchers from low and middle-income countries

54 Accelerating the scale-up of treatment for severe acute malnutrition

55 Global School Feeding Sourcebook: Lessons from 14 countries

56 The missing ingredients: Are policy-makers doing enough on water, sanitation and hygiene to end malnutrition?

57 Nutrition funding: The missing piece of the puzzle

58 Biofortification: Helping meet nutrition needs worldwide

60 Minimum Standards for Age and Disability Inclusion in Humanitarian Action

61 Regional humanitarian challenges in the Sahel

62 NOMA: A neglected disease!

64 Improving care of people with NCDs in humanitarian settings

64 eLearning module on improving nutrition through agriculture and food systems

65 FANTA’s Body Mass Index (BMI) Wheel

65 Launch of BabyWASH Coalition

66 En-net update

Views73 South Sudan nutrition: Overcoming

the challenges of nutrition information systems

Agency Profile72 Wateraid

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Editorial .................................................................

Dear readers

There are three themes running throughthis issue of Field Exchange. We havefour field articles which describe thevery real practical challenges of having

to adapt programming in the face of conflictand insecurity. An article by Mustafa Ghulamand Mohammed Alshama’a, Save the Children,describes adapting a resilience improvementprogramme in conflict affected Yemen and howa scaled up e-voucher scheme still managed toimprove dietary diversity in spite of the highlevel of insecurity. Meanwhile, an article byMercy Laker and Joy Toose, World Vision, doc-uments how a CMAM programme had to beadapted in South Sudan when conflict brokeout but still managed to provide critical life-saving treatment to young children. Afghanistanis the setting of a field article by Action Contrela Faim, which describes measures taken toallow sampling during programme coverage as-sessments that both maintained data integritywhile protecting the safety of enumeration staff.Finally, an article written about WHO’s emergencynutrition response in South Sudan documentsthe development of a specific medicines kit (andassociated training package) for the treatmentof complicated severe acute malnutrition (SAM),which allowed programming to continue in the

face of a marked deterioration in security. Whatall these articles have in common is adaptationand innovation based upon on an ‘on the ground’perspective about what is possible and how bestto preserve programme equity and effectivenessin the face of overwhelming challenges for pro-gramme staff and beneficiaries. You have to askif someone somewhere is going to pull all theseprogramming approaches together to producesome sort of guidance on ‘how to adapt nutri-tion-related programming in insecure areas’? A second theme emerging in Field Exchange 53is the role of multi-sector programming in ad-dressing undernutrition. ere are a number ofrelevant research summaries. Complementingthe recently released Lancet series on early child-hood development (ECD), we have a summaryof a series of articles on the role of nutrition in

integrated ECD, which makes the case for mul-ti-sector programming that considers responsibleparenting, learning stimulation, education, andsocial protection, in addition to health and nu-trition. Another summary presents the findingsof a study on the impact of a cash support grantin South Africa on stunting. No impact is seenand this is explained by high levels of HIV andunemployment, which may confound any effect.ere is also a summary of a study in 13 countrieslooking at the degree to which nutrition is ex-plicitly mentioned in water, sanitation andhygiene (WASH) policies and vice versa. Perhapssurprisingly for this day and age, there is limitedincorporation of nutrition and WASH in therespective policies of the other sector. Interestingly,the report authors suggest that the nutritionsector has more of a vested interest in incorpo-rating WASH objectives since we depend onWASH to achieve nutrition outcomes; typicalWASH outcomes do not depend on nutritionand so there may be less incentive for integration.ere are also two research summaries aboutthe national school feeding programme in Brazilwhich has managed to legislate for procurementfrom local farmers who provide the food for theprogramme. One of the studies looks specificallyat lessons learnt about engaging across sectorsfrom more of a political economy perspectiveand what is required to maximise success.

A final theme, and one which effectively pro-vides an overarching framework for the themesdiscussed above, is the relationship between de-velopment and humanitarian programming andhow there are strong conceptual, epidemiologicaland institutional rationales for closer integration.A critical online article by IRIN (an independentnon-profit media venture) highlighted a numberof recommendations from the Grand Bargain(a package of reforms to humanitarian funding,launched in May 2016 at the World HumanitarianSummit). Commitments are packaged under10 measures/areas for reform. One of thesemeasures is ‘Enhance engagement between hu-manitarian and development actors’. is isabout working collaboratively across institutionalboundaries on the basis of comparative advantage"and “the use of existing resources and capabilitiesbetter to shrink humanitarian needs over thelong term, with the view of contributing to theoutcomes of the Sustainable Development Goals(SDGs)”. A summary of a research prioritisationexercise on the relationship between wastingand stunting concluded that the highest priorityis to find evidence from evaluations and studieson the optimal timing of treatment and preven-tion programmes to impact wasting and stuntingas part of the same programme. An ENN inter-view with Rebecca Alum Williamand ShishayTsadik from the Ministry of Health (MoH) inSouth Sudan highlights the challenges of inte-grating an effective nutrition information system(NIS), developed largely by nutrition cluster

partners over a period of years to inform hu-manitarian programming, with governmenthealth information systems. ere are also twoarticles related to chronic disease in the contextof emergency programming, One is a summaryof a study looking at mortality and risk factorsfor chronic disease in children who had been‘successfully’ treated for SAM seven years earlierin Malawi. Functional deficits were found andmost alarming, nearly one-third of dischargedcases had died and another 15% were lost tofollow-up. ese findings really challenge ournotion of ‘cure’ when it comes to SAM; a returnto normal anthropometry is not matched witha return to pre-SAM risk level, with long termmorbidity and mortality implications. esecond article summarises a meeting held byMSF recently which focused on improving careof people with non-communicable disease (NCD)in humanitarian settings. e strand linking allthese pieces, either explicitly or through impli-cation, is that there are inextricable links betweenso called emergency and development nutrition,yet the analytical frameworks and architecturewhich underpin responses do not reflect thisadequately. Availability of resources for nutritionis undoubtedly a common challenge for all; astudy by the World Bank provides a timely re-minder of what it will cost to achieve globaltargets for stunting, anaemia, exclusive breast-feeding and SAM treatment – applicable to bothhumanitarian and stable contexts. e bill comesin at $70 billion over ten years!

Finally, we would like to draw attention to anew section of Field Exchange which we are tri-alling in this issue. We call this ‘snapshots of re-search’ where the ‘bare bones’ of studies aresummarised. e reason for introducing thissection is partly economic (to cut down onprinting costs), partly appreciating our readersmay value a digested read, and partly expedience(there is more and more research being publishedand given the common ground between emer-gencies and development, there is a broaderspectrum of research relevant to our readership).e short articles in this ‘snapshot’ are hopefullyall of interest and include studies on; the socialinequality of child malnutrition in Mozambique,climate change modelling on the effect on foodproduction and global and regional health,trends in adult Body Mass Index (BMI) in 200countries, the impact on child anaemia of awheat fortification programming in Jordan andthe effect of Lipid Nutrient Supplements (LNS)on morbidity in rural Malawian children. Pleaselet us know if this new section works for you.

We hope you enjoy this issue of Field Exchange.As ever, articles, ideas and feedback always wel-come.

Jeremy Shoham & Marie McGrathField Exchange Co-Editors

Diversity of beansin Rwanda

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By Mercy Laker and Joy Toose

Mercy Laker worked asthe Health and NutritionTechnical Lead for WorldVision South Sudan fromOctober 2014 to April2016. She is currently theHealth and Nutrition

coordinator for Care South Sudan.

Joy Toose is anEmergencyCommunicationsSpecialist with WorldVision International.

Location: South SudanWhat we know: Violent conflict typically contributes to increased malnutritionlevels and challenges humanitarian response.

What this article adds: Challenges to CMAM implementation encountered byWorld Vision in conflict-affected South Sudan included stretched governmentcapacity, underfunding, supply chain interruptions, destruction of healthfacilities, limited staff capacity and compromised access. Adaptations madeinclude investment in cluster coordination, development of alternative CMAMsites, training community volunteers, and pre-positioning therapeutic food. Amulti-sector rapid response mechanism (RRM) was piloted to access hard-to-reach locations. Experiences show that flexibility and responsiveness are crucialin conflict settings; close coordination between sectors, including logistics, isessential; and predictable, long-term funding is necessary to sustain life-savingprogramming.

Protracted hostilities in South Sudanhave caused widespread displace-ment; high rates of death, diseaseand injury resulting in disrupted

livelihoods; severe food insecurity and amajor malnutrition crisis1. Even before thecurrent conflict began, the nutrition situationwas chronic. Of 21 counties assessed duringthe 2013 lean season, 17 had global acutemalnutrition (GAM) rates above the emer-gency threshold of 15%.

Between December 2013 and February2015, the number of children suffering fromsevere acute malnutrition (SAM) doubled tomore than 229,0002. In the worst-hit areasGreater Upper Nile, Warrup and NorthernBahr el Ghazal in 2015, nearly one in threechildren under five were malnourished. emalnutrition situation was classified as critical(GAM between 15 and 29 per cent) or verycritical (GAM above 30 per cent) in morethan half the country. Since the beginning ofthe conflict in December 2013, more than1.5 million people have been displaced in-ternally, including more than 800,000 children3.People fleeing their homes are forced to aban-don their fields and livestock. Many havesought refuge on UN peacekeeping bases orother informal settlements and can no longergrow crops or tend livestock.

e majority of South Sudanese familiesrely on emergency food assistance to survive.ose not displaced by fighting have faceddifficulties in sowing crops due to interruptionsin trade and supply corridors for seeds andsupplies. Deteriorating food security is com-pounded by lack of access to clean water,sanitation and basic healthcare, increasedprevalence of disease, and negative impacton feeding practices.

Partnering with United Nations (UN)agencies and other non-governmental organ-isations (NGOs), World Vision’s response tothe malnutrition crisis in South Sudan ismulti-sectoral. e community-based man-agement of acute malnutrition (CMAM) modelis used to treat severe and moderate acutemalnutrition (SAM/MAM), complementedby food assistance, agricultural initiatives toincrease food production and improved accessto safe water, sanitation and basic healthcareto children under five years of age and pregnantwomen. is article documents how WorldVision’s nutrition team worked with the nu-trition cluster through 2014 and 2015 to adaptits CMAM programme to overcome the chal-lenges faced in South Sudan.

Contextual challenges andprogramme adaptationsA combination of vast geographical area,poor infrastructure and an unpredictable se-curity situation makes South Sudan one ofthe most challenging and costly operatingenvironments4. Contextual challenges forconventional CMAM programming, andadaptations made by World Vision to respondto them, include the following:

Gaps in coordinationIn February 2014, a Level 3 Humanitarian

Field Articles ..................................................

Lessons fromSouth Sudan

Nutritionprogramming inconflict settings:

This article is based on a detailed case study bythe authors available at: www.wvi.org/disaster-management/publication/nutrition-programming-conflict-settings-south-sudan-case-study

A young child enrolled in atreatment programme

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1 UNOCHA; South Sudan Humanitarian Response Plan 2015. reliefweb.int/report/south-sudan/south-sudan-humanitarian-response-plan-2015

2 UNICEF; South Sudan on the edge of nutrition catastropheif hostilities don’t end now. UNICEF Press Release 4 February 2015. www.unicef.org/media/media_79711.html

3 UNICEF; South Sudan Humanitarian Situation Report 23 April 2015. reliefweb.int/report/south-sudan/unicef-south-sudan-humanitarian-situation-report-57-10-23-april-2015

4 GHA; South Sudan: Donor response to the crisis, (2014) 4. www.globalhumanitarianassistance.org/report/south-sudan-donor-response-to-the-crisis

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System-Wide Emergency Response was declaredin response to the crisis. is reflected the scale,complexity and urgency of the crisis and the in-ability to implement effective response withoutsystem-wide mobilisation. Due to the fragilityand stretched capacity of the South Sudan Gov-ernment and Ministry of Health (MoH), thebulk of leadership and service delivery wastaken on by the UN and partner NGOs5. WhereCMAM programming would usually seek toalign with and complement an existing MoHstrategy and operations, in South Sudan muchof the strategic planning and day-to-day coor-dination relies on support from UNOCHA(United Nations Office for the Coordination ofHumanitarian Affairs) through the humanitariancountry team and the sector cluster groups.

Gaps in multi-sector resourcese response in South Sudan has been consis-tently underfunded. In 2015, only 41 per centof the required US$1.6 billion had been com-mitted6. Stretched resources le gaps in the sys-tem-wide response.

Adaptation: In the context of these capacityand resource challenges, it is more importantthan ever for humanitarian agencies to activelyparticipate in the cluster system. is demandsagency commitment to attend the bi-weeklycluster meetings and ad hoc sessions addressingspecific operational issues, improve focus onHRP targets, and leverage limited resources.World Vision’s nutrition team also prioritisedcluster reporting that ensures better coordinationof programmes and helps identify and addressgaps or target areas.

Breakdown in ready-to-use-therapeutic food (RUTF) supplychainSupplies for targeted supplementary feedingprogrammes (TSFP) were provided by WFP, andsupplies for outpatient therapeutic programmes(OTP) and stabilisation centres (SCs) were pro-cured through UNICEF. Stretched resources,poor road access and on occasion insecurityoen resulted in breakdown of the supply.

Adaptation: World Vision secured alternativesupplies from Canadian and US offices as gis-in-kind, creating a successful buffer to protectprogramming.

Poor local health infrastructuree impact of the current conflict on health in-frastructure in South Sudan surpasses that ofthe two-decade civil war that ended in Sudan’sindependence. Where fighting has spread, healthfacilities have been destroyed. Before the crisis,there were more than 300 outpatient treatmentcentres across the country; by mid-2014, thenumber had dropped to 183. Access to otherprogrammes addressing acute malnutrition hasalso declined drastically. Where health facilitiesstill operate, they face significant challenges,including lack of resources for training, lowand irregularly paid wages, a lack of supervisionat all levels, and high staff turnover.

As a result, humanitarian agencies oenstruggle to find an appropriate base for CMAM

operations and access to referred services forchildren or pregnant women who require addi-tional medical support. Referred children andpregnant women oen have difficulty accessingservices or medication due to distance or cost.

Adaptation: In areas without a functioninghealth facility, World Vision invested in a networkof community nutrition volunteers and securedalternative sites such as places of worship forCMAM activities, oen transporting equipmentand RUTF supplies in and out on an ongoingbasis; a challenge that is exacerbated by hu-manitarian access issues (see below.)

is situation also interferes with capacity-building of local health staff, essential for thesustainability of the programme, which shouldultimately transition to local health services.

Adaptation: With capacity-building of localhealth services out of reach in many areas ofoperation, the focus is on building communitycapacity through volunteers who actively par-ticipate in case-finding, referrals and follow-up.

However, this community capacity-buildingdoes not allow for transition of CMAM respon-sibilities to government. World Vision acknowl-edges the need and has continued to resourceand respond with CMAM interventions in someof the most hard-to-reach locations in SouthSudan.

Access and population movementHumanitarian access to populations is hinderedby lack of infrastructure in South Sudan andby ongoing conflict as fighting prevents stafffrom travelling to affected communities. Poorroad access and flooding during the rainy season,combined with the lack of secure storage forRUTF, can mean that supplies must travel longdistances by boat and by foot – increasing thetime, cost and risk of programming. is canresult in programme activities being delayed orsuspended. In addition, the nomadic lifestyle ofSouth Sudanese means high mobility even inthe relatively stable locations, while the onset ofconflict resulted in recurrent massive population

displacements. e fluidity can make it difficultto achieve the eight weeks of contact requiredfor CMAM treatment.

Adaptation: e CMAM project model offerssome measures which mitigate these impacts:• Increasing the ration of RUTF to malnour-

ished children – providing two or more rations, rather than one week’s supply, when fighting is predicted.

• Training community volunteers to monitor the children receiving treatment and help ensure that children receive additional rations if access is impossible.

• Where health facilities are being used, posi-tioning supplies during the dry season be-fore roads become flooded and inaccessible.

Rapid response mechanism(RRM)In partnership with other humanitarian actorsin South Sudan and with funding from theCommon Humanitarian Fund (CHF), WorldVision trialled a multi-sector RRM to meet thecritical needs of displaced populations in hardto-reach areas of the most affected states. RRMmissions deploy mobile teams of nutrition water,sanitation and hygiene (WASH); health; childprotection; and education technical specialists.(see Figure 1).

rough RRM, between July 2014 and March2015 World Vision established 14 OTP sitesacross Unity and Upper Nile States (exceedingthe projected 13). It screened 25,729 childrenfor malnutrition, treated 825 children for MAM(through supplementary feeding programmes),and 301 children for SAM through OTPs. Ittrained 142 community nutrition volunteers inCMAM and infant and young child feeding inemergencies; 36 health workers in CMAM; and180 mother-to-mother support group leaders.

Figure 1 Objectives of the multi-sector rapid response team

5 WHO; WHO responds to health crises facing war-wracked South Sudan, (September 2014); Ministry of Health, Health sector development plan 2011–2015, Government of South Sudan, (2011).

6 GHA; South Sudan: Donor response to the crisis, (2014) 4.

HEALTH HEALTH

OBJECTIVES OF THE RRM TEAMS INCLUDE:

NUTRITION EDUCATIONCHILD

PROTECTION

To deliver criticallife-saving healthservices to reduceexcess mortalityand morbidity.

To provide safedrinking water andemergency latrines

to vulnerablecommunities, andto promote good

hygiene andprevent the

outbreak andspread of water-related disease.

To provide essentialemergency

nutrition services to reduce

malnutrition-related mortality in children under 5, pregnant and

lactating women,and other

vulnerable groups.

To provide learningopportunities,including the

provision of life-saving messages,

as a safe andprotective

environment andentry point for

other programmeinterventions.

To identify, registerand commence

tracing ofunaccompanied,

separated andmissing girls andboys; set up childfriendly spaces for

psychosocialsupport.

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Field Article

What we learnedIn some locations, RRM provided beneficialcomplementarity surge capacity for existingCMAM programmes. In Bol and Otego districtsin Fashoda, for instance, the RRM greatly in-creased the coverage of existing CMAM pro-grammes through mass MUAC (mid-upper armcircumference) screening and referral of identifiedchildren to the existing OTPs for follow-up.

e RRM was quick to fill gaps when apartner was phasing out; for instance, whenMédecins Sans Frontières pulled out of Fashoda,the RRM took over the OTP sites in Luland Kodok. In Koch, the RRM made an impacton the hard-to-reach districts of Noborand Gany, where the existing partner could notreach. In addition, World Vision’s mobile RRMteam took part in inter-agency needs assessments,including Kaldak and Canal, and pre-positionednon-food items (NFI) and food items in Rumbekto support activities in Canal and Khorfulus.

In locations where the RRM team trainedcommunity nutrition volunteers and mother-to-mother support groups, the number of childrenscreened and enrolled tended to be higher andthere was better follow-up of children even aerprovision of the RUTF. In Melut and Manyo,for instance, volunteers and health workers con-tinued to monitor and provide food to registeredchildren, even aer the project phase-out.

In remote RRM sites where the caseload wasvery high with limited partner capacity, WorldVision sought additional funding from otherdonors to establish a longer-term presence, suchas the mission in Koch, Unity State, which waslater funded by Irish Aid for one year beforebeing transitioned back to World Relief aerthe caseload was contained and capacity built.

Flexibility and sensitivity to a changing op-erational context were key to achieving sometargets, such as establishment of 14 temporaryOTP sites using tents rather than semi-permanentstructures as stipulated in the proposal. Com-plementarity with other existing programmeswas critical in achieving project objectives.

ChallengesAlthough the RRM was meant to support existingnutrition programmes, it was sometimes mis-understood as replacing, rather than comple-menting, static programmes. In some instances,this resulted in territorial tendencies, withpartners on the ground claiming universal cov-erage even when communities and the County

Health Department (CHD) reported otherwise.is affected operations.

e project design underestimated logisticalchallenges around accessing hard-to-reach lo-cations. Some proposed locations were completelyinaccessible in the rainy season, and the logisticscluster was sometimes overstretched with nu-merous priority locations and limited air equip-ment. Consequently, several planned activitieswere not executed.

During design, it was difficult to make accuratecaseload projections due to ongoing displace-ments, hence lack of accurate population num-bers, while lack of prevalence and incidencedata resulted in overestimations. For instance,although the project exceeded its target numberof children screened, the proportion admittedto OTPs was significantly lower than expected.

Low RRM coverage in some locations wasdue to changing contexts, with unanticipateddrops in the incidence and prevalence of acutemalnutrition in targeted areas. It is also possiblethat some malnourished children were notreached due to insecurity and population move-ments. For instance, operations in Canal Countywere suspended due to recurrent insecurity.

Some proposed interventions were not ap-propriate for the RRM model. For example,constructing semi-permanent OTP sites wasnot possible due to difficulties finding skilledcontractors and transporting materials to thehard-to-reach locations and insecurity.

Inability to access commodities sometimesprevented the implementation of certain compo-nents of CMAM; better early integration with themobile food aid team could have mitigated this.

RecommendationsDevelopment of terms of reference (ToR) forthe RRM prior to implementation and popu-larising it among partners would have resultedin more success; the RRM technical workinggroup later developed a ToR. More flexibilitywould enable partners to implement the RRM,allowing it to happen where there are no field-level agreements or partnership corporate agree-ments in place. Further integration of food-aidmobile teams and nutrition RRM teams wouldenable partners to implement the full continuumof CMAM, including interventions to preventmalnutrition. e logistics cluster must prioritiseits support; hard-to-reach locations presentmajor logistical bottlenecks which partnerscannot always overcome alone. Outsourcing serv-

ices during peak seasons can result in moreeffective responses in future. Inter-cluster col-laboration is needed to jointly develop an RRMroster to regulate activities. is will enable bettercoordination among the partners’ various rapidresponse teams. Mapping of capacity gaps amongpartners prior to RRM design would help identifyspecific areas of intervention, avoiding conflictand duplication of activities. Finalising the ToRfor the RRM and ensuring it is widely disseminatedto all partners will enable common understandingof the mutual benefit the model brings.

CMAM for child survival amidconflict: ResultsIn 2014, World Vision successfully treated 8,964children; 3,537 for SAM and 5,437 for MAMthrough CMAM. World Vision operated threeSCs and 33 OTPs in Warrap and Upper Nilestates. Food security interventions and WASHprojects reached 190,152 people during the sameperiod. is response continued in 2015. Despitedisruption of services due to eruptions of violence,World Vison managed to reach more than235,000 people with food assistance; 97,000people with WASH interventions; and 26,000children and pregnant or lactating mothers withtreatment for malnutrition. In the 2015 calendaryear, humanitarian actors have reached 757,435people with nutrition interventions. Withoutinterventions across these key areas, the currentlevel of food security and nutrition in SouthSudan would be far worse.

Lessons learnedree higher-level themes emerged in SouthSudan that may be relevant to nutrition pro-gramming in other conflict-affected contexts:• Flexibility and responsiveness is crucial in

the context of protracted conflict, with teams empowered to respond to rapidly changing conditions. On-the-ground nutri-tion teams must also have support to designand test new initiatives to overcome chal-lenges. ey should also be accountable for capturing and sharing the results and learn-ings of these initiatives.

• Close coordination within and between NGOs, the UN and humanitarian clusters isessential given weakened national infrastructure. Ongoing insecurity and humani-tarian access issues mean significant supportfrom UNOCHA and the logistics cluster is required to assist with access negotiations and to deliver nutrition programmes.

• In the absence of transitioning capacity to local actors, predictable and long-term funding is essential to sustain critical pro-gramme delivery and expert staff retention.

World Vision’s experience in South Sudan showsthat CMAM remains a critical tool for addressingemergency levels of GAM in a conflict-affectedcontext. Direct treatment of malnutrition iscrucial to protect children from death and givethem (and ultimately their country) the bestchance of a secure future.

For more information, contact: Joy Toose, email:heainfo@wvi.org

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Transporting RUTF

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By Leni Martinez Del Campo, Emily Sylvia and the Concern Burundi Team

Leni Martinez del Campo wasthe food and nutrition securityofficer at Concern Worldwide,where she focused onadvocating for greater politicalsupport and financialresources for nutrition. She is a

graduate of the MPA in Development Practiceprogramme at Columbia University.

Acting on lessons learned

Pilot micronutrient powderdistribution in Burundi:

The authors acknowledge the contribution of the Concern Burundi team to the development of thisarticle and thank Kirk Pritchard of Concern for helping coordinate inputs.

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The current state of childnutrition in Burundi In Burundi, four out of five people live on lessthan US$1.25 per day, making it one of thepoorest countries in the world. It is also amongthe countries with the highest prevalence ofstunted children: an estimated 58% of childrenunder five years of age are stunted (height forage <-2 z scores). is is significantly highercompared to other countries in the East Africaregion with similar per capita incomes1. In ad-dition, 35% of children are underweight and7% are wasted2. Less outwardly visible, micronu-trient deficiencies are also prevalent. Twenty-five per cent of children under five years of ageare vitamin A deficient and 56% are anaemic.Zinc deficiency affects 47% of the population3.Adequate micronutrient intake is importantthroughout life, but critical during the first 1,000days (from conception to second birthday) toensure adequate cognitive and physical devel-opment. It is estimated that Burundi loses ap-proximately US$30 million a year due to mi-cronutrient deficiencies4.

MNP distribution project In an effort to tackle micronutrient deficiencieswithin the 1,000-day window of opportunity,the Ministry of Public Health and the FightAgainst AIDS of Burundi, in partnership withUNICEF, has undertaken widespread distributionof micronutrient powders (MNPs) for childrenaged 6-23 months as part of the Burundian Na-tional Integrated Program for Food and Nutrition(PRONIANUT). is article shares experiencesfrom the pilot MNP distribution initiative in2014 and 2015.

A pilot MNP distribution was carried out inDecember 2014 and April 2015 during Mother-Child Health Week (a twice-yearly event) inCibitoke and Ngozi provinces. All mothers withchildren aged 6 to 23 months received a two-month supply of MNP sachets (60 sachets) totest acceptability and explore uptake. Communityhealth workers/agents de santé communautaire(ASCs) and peer health educators/maman lu-mières (MLs) provided mothers with support,sensitisation and education on the adequate use

Location: BurundiWhat we know: Micronutrient deficiencies are prevalent amongst children in Burundi. Micronutrientsupplementation 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 andsupported by community health workers and peer educators. A post-distribution survey of mothers foundhigh distribution coverage (97%), good acceptance of the product, and reported child health benefits (lesssickness, 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 interventionperiod. Identified barriers were addressed to improve subsequent phases. This experience reinforces theimportance of community engagement, feedback mechanisms and adaptive programming.

Emily Sylvia is a recentgraduate of the MPA inDevelopment Practiceprogramme at theColumbia UniversitySchool of Internationaland Public Affairs, where

she specialised in agriculture and food securitywith a focus on nutrition-sensitive agriculture.

of MNPs and nutrition messaging. ConcernWorldwide Burundi was invited to join thisprogramme to assist in the implementation,sensitisation and education on the adequate useof MNPs.

Concern conducted a post-distribution survey(exit interviews and focus groups) in CibitokeProvince three months aer the December 2014distribution. e December 2014 target was28,666 children, of whom 28,007 were reached.e survey evaluated the effectiveness of com-munication and messaging during MNP distri-bution, focusing on the level of knowledge and

1 Burundi Country Profile. Global Nutrition Report 2014. http://globalnutritionreport.org/files/2014/11/gnr14_cp_burundi.pdf

2 Nutrition at a Glance. World Bank. http://siteresources.worldbank.org/NUTRITION/Resources/2818461271963823772/ Burundi.pdf

3 See previous footnote.4 UNICEF and the Micronutrient Initiative. 2004. Vitamin and

Mineral Deficiency: A Global Progress Report and World Bank. 2009. World Development Indicators (Database), citedin http://siteresources.worldbank.org/NUTRITION/Resources/281846-1271963823772/Burundi.pdf

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use of the product, storage, and perceived sec-ondary effects of use, to improve the sensitisationcomponent for subsequent phases of the project.Specifically, it examined: • Were mothers with children aged 6 to 23

months who received MNPs able to use them correctly at home?

• What determinants influenced the use of MNPs among mothers with children aged 6 to 23 months?

A sample of 114 mothers was interviewed forthe quantitative evaluation. A sample of 30mothers, divided into six focus groups, was in-terviewed for the qualitative evaluation.

Findings from the post-distribution surveye survey identified a number of positiveoutcomes. Most mothers perceived that theirchildren were healthier and more energetic(see Figure 1). Mothers reported fewer boutsof child diarrhoea during the intervention pe-riod. Mothers had a positive perception of theproduct; all mothers said they would give theirchildren MNPs again if provided. No significantcultural barriers were identified. e surveysubstantiated high coverage recorded (97.7%),and all mothers reported receiving MNP sachetsfree of charge from medical personnel.

The survey also identified a number of keybarriers, which are closely interlinked: 1. Poor community mobilisation by ASCs

and MLs;2. Poor follow-up with mothers and health

workers;3. Lack of clarity of the communication/

education pamphlet; 4. Mislabelling on packaging; and5. Unclear messaging with regard to the

treatment target group.

e survey suggests that poor community mo-bilisation was closely linked to insufficient train-ing of ASCs and MLs, who play a critical rolein the dissemination of information and mir-roring of best practices in their communities.ey received only one day of training on theadequate use and importance of MNPs oneweek prior to Maternal-Child Health Week;this was insufficient to allow full understandingof the process and MNP utilisation (a new in-tervention to them). e short period betweentraining and distribution did not allow the sup-port agents to conduct visits to homes in theircommunities to sensitise mothers prior to dis-tribution. In addition, there was no well-definedfollow-up strategy to encourage mothers to useMNPs and to answer any questions that aroseduring the two months following distribution.

e education pamphlet contained two keymessages on the use of MNPs and the impor-tance of a balanced diet but failed to explainhow these two are linked, and did not containsufficient and clear information on the use ofthe sachets. For example, the survey revealedthat mothers were not clear on the types offoods that could be used with MNPs. e pam-phlet indicated that porridge was the foodwith which the MNPs could be used, leadingmothers to believe that they could only beserved over porridge. Additionally, the imagesused failed to communicate accurately thepreparation process, resulting in confusionover the time between adding the content ofthe sachets to the food and feeding it the child,and the temperature the food needed to reachfor the powders to be added.

e packages for the sachets displayed theincorrect age group, stipulating that the productshould be consumed by children aged between6 and 59 months rather than 6-23 months, re-sulting in mix-up among ASCs/MLs as well asmothers concerning who the product was in-

Figure 1 Perceived effects of the useof MNPs

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Figure 2 Comparison of the educational pamphlets pre and post-pilot

BEFORE

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Field Article

tended for. e survey revealed that during thefirst day of distribution, MNPs were distributedto mothers with children aged 6-59 months,instead of those with children aged 6-23 months.Consequently, only 45% of mothers interviewedwere aware that the MNPs should be given tochildren between the ages of 6 and 23 months,while 14.9% thought 6-59 months was the targetage; 16.6% did not know; 15.8% were ‘other’; and0.8% thought 0-6 months was the target group.

At the time of the post-distribution survey,three months aer distribution, 64% of mothers

AFTER

Figure 2 Comparison of the educational pamphlets pre and post-pilot(Cont’d)

still had leover sachets; at the estimated rate ofuse (1/day), none should have been leover followingthe two-month pilot period. e main reasonsgiven by mothers for interrupted use were: theyforgot (36%); the child was sick (24%); they werenot present (18%); there was no porridge (15%); orthey lost interest (7%). Mothers were uncertainwhether MNPs could be consumed in tandem withmedications and therefore stopped their use if theirchild became ill.

Recommendations and follow-upAlthough there were problems around mobilisation,

communication and labelling that affecteduptake and use, distribution coverage washigh and mothers had a high acceptance ofthe product, a good perception of its effects,and were willing to use it. Recommendationsto address the identified barriers in futureMNP 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 mobilisa-tion 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 UNICEFto integrate these changes into the programmedesign and modify the pamphlet, using picturesrather than sketches to improve accessibility(see Figure 2). is was used in a cascadetraining by PRONIANUT, starting with na-tional-level actors and reaching to communitylevel, to enable the ASCs and MLs to sensitisemothers and teach them adequate use ofMNPs more effectively. A new national pack-aging design will be used use for MNP suppliesin 2016. Future rollout looks to integrateMNP distribution in the regular health systemat both health facility and community levels.At the community level, the provision bycommunity health workers will enable ade-quate coverage and good follow-up.

Conclusions UNICEF and Concern worked together toidentify weaknesses in the project and actedon them to improve subsequent phases ofMNP distribution. is included investmentby UNICEF and PRONIANUT in buildingthe capacity of the ASCs and MLs. e ex-perience highlights the importance of sensi-tisation, education and engagement of ben-eficiaries in planning and implementation;of stakeholder coordination and communityinvolvement in building communicationstrategies; and of community awareness andsensitisation to relieve pressure on mothers.e project is a good example of how, throughopen lines of communication and feedbackmechanisms, it is possible to overcome bar-riers, and how a project can be redesignedto have greater impact and improve the livesof the people it targets.

For more information, contact: Leni Martinezdel Campo, email: lenimtz@gmail.com

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Research .............................................................

Factors influencing pastoral and agropastoral household

vulnerability to food insecurity in Kenya

Kenya has a population of more than 38million, 10% of whom are classified asfood-insecure. e Kenyan drylands are

populated largely by livestock-dependent pastoraltribes who are particularly vulnerable to foodshortages. Prevalent high food and non-foodprices, crop failure, livestock diseases and conflicthave compounded the already precarious foodinsecurity in the arid and semi-arid lands(ASALs). Factors contributing to food insecurityand related survival mechanisms are specific todifferent people and regions, but there is lack ofclarity in Kenya on possible causes and solutionsto the problem. Further research, particularlyat the household level, is needed to informpolicy and action in adapting to the impacts ofclimate change.

is study establishes the determinants of

household vulnerability to food insecurity inpastoral households of Kajiado County andagropastoral households of Makueni County inKenya. Interviews were conducted with a ran-domly selected sample of 198 households. Incomeper adult equivalent was used to estimate house-hold vulnerability to food insecurity, which wascalculated as the proportion of households whofall below the poverty line of Ksh 1,239 (£9.99)per adult equivalent per month. Descriptiveanalysis showed that 59% of pastoral householdsof Kajiado County were vulnerable to food in-security, compared to 27% of agropastoral house-holds in Makueni County. Additionally, a two-stage least squares approach (regression analysis)established that vulnerability of households tofood insecurity is determined by land size,household size, rainfall and herd size for MakueniCounty, and by access to climate information,

herd size, off-farm employment and gender ofhousehold head for Kajiado County.

e findings imply that Makueni Countyneeds access to and control over land resources,destocking through improved livestock breeds,and creation of a microclimate to enhancerainfall levels. e authors recommend thatpolicies in Kajiado County promote access toclimate information, diversification of livelihoodsand female access to production resources.

Amwata DA, Nyariki DM and Musimba NRK(2016). Factors Influencing Pastoral andAgropastoral Household Vulnerability to FoodInsecurity in the Drylands of Kenya: A CaseStudy of Kajiado and Makueni Counties. J. Int.Dev., 28: 771-787. doi: 10.1002/jid.3123. onlinelibrary.wiley.com/wol1/doi/10.1002/jid.3123/full

Determinants and trends of

socioeconomic inequality in child

malnutrition in Mozambique

Mozambique has experienced a slowdecrease in absolute levels of childmalnutrition over the last 15 years.

However, levels remain very high, with chronicmalnutrition (stunting) prevalence of more than40% in children under five years of age, one ofthe highest in the world. Previous studies onchild malnutrition in Mozambique have mainlyfocused on absolute levels of malnutrition andrelative trends. is study examines the extentof socioeconomic inequality in child malnutrition,focusing on height-for-age Z-scores, using datafrom the Household Budget Survey 1996-1997and 2008-2009, and from the Development andHealth Statistics 2003 and 2011. Pro-rich in-

equalities in the distribution of malnutrition arefound for all years, and further analysis revealsthat most of the inequality in malnutrition isdue to inequality in food consumption. e au-thors claim that, while absolute levels of chronicchild malnutrition tended to decrease over time,socioeconomic inequality in malnutrition didnot; and actually seems to have increased slightlyover the same time period.

Salvucci V. Determinants and Trends of Socioe-conomic Inequality in Child Malnutrition: eCase of Mozambique, 1996-2011. 2016. J. Int.Dev., 28: 857-875. doi: 10.1002/jid.3135.

The migrant camp that doctors built

All around the edges of Europe, as thenumbers of refugees and economic mi-grants have surged in recent years, char-

ities and individual volunteers rather than gov-ernments have provided much of the humani-tarian assistance on the ground. Although manyEuropean countries have officially committedto providing medical services to undocumentedmigrants,

e medical charity Médecins Sans Frontières(MSF) has built its first refugee camp, at Grand-

Synthe near Dunkirk, to provide basic humani-tarian assistance to people in need, regardlessof their status. Normally the charity providesmedical aid at refugee camps in developingcountries that are built and run by UnitedNations agencies. Doctors at the camp, knownas La Linière, have been treating migrants forhealth issues such as respiratory problems anddermatological problems (including eczema andscabies). ere are also chronic diseases andmental health problems. Aer months of lobbyingby non-governmental organisations (NGOs),

the state hospital at Grand-Synthe has opened aclinic specially for migrants. e new campgoes against French Government policy, whichis to encourage migrants to give up their dreamof getting to Britain and instead claim asylumin France and move to government-providedaccommodation for migrants elsewhere in thecountry.

Sophie Arie e migrant camp that doctorsbuilt. BMJ 2016;352:i1696dx.doi.org/10.1136/bmj.i1696

Measuring height of amalnourished child atMoamba Health Centrein Mozambique

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Trends in adult body-mass index in 200 countries

from 1975 to 2014: A pooled analysis

Underweight and severe and morbid obe-sity are associated with highly elevatedrisks of adverse health outcomes. is

study estimated trends in mean body mass index(BMI) by using 1,698 population-based datasources, with more than 19·2 million adult par-ticipants (9·9 million men and 9·3 millionwomen) whose height and weight had beenmeasured, in 186 of 200 countries for which es-timates were made; these 186 countries covered99% of the world's population.

Global age-standardised mean BMI increasedfrom 21·7 in 1975 to 24.2 in 2014 in men, andfrom 22·1 in 1975 to 24.4 in 2014 in women.Regional mean BMIs in 2014 for men ranged

from 21·4 in central Africa and south Asia to29·2 in Polynesia and Micronesia; for womenthe range was from 21·8 in south Asia to 32·2 inPolynesia and Micronesia. Over these fourdecades, age-standardised global prevalence ofunderweight decreased from 13·8% to 8·8% inmen and from 14·6% to 9·7% in women. SouthAsia had the highest prevalence of underweightin 2014, 23·4% in men and 24·0% in women.Age-standardised prevalence of obesity increasedfrom 3·2% in 1975 to 10·8% in 2014 in men,and from 6·4% to 14·9% in women. Globally,2·3% of men and 5·0% of women were severelyobese (BMI ≥35); the prevalence of morbid obe-sity (BMI ≥40) was 0·64% in men and 1·6% inwomen.

If post-2000 trends continue, the probabilityof meeting the 2025 global obesity target – tohalt the rise in obesity at its 2010 levels – is vir-tually zero. Rather, if these trends continue, by2025 global obesity prevalence will reach 18%in men and surpass 21% in women; severeobesity will surpass 6% in men and 9% inwomen. Nonetheless, underweight remainsprevalent in the world’s poorest regions, especiallyin south Asia.

Trends in adult body-mass index in 200 coun-tries from 1975 to 2014: A pooled analysis of1,698 population-based measurement studieswith 19·2 million participants. 2016. eLancet 387 (10026) (October 15): 1377-1396

Effect of lipid-based nutrient supplements on

morbidity in rural Malawian children

The WHO recommends the use of ironsupplements or home fortificants (suchas multiple micronutrient powders and

lipid-based nutrient supplements (LNS)) to im-prove iron status and reduce anaemia prevalenceamong infants and children aged 6-23 monthsin low-income countries. However, safety ofhome fortificants in children is uncertain inareas where infections are common. One largetrial using iron and folic acid supplements inZanzibar reported increased risk of malaria anddeaths.

A randomised controlled trial in rural Malawitested the hypothesis that provision of LNS con-taining iron does not increase infectious morbidityin children. Infants aged six months (n=1,932)were randomised to receive 10, 20 or 40g LNS/dor no supplement until age 18 months. All LNS

contained a total of 6mg iron in the daily doseprovided. Morbidity outcomes (serious adverseevents, non-scheduled visits and guardian-reportedmorbidity episodes) were compared betweencontrol and intervention groups. Findings werethat provision of 10 and 20 g LNS/d containing6mg iron/d did not increase morbidity in thechildren. Provision of 40g LNS/d did not affectguardian-reported illness episodes, but may haveincreased malaria-related, non-scheduled visits.

Bendabenda J, Alho L, Ashorn U, Cheung YB,Dewey KG, Vosti SA, Phuka J, Maleta K andAshorn P. 2016. e effect of providing lipid-based nutrient supplements on morbidity in ru-ral Malawian infants and young children: a ran-domized controlled trial. Public Health Nutri-tion, 19(10), pp. 1893-1903. doi:10.1017/S1368980016000331.

Thailand eliminates mother-to-child

transmission of HIV and syphilis

On June 7 2016, WHO certified thatailand had eliminated mother-to-child transmission of HIV and syphilis.

is is not only a public health success story forailand, but also an affirmation of how inter-nationally agreed goals –such as the UN’s 2001Declaration of Commitment on HIV/AIDS andthe Sustainable Development Goals – can helphealth ministries to mobilise political will andpublic funds, and commit to implementation.

ailand’s commitment to address mother-to-child transmission of HIV started in the

1980s, with family education encouraging couplesto be tested for HIV before having children.Aer research found that use of short-coursezidovudine could cut the risks of mother-to-child transmission by half, ailand began acountrywide programme that provided zidovu-dine as a routine part of antenatal care, tripledthe budget for prevention of mother-to-childtransmission (PMTCT) services, and loweredcosts by manufacturing generic versions of zi-dovudine locally. Universal healthcare began in2001 and was made free in 2007; this was ex-tended to include migrant workers, in whom

much higher rates of HIV have been recorded.In 2015, 99·6% of infants born to HIV-positivemothers in ailand received antiretroviral pro-phylaxis.

Sidibé, Michel, and Poonam Khetrapal Singh.2016. ailand Eliminates Mother-to-ChildTransmission of HIV and Syphilis. e Lancet387 (10037) (October 15): 2488–2489.doi:10.1016/S0140-6736(16)30787-5. www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(16)30787-5.pdf

Nutritioninterventions forchildren under 5in MlombaSchool, Malawi

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Decline in the prevalence of anaemia among children

through wheat flour fortification in Jordan

Children of pre-school age are the mostvulnerable to the detrimental long-termeffects of anaemia, including impairment

of cognitive and physical development and in-creased morbidity and mortality. In developingcountries, 30-80% of pre-school children areanaemic at one year of age. WHO classifiesanaemia prevalence of ≥40% as a severe publichealth problem and prevalence of 20-39·9% asa moderate public health problem.

Deficiencies of vitamin A, iron, zinc andiodine have been identified as public healthproblems in Jordan. e Government has im-plemented nationwide food-fortification pro-

grammes of salt and wheat flour. is studyused retrospective analysis of the data from tworepeated, national, cross-sectional surveys con-ducted in 2007 and 2009 of pre-school childrenaged 16-20 months and 34-36 months respectivelyaer implementation of wheat flour fortificationwith multiple micronutrients in Jordan. A totalof 3,789 and 3,447 children aged 6-59 monthswere tested in 2007 and 2009 respectively. eprevalence of anaemia in pre-school childrendeclined from 40·4% in 2007 to 33·9% in 2009.e decline in prevalence was more pronouncedamong children aged >24 months (−13·7 points);children living in urban areas (−8·0 points);

children from rich households (−9·0 points);children who had never been breast-fed (−17·0points); and well-nourished children (−6·8points). In both surveys, presence of childhoodanaemia was strongly associated with child age≤24 months, living in poor households, breast-feeding for ≥6 months, malnourishment, poormaternal education and maternal anaemia.

Al Rifai R, Nakamura K and Seino K. 2016.Decline in the prevalence of anaemia amongchildren of pre-school age aer implementationof wheat flour fortification with multiple mi-cronutrients in Jordan. Public Health Nutri-tion, 19(8), pp. 1486-1497.

Making progress towards food

security in rural Rwanda

Determining interventions to addressfood insecurity and poverty, as well assetting targets to be achieved in a specific

time period, have been a persistent challengefor development practitioners and decision-makers. Food and agricultural assistance pro-grammes have been widely implemented in sub-Saharan Africa to tackle food insecurity, butthere is little evidence demonstrating the impactof those programmes.

is study assessed the changes in food accessand consumption at the household level of anintegrated food security intervention in threerural districts of Rwanda. Household Food In-security Access Scale (HFIAS) scores and house-hold Food Consumption Scores (FCS) werecompared at baseline and aer one year of pro-gramme implementation. All 600 households

enrolled in the Food Security and LivelihoodsProgramme (FSLP) were included in the study.ere were significant improvements (P < 0·001)in HFIAS and FCS. Severe food insecurity de-creased from 78% to 49%, while acceptable foodconsumption improved from 48% to 64%. echange in HFIAS was significantly higher(P=0·019) for the poorest households. However,future assessments are needed to evaluate themaintenance of HFIAS and FCS improvementsand the programme’s sustainability.

Nsabuwera V, Hedt-Gauthier B, Khogali M,Edginton M, Hinderaker SG, Nisingizwe MP,Tihabyona JdD, Sikubwabo B, Sembagare S,Habinshuti A and Drobac P. Making progresstowards food security: evidence from an inter-vention in three rural districts of Rwanda.2015:1-9 Public Health Nutr.

Research Snapshots

Global and regional health effects of future food production

under climate change: A modelling study

One of the most important consequencesof climate change could be its effect onagriculture. Although much research

has focused on questions of food security, lesshas been devoted to assessing the wider healthimpacts of future changes in agricultural pro-duction. is modelling study estimates excessmortality attributable to agriculturally mediatedchanges in dietary and weight-related risk factorsby cause of death for 155 world regions in theyear 2050. e researchers linked a detailedagricultural modelling framework (the Inter-national Model for Policy Analysis of AgriculturalCommodities and Trade (IMPACT)) to a com-parative risk assessment of changes in fruit and

vegetable and red meat consumption and body-weight for deaths from coronary heart disease,stroke, cancer and an aggregate of other causes.

e model projects that by 2050 climatechange will lead to per-person reductions of3·2% (SD 0·4%) in global food availability; 4·0%(0·7%) in fruit and vegetable consumption; and0·7% (0·1%) in red meat consumption. esechanges will be associated with 529,000 climate-related deaths worldwide (95% CI 314 000-736000). Twice as many climate-related deaths wereassociated with reductions in fruit and vegetableconsumption than with climate-related increasesin the prevalence of underweight, and mostwere projected to occur in south and east Asia.

Adoption of climate-stabilisation pathways wouldreduce the number of climate-related deaths by29% to 71%, depending on their stringency.Strengthening public health programmes aimedat preventing and treating diet and weight-related risk factors could be a suitable climatechange adaptation strategy.

Springmann M, Mason-D’Croz D, Robinson S,Garnett T, Charles H, Godfray J, Gollin D,Rayner M, Ballon P and Scarborough P. Globaland Regional Health Effects of Future Food Pro-duction under Climate Change: A ModellingStudy. 2016. e Lancet 387 (10031) (October14): 1937-1946. doi:10.1016/S0140-6736(15)01156-3.

Mothers waiting at a distributionof nutrition products (Super

Cereal) in southeastern Rwanda

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Meta-analysis of associations between

stunting and child development

Despite documented associations betweenstunting and cognitive development,few population-level studies have meas-

ured both indicators in individual children orassessed stunting’s associations with other de-velopmental domains. Because stunting is moreeasily measured, it is oen used as a proxy fordevelopmental delay. Yet, although stunting anddevelopmental delay are associated and sharemany risk factors (illness, poverty, low birthweight, maternal depression, lack of breastfeeding),other risk factors for developmental delay – suchas exposure to violence or toxic metals, lack ofcaregiver responsiveness and inadequate stimu-lation – will not necessarily result in stunting.

is meta-analysis, using publicly availabledata from 15 Multiple Indicator Cluster Surveys(MICS-4) in low- and middle-income countries,assessed the association between stunting anddevelopment, controlling for maternal education,family wealth, books in the home, developmen-tally supportive parenting and sex of the child,stratified by country prevalence of breastfeeding(BF) (‘low BF’<90 %, ‘high BF’ ≥90 %). Ten-item Early Childhood Development Index (ECDI)scores assessed physical, learning, literacy/nu-meracy and socio-emotional developmental do-mains. Children (aged 36-59 months) on track

in three or four domains were considered ‘on-track’ overall. e authors found that stuntingis associated with many but not all developmentaldomains across a diversity of countries and cul-tures. However, associations varied by nationalbreastfeeding prevalence and developmental do-main. Mean prevalence of breastfeeding at sixmonths was 89.1% and mean percentage of chil-dren aged 36-59 months with on-track devel-opment was 65.5%, ranging from 42.6% in SierraLeone to 85.9% in Belize. Severe stunting (height-for-age Z-score <-3) was negatively associatedwith on-track development. Any stunting, in-cluding severe stunting, was negatively associatedwith physical development and literacy/numeracydevelopment in high BF countries but not lowBF countries. Any stunting (Z-score <-2) wasnegatively associated with on-track developmentin countries with high BF prevalence.

Miller AC, Murray MB, omson DR and Ar-bour MC, 2016. How consistent are associationsbetween stunting and child development? Evi-dence from a meta-analysis of associations be-tween stunting and multidimensional child de-velopment in fieen low- and middle-incomecountries. Public Health Nutrition, 19(8),pp.1339-1347. 10.1017/S136898001500227X.

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

Research Snapshots

Who should finance the World Health

Organization’s work on emergencies?

In May 2015, the 68th World Health Assemblyapproved the decision to reform the work ofthe World Health Organization (WHO) on

emergencies by creating a single programme foroutbreaks and health emergencies. is is ac-companied by a Contingency Fund for Emer-gencies (CFE) to rapidly scale up WHO’s initialresponse to outbreaks and emergencies withhealth consequences (using the objective criteriaset out in WHO’s Emergency Response Frame-work), that merges two existing WHO funds1.Latest estimates are that core funding needs forthe programme and the initial capital of theCFE will range from US$100 to US$300 million(£81.77 to £245.32 million) per year respectively,but it is currently unclear how such resourceswill be raised. Previous attempts to set up similarcontingency funds at WHO were hindered byinsufficient funding.

is comment explores WHO funding optionsfor the CFE. ese include: voluntary contribu-tions from member states (although less realisticdue to global economic downturn); privatesector foundations who have been responsiveto fund appeals (although this would involvere-examining WHO rules on managing conflictsof interest relating to guidance norm setting(the authors suggest these might be less essentialfor its emergency programmes and cite WFP(UN World Food Programme), who engagewith a wide range of private corporations, in-cluding Coca-Cola, Unilever, and Danone));collecting flexible voluntary contributions becauseof the unpredictable nature of emergencies (achallenge for WHO, since 93% of such contri-butions are earmarked for specific activities);and bilateral agreements with governments toredirect resources from taxation systems (e.g.

carbon emissions, air fuel and transportationand tobacco have all been proposed as potentialnew funding sources for global health). WHOshould also seek to understand the institutionalconstraints, particularly with regard to budgeting,that precipitated the slow response to the 2014Ebola outbreak. Major changes at an organisa-tion-wide level will be required for WHO totruly lead the process of response to healthemergencies on a global scale.

Y-Ling Chi, Krishnakumar J, Maurer J, LoncarD, Flahault A. 2016. Who should finance WHO’swork on emergencies? e Lancet 387 (June 25):2584-2585. www.thelancet.com/pb/assets/raw/Lancet/pdfs/S0140673616305864.pdf

1 WHO Rapid Response Account and WHO-Nuclear Threat Initiative Emergency Outbreak Response Fund.

A father waits for a check-up at a communityclinic in the Northern Region of Ghana

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The double burden of malnutrition(DBM) affects many low and middle-income countries (LMICs). e rateof increase of childhood overweight

and obesity in LMICs is more than 30% higherthan in developed countries (Wang & Lobstein,2006) and there are more overweight and obesechildren in LMICs than in high-income countries(WHO 2015). Physical inactivity and unhealthydiet characterise socio-economic transition(Boutayeb & Boutayeb, 2005). Additionally, theemergence of nutrition-related non-communi-cable diseases (NR-NCDs) may be compoundedby problems of undernutrition, which themselvesincrease the risk of developing NCDs in adult-hood (Darnton-Hill et al, 2004). A child whogrows inadequately can be under-nourished ininfancy but become overweight or obese laterin life if the individual consumes energy-densefoods in excess. e same household can some-times comprise both an under-nourished childand an overweight adult (WHO, undated).Childhood obesity increases the child’s risk ofmental and physical health effects, which mostLMICs are not equipped to treat ((Boutayeb &Boutayeb, 2005), placing an additional burdenon already fragile health systems.

Tackling the double burden ofmalnutrition in low and middle-income countries: response of theinternational community

Location: LMICs

What we know: e double burden of malnutrition (DBM) affects many low and middle-income countries (LMICs); there is growing recognition of the emerging problem.

What this article adds: A recent study assessed existing activities, barriers and enablers of19 international organisations in tackling the DBM in LMICs. Most work has been at pol-icy level which has not yet translated into interventions. Ten agencies were not imple-menting related programming; barriers included lack of funding, obesity prevention not alife-saving intervention, lack of agency expertise, lack of guidelines and lack of impactevaluation. Shortage of evidenced interventions and donor engagement/funding particu-larly limit progress. Most respondents favoured using existing international fora to facili-tate necessary information exchange. Recommendations include systematically includingoverweight/obesity data in nutrition surveys; researching the impact of acute malnutri-tion treatment/rapid weight gain on chronic disease; and monitoring possible conflicts ofinterests in public/private partnerships.

ere is growing international recognitionof the emerging problem of overweight andobesity in LMICs. However, in practice NGO-led nutrition programming focuses on alleviatingwasting and stunting, with very few tacklingthe problem of obesity (INFPR, 2014).

A recent study assessed existing activities ofinternational organisations and UN agencies intackling the DBM in LMICs, as well as evaluatingthe barriers and enablers they face in doing so.

MethodA mix of purposive and snowball sampling wasused to identify participants for semi-structuredinterviews. e interview transcripts were analysedusing a framework analysis (Ritchie & Spencer,1993). Participants (representatives of internationalorganisations involved in agency nutrition strategydevelopment) were identified from InternationalConference on Nutrition (ICN2) participants,those engaged in the Scaling Up Nutrition (SUN)Movement and researcher contacts. Nineteen in-terviews were conducted (only one per agency).

FindingsAll participants were senior staff at agencyheadquarters categorised in five programming

Research .................................................................

sectors: Children (n=5), Food Security (n=1),Health (n=8), Nutrition (n=4) and Relief (n=1),although most had overlap. Ten organisationshad more than 20 years of experience. e ma-jority of organisations implemented programmes(n=14); four were policy-based (three UN agen-cies) and one was an advocacy organisation.Ten agencies were working in both developedand developing countries; nine in developingcountries only.

Nine (47%) of the organisations did not in-tegrate any obesity or NR-NCD related activitieswithin their work. ree agencies (16%) inte-grated the theme of DBM within health educa-tion and two agencies (11%) did so withinsocial and behaviour-change activities. Fouragencies (26%) had a policy on DBM. Two or-ganisations (10%) had no plans to addressDBM, and seven (37%) had only just begun in-ternal conversations about obesity preventionand NR-NCD programmes.

Most work to date has been at a policy leveland was conducted by UN agencies to addressmalnutrition in all its forms, mainly in responseto the nutritional landscape faced in the Syriacrisis (UNICEF, 2014; (Dolan et al, 2014). How-ever, very few DBM interventions were identifiedamongst implementing agency respondents.Two programme examples were: a ‘One Goal’programme led by World Vision in India (Ed-wards, 2015) and the ‘Double Fardeau of Nu-trition’ (DFN) Project in West Africa, partlysupported by Helen Keller International (PôleFrancophone Africain, 2015).

Reported barriers to including DBM activitieswere lack of funding (n=13), the fact that obesityprevention was not a lifesaving intervention (n=12),lack of agency expertise (n=11), lack of guidelinesand impact evaluation on prevention of obesity(n=9), and lack of specific disaggregated data(n=7). Some found it difficult to judge whetherDBM was a health or nutrition problem.

e most commonly cited enabler for DBMprograming was having more evidence (n=12).

By Alexandra Rutishauser-Perera

Alexandra Rutishauser-Perera is aHumanitarian Nutrition Adviser with Savethe Children. She has ten years ofexperience of public health nutrition withseveral international non-governmentalorganisations in West and East Africa andSouth-East Asia.

This article summarises key findings of aMasters dissertation undertaken by theauthor in 2015. The author acknowledgesher MSc supervisor, Dr Cecile Knai, for hersupport.

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Researche types of evidence needed included disag-gregated data on prevalence, the determinantsof obesity, evidence-based programming on pre-vention of obesity, and cost effectiveness of ac-tivities targeting overnutrition. Addressing mi-cronutrient deficiencies by focusing on foodquality and higher intake of fruits and vegetables(e.g. school feeding in South Africa), or treatingundernutrition (which at a young age can pre-dispose to obesity later in life) were suggested asentry points to develop activities on DBM (n=7).Other factors that contributed to decisions tobecome involved in DBM programming includedexistence of a donor strategy to address DBM(n=6), being operational in a country affectedby obesity (n=4), obesity prevention included inthe targets of the World Health Assembly (WHA)(n=3), and internal expertise (n=2).

Ten participants felt it was not necessary tocreate a new forum to exchange information onDBM. Only three respondents favoured devel-opment of a DBM-specific forum. e top fiveforums suggested were the SUN Movement (n=7),ICN (n=5), ENN (n=5), UNSCN (n=5), and theCommittee on World Food Security (CFS).

Potential negative consequences of currentnutrition programming on DBM were: promotionof energy-dense food (n=8); public/private orNGO/private partnerships (n=7); and rapidcatch-up growth in infancy for underweight in-fants or young children potentially increasingchildhood obesity prevalence (n=4). Seven par-ticipants suggested ways to mitigate negativeconsequences, including more systematic quan-titative analysis of those potential risks; con-centrating on effective activities such as breast-feeding; having a more food-based approachregarding the prevention of undernutrition; andincluding nutrition and counselling in all foodsecurity and nutrition programmes.

DiscussionDevelopment assistance providers have startedto include prevention and management of NCDsin their programme activities. However thescope of these interventions is still limited geo-graphically and not integrated into nutritionprogramming. e US ASSIST project stillfocuses on Europe and Central Asia, with onlya few NCD projects in India and Uganda (US-AID).e UK Department for International De-velopment (DFID) is exceptional in that it in-cludes commitment to prevent and treat thefour major NCDs (cardiovascular disease, cancer,chronic respiratory disease and diabetes) in its2010-2015 policy.

Despite global improvement in reportingthe prevalence of overweight/obesity in dif-ferent age groups, the data reported are stillnational-level only (Global Nutrition Report,Malnutrition Mapping Project) (INFPR, 2014;GAIN 2015). The international guidelines onnutrition surveys do not include indicatorson overweight/obesity (AAH, 2006). Addi-tionally, there is also a lack of consensus onhow to define overweight/obesity in childhoodand adolescence (Poskitt, 2009). Data on the

economic consequences of obesity in adultsin high-income countries are now well re-ported, but concentrate mostly on healthcareexpenditure; the consequences of childhoodobesity are almost never mentioned (Bhuttaet al, 2008).

Many believe that the SUN Movement providesan opportunity to address the DBM. However,an external evaluation of the 2014 SUN movementsuggested that the movement might dilute its ad-vocacy if it stops focusing solely on undernutrition.

ICN2 focused on the problems of overweight,obesity and undernutrition. However, the timingof the event limits its utility for timely exchangeof information. e Committee on World FoodSecurity (CFS), an intergovernmental bodycreated to serve as a forum for review and followup of food security policies, has agreed to integratethe problem of overweight and obesity into itsagenda (FAO, 2015). e CFS is interlinked withthe UN Standing Committee on Nutrition (UN-SCN), which connects UN agencies and partnersworking on nutrition and food policy. e UN-SCN has a dedicated section on Nutrition andNCDs (UN 2015), but funding issues seem toimpede its scope of work (WPHNA 2011).

Among the most cited forums in the study,ENN is the most used by field nutrition workers.Since its special edition of Field Exchange onthe Syria response in March 2015, ENN now in-cludes articles on the double burden of malnu-trition in its communications (Dolan et al, 2014).

e potential for negative consequences ofprevention and treatment programmes for un-dernutrition on childhood obesity are reflectedin the literature. Examples include:• Promotion of sweet, energy-dense products

may send misleading messages to parents aswell as habituate children’s tastes for sugar-rich and calorie dense foods (GIFA 2014).

• Rapid catch-up growth may lead to obesity, rather than increase the height of children, especially when used in prevention (WPHNA; Gupte 2013).

• Action Contre la Faim argues that thepotential risk of ready-to-use therapeutic food (RUTF) leading to obesity needs to be further researched, but will continue to use RUTF to treat SAM until the risk is verified (ACF 2012).

e need to evaluate those risks objectively infield programmes persists.

An increase in public/private partnershipsand inherent risks to public health are also con-cerns. e Lancet series on the global obesitypandemic noted: “Governments and internationalorganisations such as the UN need to provideglobal leadership on these issues and not abdicatethem to the private sector” (Swinburn et al,2013). A positive example of private sector en-gagement was given in feedback, noting thatnot all public-private partnerships are the same.Actors working in the field of nutrition requestmore transparency and monitoring of thosepartnerships in order to be able to “maximisebenefits and minimise risks” (Kraak et al, 2012).

Conclusion and recommendationsis study identified that, despite increased interestamong international organisations and UN policydevelopment on prevention of obesity and NCDs,there is an intervention gap in LMICs in cateringfor the DBM. Lack of donor engagement/fundingand lack of evidenced interventions limit progress.ere are concerns regarding consequences ofcurrent undernutrition treatment programmesfor future NCD burden. Key recommendationsemerging from this study include:

1. e collection and reporting of childhood and maternal overweight/obesity data shouldbe systematically included in all nutrition surveys;

2. Advocacy for the inclusion of the WHA target on childhood obesity in the SDGs is needed;

3. Epidemiological and operational information on DBM should be integrated into existing international nutrition forums,and particularly more systematically withinthe SUN movement;

4. More research is needed on the impact of the promotion of RUTF and rapid weight gain in acute malnutrition treatment pro-grammes; and

5. Greater monitoring of possible conflicts of interests in public/private partnerships is required.

Further research, involving a full mapping ofDBM activities of international organisationsand an exploration of operational evidence onprevention of obesity in LMICs, has the potentialto contribute to the halt in the rise of diabetesand obesity as recommended in the WHAtarget. The link between undernutrition andovernutrition may also be an entry point toadvocating with donors to add the DBM totheir development agenda.

For more information, contact: a.rutishauser-perera@savethechildren.org.uk

Watch Alexandra Rutishauser-Perera’s talk onthis topic at the TEDx LSHTM:https://www.youtube.com/watch?v=G7AG-DvobHE

ReferencesAAH. Action Against Hunger. MeasuringMortality,Nutritional Status, and Food Security in CrisisSituations: SMART Methodology. Version 1, 2006.

ACF 2012. Putting nutrition products in their place: ACFposition paper. Field Exchange. January 2012;Volume42:p57.

Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K,Giugliani E, et al. What works? Interventions for maternaland child undernutrition and survival. The Lancet2008.371(9610):417-40.

Boutayeb A and Boutayeb S. The burden of non-communicable diseases in developing countries.International Journal for Equity in Health. 2005;4(1):2.

Darnton-Hill I, Nishida C, James WP. A life course approachto diet, nutrition and the prevention of chronic diseases.Public Health Nutr. 2004;7(1a):101-21.

Dolan C, McGrath M, Shoham J. ENN’s perspective on thenutrition response in the Syria crisis. Field Exchange.November 2014 (Issue 48).

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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-scalesocial protection effort by the Government of Ethiopia targeting rural, food-insecure house-holds.

What this article adds: A recent qualitative study explored the role of power and politics inthe PSNP in seven communities in two regional states of Ethiopia. e authors conclude thatwhile there is positive impact, the implementation of the programme is problematic. In thesecommunities, the PSNP was highly politicised, systematically neglected all of the participato-ry components outlined in the programme design, excluded the feedback mechanisms andentrenched political power. Understanding the existing political climate in operational envi-ronments is critical.

Ethiopia has made significant progressin reducing poverty, with a decreaseof the population living in povertyfrom 46% in 2005 to 30% by 2010 (the

population increased from 57 to 88 millionduring the same period). e country has oneof the fastest-growing economies in the world;gross domestic product (GDP) was between 8.6and 13.6% from 2004 to 2016. e ProductiveSafety Net Programme (PSNP) is one of theGovernment of Ethiopia’s (GoE) most effectiveprogrammes to support people living in ruralareas, who make up over 80% of the population.

e PSNP began in 2005 to support food-insecure households and enable them to overcomevulnerabilities without eroding their assets, andover time to support households to build assets.In 2015, more than seven million people hadbeen supported by it, with an expected expansionto ten million people. e PSNP is mainly im-plemented by the GoE, with assistance fromdevelopment partners. e programme, now inits fourth phase, has been widely studied and

found to have positively impacted food-insecurehouseholds. Some studies claim that the impactis modest compared with progress made incomparable non-client households, althougheven critical assessments point to significantpositive change. e PSNP has three key com-ponents (see Box 1). A recent study exploredthe roles of power and politics in the imple-mentation of the PSNP. e authors contrastthe plan (the Programme Implementation Man-ual) with its practice and explore why divergencesmay be occurring.

Methodse qualitative research methods involved detailedinterviews with clients and former clients of thePSNP, as well as relevant government staff (com-munity leaders, development agents, communityhealth workers and school staff) in seven com-munities in southern Ethiopia from two regionalstates. Given political sensitivities in the country,researcher connections were utilised to selectcommunities for the study. ese relationshipswere pivotal in establishing the trust needed to

gain insight that might not otherwise have beenshared. Interviews consisted of four group in-terviews with each community-based governmentbody (in groups of two to six staff members),and 46 key informant interviews with PSNPclients, which were conducted voluntarily andanonymously. A large number of issues wereraised by both government staff and communitymembers; this research focused primarily onthe common concerns and key discrepancies inthe experiences of PSNP clients. Due to regionaldiversity within Ethiopia, this study was neverexpected to have great external validity.

FindingsSelection and graduation• Fair and transparent selection is one of PSNP’s

core principles, yet current clients and graduates in all the communities voiced

Edwards E. CHNCA, World Vision International. ‘One Goal’to end malnutrition in Asia - using the power of football2015. Available from: wvi.org/child-health-now/article/%E2%80%98one-goal%E2%80%99-end-malnutrition-asia-using-power-football

FAO 2015. Food and Agriculture Organization, editor The2nd International Conference on Nutrition (ICN2) andSustainable Food Systems Post-2015. Advancing Nutritionfrom ICN2 to post 2015, which role for CFS?; 15 October2014; Rome.

GAIN. Malnutrition Mapping Project [cited 2015].Available from: www.gainhealth.org/

GIFA 2014. Breastfeeding briefs [press release]. GenevaInfant Feeding Association (GIFA), an affiliate of theInternational Baby Food Action Network (IBFAN) 2014.

Gupte S. Recent Advances in Pediatrics. Special Volume 23 -Pediatric Gastroenterology, Hepatology and Nutrition:Jaypee Brothers, Medical Publishers Pvt. Limited; 2013.

INFPR. International Food Policy Research Institute. Global

Nutrition Report 2014: Actions and Accountability toAccelerate the World’s Progress on Nutrition. Washington,DC. 2014.

Kraak VI, Harrigan PB, Lawrence M, Harrison PJ, JacksonMA, Swinburn B. Balancing the benefits and risks of public-private partnerships to address the global double burden ofmalnutrition. Public Health Nutr. 2012;15(3):503-17.

Pôle Francophone Africain sur le double fardeaunutritionnel [cited 2015]. Available from:http://poledfn.org/

Poskitt EM. Countries in transition: underweight toobesity non-stop? Ann Trop Paediatr. 2009;29(1):1-11.

Ritchie J and Spencer L. Qualitative data analysis forapplied policy reseach in analysing qualitative data.London: Routledge 1993.

Swinburn BA, Sacks G, Hall KD, McPherson K, FinegoodDT, Moodie ML, et al. The global obesity pandemic:shaped by global drivers and local environments. TheLancet 2011. 378(9793):804-14.

1 Cochrane, Logan, and Y Tamiru. 2016. Ethiopia’s Productive Safety Net Program: Power, Politics and Practice. Journal of International Development 28 (5): 649–665. doi:10.1002/jid.3234.

ResearchUN 2015. United Nations System Standing Committee onNutrition 2015. Available from: www.unscn.org/.

UNICEF State of the World’s Children Report.2014;20Jan.pdf

USAID. United States Agency for InternationalDevelopment Assist Project. Applying Science toStrengthen and Improve Systems. [cited 2015]. Availablefrom: www.usaidassist.org/

Wang Y and Lobstein T. Worldwide trends in childhoodoverweight and obesity. International Journal of PediatricObesity. 2006;1(1):11-25.

WHO [undated]. World Health Organization Child GrowthStandard, backgrounder 4. Available from: www.who.int

WHO 2015. World Health Organization Interim Report ofthe Commission on Ending Childhood Obesity. 2015.

WPHNA. World Public Health Nutrition Association 2011.Available from:www.wphna.org/htdocs/2011_feb_hp5_scn_crisis.htm

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Public works programmeEligible households with able-bodied adultsare enrolled on this programme, with workgeared towards enhancing infrastructureand enriching community-based resources,such as schools. Public works activities occurfor six months each year, during whichclients receive a salary based uponhousehold size. Clients are expected tograduate from the programme when theygain sufficient assets.

Direct support programmeThose who are unable to work due todisability, illness or age are enrolled in thedirect support programme (payments are for12 months of the year).

Temporary programmeTemporary clients are pregnant or lactatingmothers or caregivers for a malnourishedchild, who are enrolled in the public workscomponent and temporarily shifted intodirect support.

Box 1 Overview of PSNP

Admission profile and discharge outcomes for infants

aged less than six months admitted to inpatient

therapeutic care in ten countries

Location: Global (Burundi, DRC, Kenya, Liberia, Myanmar, Niger, Somalia, Sudan, Tajikistan, Uganda)

What we know: e burden of acute malnutrition in infants less thansix months old is significant; there is a weak evidence base to informguidance on their management.

What this article adds: A secondary data analysis described the profileand treatment outcomes of 4,002 infants<6mo relative to 20,045 chil-dren aged 6-60 months from inpatient therapeutic feeding centres inten countries. Infants <6mo accounted for 12% of admissions. In-fants<6mo had more missing length and MUAC data, weight-for-height that could not be calculated (length <45cm) and nutrition in-dices that were extreme values. Infants <6mo had a higher relative riskof death, despite a better nutritional profile than older children at ad-mission; this requires cautious interpretation due to the high level ofheterogeneity between countries in the dataset. Contextual data onSAM prevalence, disease burden and service quality for infants<6mowas not available. Systematic compilation and analysis of routine dataon infants<6mo and research on definition of SAM is needed.

Researchconcern regarding the lack of transparency in client selection, and why and how graduation occurs.

• Described in the Manual as “community-based targeting”, in reality local leaders and government staff selected clients without anycommunity participation – a process that resulted in bias, with family members and friends of local leaders gaining entry prefer-ence and holding longer terms.

• Selection decisions were also linked to political affiliation, with the exclusion of known opposition party supporters.

• Data supports claims that numbers of graduates are determined at higher levels ofgovernment, based on quotas to ‘confirm’ that the programme is successful (i.e. clientsare expected to graduate aer five years).

• A number of political purposes are at play; the PSNP is being used for political patron-age, punishment (clients were graduated forpolitical reasons), and for broader political objectives of meeting regional and national targets.

Lodging an appeal• According to the Manual, the grievance

mechanism is run by an Appeals Committeeat the community and district levels, but notone current or former client had heard of this.

• Overlapping responsibilities (i.e. staff likely to be on both committees that select clients as well as theoretical ones that handle appeals) reduce effectiveness.

• Questions were not escalated to higherlevels of government due to fear of reper-cussions; e.g. being labelled as an anti-gov-ernment agent.

Participation• e manual states that public works’ pro-

grammes should be decided by the commu-nity members, but in practice government staff choose and direct group leaders to repair roads, etc. PSNP clients have no par-ticipation in the decision-making process.

Work commitment• ere is limited adherence to the per person

working cap (no more than 15 days/month per adult household member) set out in theManual to prevent overburdening clients.

• In practice, each public works client was re-sponsible for working six days per week for six months of the year; also ‘voluntary’ par-ticipation in works continued beyond six months (refusal may be equated with political opposition, resulting in exclusion from benefits).

• e Government benefits from lack of ad-herence to labour caps, as most of the work involves government-run facilities such as schools and roads.

Power tends to corrupt• ere were multiple reports and examples

of corruption, e.g. public workers made to farm land belonging to the community chairman, or people with a good relationship withthe chairman were enrolled in the PSNP butnot required to work.

Discussione study authors conclude that the programmehas had a large and beneficial impact, but itsimplementation has been shaped and co-optedto maintain and strengthen political power. Fur-thermore, the findings challenge donors andpractitioners to recognise the ways in whichtheir funding and approaches to programmedesign are both empowering and disempoweringindividuals and to better understand the existingpolitical climate in operational environments.

IntroductionAcute malnutrition is a serious global health problem, with wastingaffecting 50 million children under five years old and accounting for11.5% of mortality in this population. An estimated 8.5 million ofwasted children are infants aged less than six months (infants <6mo).is high global burden has only recently been recognised, with theinclusion of infants <6mo in the latest World Health Organization(WHO) guidelines for the management of severe acute malnutrition(SAM)2. Such recognition needs to be underpinned by developingthe evidence base in order to improve care in this age group.

is study describes the profile and outcomes associated with themanagement of acute malnutrition in infants <6mo under prevailingtreatment protocols (pre-2013 WHO guidelines) to expand under-

1 WHO (2013) Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children. World Health Organization: Geneva.

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 admitted to inpatient therapeutic care in 10 countries. A secondary data analysis. Maternal & Child Nutrition, doi: 10.1111/mcn.12345.

Summary of research1

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standing about the effectiveness of current carestrategies and to provide the baseline evidenceto help guide improved future care.

Study methodsA secondary analysis was undertaken of rou-tinely collected and fully anonymised inpatienttherapeutic care programme data in ten coun-tries. The data came from an appeal fordatasets on acute malnutrition care of infants<6mo. Twenty-three datasets from ActionContre la Faim containing individual-levelinpatient therapeutic care programme datafrom 25,195 children aged 0-60 months from34 field sites located in 12 countries weresourced. The majority (82%) of children inthe study dataset were admitted to therapeuticfeeding centres (the remainder were admittedto a day care, home treatment or stabilisationcentre). Data from two countries, Afghanistanand Ethiopia (n = 1150), was excluded astheir programme data comprised largely in-fants<6mo and no older children for com-parison. A final sample of 24,045 childrenaged 0-60 months (4,002 infants<6mo; 20,0436-60 months) from ten countries was usedfor analysis.

Available data for most children at admis-sion included: age, the presence of bilateralpitting oedema, and anthropometric data(weight, length or height and mid-upper armcircumference (MUAC)). Anthropometric datawere also available at discharge. However,there was a large heterogeneity in the typeand timing of data collected. As a consequence,this analysis focused only on anthropometricand oedema data at admissions and outcomesat discharge. Discharge outcomes were codeddifferently within and between datasets: dis-charge codes were grouped into one of foursphere discharge codes: recovered, died, de-faulted and non-recovered.

Data were manipulated and analysed inStata soware. Anthropometry was calculatedbased on the 2006 WHO Growth Standards.Extreme values were flagged as outliers usingcommonly applied cleaning criteria (Crowe etal, 2014).

ResultsInfants <6mo accounted for 12% of childrenreceiving inpatient therapeutic care for acute

malnutrition. e quality of anthropometricdata at admission was more problematic in in-fants <6mo than in older children. Infants hadmore missing length (a 6.9 percentage pointdifference for length values, 95% CI: 6.0, 7.9;p<0.01) and MUAC data, anthropometric meas-ures that could not be converted to indices (a15.6 percentage point difference for weight-for-length z-score values, 95% CI: 14.3, 16.9;p<0.01, and nutrition indices that were extremevalues (a 2.7 percentage point difference forany anthropometric index being flagged as anoutlier, 95% CI: 1.7, 3.8; p<0.01.

Infants <6mo had better nutritional statusat admission to treatment centres than olderchildren, with lower proportions of oedemaand global acute malnutrition (GAM). (Asignificantly larger proportion of infants<6mo were moderate acute malnutrition(MAM) and a significantly lower proportionwere SAM).

A high proportion of both infants <6moand older children were discharged as recovered.However, infants <6mo showed a greater riskof death during treatment (risk ratio 1.30, 95%CI: 1.09, 1.56; p<0.01 than older children, al-though there was a high level of variation inthe risk ratio between study sites (86.6% variationin risk ratio attributable to heterogeneity; X2 =67.0 p<0.01).

Discussion andrecommendationsTo the authors’ knowledge, this was the firstanalysis of programme data from a variety ofcountries on infants <6mo receiving thera-peutic care for acute malnutrition. A keyfinding is that infants <6mo make up an im-portant proportion of the children in thera-peutic feeding programmes run by interna-tional relief agencies.

Collecting anthropometric data in infants<6mo was a challenge, highlighted by thegreater proportion of missing data at admission,particularly length. MUAC data is not recom-mended as an admission criterion for infants<6mo, since cut-offs were (and are still not)established for this age group. e WHZ indexcould not be calculated for a significantlygreater proportion of the infants <6mo basedon admission anthropometric data; the main

ReferencesCrowe et al, 2014. Crowe S., Seal A., Grijalva-Eternod C.and Kerac M. (2014). Effect of nutrition survey ’cleaningcriteria’ on estimates of malnutrition prevalence and diseaseburden: secondary data analysis. PeerJ 2, e380.

ENN & CIHD, 2010. ENN & CIHD, 2010. MAMI Project.Technical review: current evidence, policies, practices &programme outcomes. Available at:www.ennonline.net/mamitechnicalreview

Researchreason that WHZ could not be calculated (467out of 471 cases) was that infant length waslower than 45 cm, the minimum referencevalue needed for calculating this index. at agreater number of WHZ were flagged for infants<6mo suggests that further work is necessaryto better understand if the cleaning criteriadeveloped for older children should be appliedto this younger age group.

Infants <6mo presented a better anthro-pometric profile than older children at ad-mission to therapeutic care, even after ac-counting for oedema. Alternative non-anthro-pometric criteria, such as clinical signs of in-fection, disability, feeding difficulties and ma-ternal factors, may have been used for admis-sion; an assumption that is supported by a re-view of admission criteria used for this agegroup (ENN & CIHD, 2010). The degree towhich use of non-anthropometric criteria mayhave contributed to the better nutritionalprofile of admissions could not be quantified.Possible explanations for significantly loweroedema amongst infants<6mo are difficultiesin diagnosis in this age group, and clinicallydetectable oedema might only occur after cer-tain developmental milestones.

is analysis found that high proportionsof both infants <6mo and older children recoveraer receiving therapeutic care for acute mal-nutrition. However, a meta-analysis of the datarevealed that infants <6mo have a higherrelative risk of death, despite a better nutritionalprofile at admission; these observations needcautious interpretation due to the high levelof heterogeneity between countries in thedataset. ese results may reflect differencesin the quality of therapeutic care given toinfants <6mo and different infant profiles;prevalence of acute malnutrition in the com-munity, disease burden of infants <6mo, anddata on service quality were not available. Animportant limitation is that malnourished in-fants<6mo may have been under-representedin this study; most programmes were lesslikely to have actively sought malnourishedinfants<6mo compared to older children.

is study contributes to the call for priori-tising research on how acute malnutrition isdefined among infants <6mo, which is funda-mental to determining management strategies.e authors conclude that there is an urgentneed for monitoring programme performancefor infants <6mo involving systematic compi-lation and analysis of routine data.

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Chronic disease outcomes after SAM

in Malawian children (ChroSAM):

A cohort studySummary 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 aer inpa-tient SAM treatment and compared with sibling and community controls. Seven years post-treatment, nearlyone-third of discharged cases had died and another 15% were lost to follow-up. SAM survivors had lowerheight-for-age (HAZ) compared with controls, although with evidence of catch-up growth. Associated func-tional impairments were found, such as poorer physical strength, poorer physical capacity, and lower schoolachievement, compared to controls. Results suggest that SAM has long-term adverse effects (patterns ofgrowth associated with future NCDs), but with potential for rehabilitation (evidence of catch-up growth andlargely preserved lung and cardiometabolic functions). Recommendations for future follow-ups include estab-lishing the effects of puberty and later dietary or social transitions.

Extensive research links nutrition inearly life with adult health and non-communicable diseases (NCDs), a fieldof research known as developmental

origins of health and disease (DOHaD). Mostevidence for DOHaD describes associations be-tween in utero or very early postnatal exposuresand adult NCD risk. However, it is biologicallyplausible that early life events such as severeacute malnutrition (SAM) during late infancyor early childhood, and the rapid catch-upgrowth that occurs during and aer treatment,could have long-term health implications.

e chronic disease outcomes aer SAM inMalawian children (ChroSAM) study followedup children seven years aer they had receivedSAM inpatient treatment. Researchers investi-gated the effects of SAM on growth, body com-position, functional outcomes and risk factorsfor NCDs.

Study overview The original prospective cohort comprised1,024 patients admitted for SAM treatment atQueen Elizabeth Hospital in Blantyre, Malawi,during a nine-month period (July 2006 toMarch 2007). All patients were treated withinitial inpatient stabilisation using therapeuticmilk, followed by nutritional rehabilitationwith ready-to-use therapeutic food (RUTF) athome. The median age at admission was 24months. The ChroSAM study group was madeup of 320 surviving children from the originalcohort, identified from a one-year post-discharge

follow-up study (n=477). For comparison, theresearchers aimed to recruit one sibling control(the sibling closest in age to the case child)and one community control (a child of thesame sex and close in age living in the samecommunity) per child in the case group. Chil-dren who had been treated for SAM were noteligible as controls.

The study’s outcomes of interest included:anthropometry, body composition, lung func-tion, physical capacity (measured as handgripstrength, step test and physical activity), schoolachievement and blood markers of NCD risk.Multivariate linear regression was used to com-pare all outcomes, adjusted for age, sex, HIVstatus and socioeconomic status, as well as pu-berty in the body composition regression model.Data collectors were not blinded to the case orcontrol status of the children. With 320 cases,217 sibling controls and 184 community controls,the authors calculated that the study was ade-quately powered (at least 90% to detect a Zscore difference of 0.5 between the cases andcontrols based on reference data for growthand lung function outcome). The sample sizewas considered adequate for all outcomes exceptphysical activity (steps per day), which wasunderpowered.

ResultsOf the 1,024 children originally admitted, 238(23%) died during treatment. At one-year fol-low-up, 24% of children were known to havedied (192/786 of those discharged); an additional

117 were lost to follow-up. Of 398 childrentraced seven years post-discharge, 46 (11.5%)had died. us, of 786 children discharged fromSAM treatment, nearly one-third (30%) wereknown to have died seven years later and another15% were lost to follow-up. (See Figure 1.)

Key findings show:• Case children had more severe stunting than

controls (adjusted difference vs community controls 0·4, 95% CI 0·6 to 0·2, p=0·001; adjusted difference vs sibling controls 0·2, 0·0 to 0·4, p=0·04), although they showed evi-dence of catch-up growth.

• ese children also had shorter leg length ((adjusted difference vs community controls2·0 cm, 1·0 to 3·0, p<0·0001; adjusted difference vs sibling controls 1·4 cm, 0·5 to 2·3, p=0·002), but similar sitting height.

• Cases had other body composition differ-ences than controls, including: smaller mid-upper arm circumferences (MUAC) (adjusted difference vs community controls 5·6 mm, 1·9 to 9·4, p=0·001; adjusted difference vs sibling controls 5·7 mm, 2·3 to9·1, p=0·02); smaller calf circumference (adjusted difference vs community controls 0·49 cm, 0·1 to 0·9, p=0·01; adjusted

1 Lelijveld, Natasha, Andrew Seal, Jonathan C Wells, Jane Kirkby, Charles Opondo, Emmanuel Chimwezi, James Bunn, et al. 2016. “Chronic Disease Outcomes after Severe Acute Malnutrition in Malawian Children (ChroSAM): A Cohort Study.” The Lancet Global Health 4 (9) (September 14): e654–e662. doi:10.1016/S2214-109X(16)30133-4.

Research

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786 alive at discharget

1024 children admitted

477 known to be alive at1 year post-discharge

398 found 7 yearspostdischarge

32 declined totake part

320 recruitedinto ChroSAM

238 deaths in hospital

117 not found

192 died

79 not found

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Figure 1 Recruitment of the case group

Flow diagram showing recruitment, starting with original recruitment in 2006 for the PRONUT study, followed by one-year followup in the FuSAM study, and the present follow-up (ChroSAM).

Researchdifference vs sibling controls 0·62 cm, 0·2 to1·0, p=0·001); smaller hip circumference (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 to2·8, p<0·0001); and less lean mass (adjusteddifference vs community controls –24·5, –43to –5·5, p=0·01; adjusted difference vs siblingcontrols –11·5, –29 to –6, p=0·19).

• Survivors of SAM had functional deficits such as weaker handgrip (adjusted differencevs community controls –1·7 kg, 95% CI –2·4to –0·9, p<0·0001; adjusted difference vs sibling controls 1·01 kg, 0·3 to 1·7, p=0·005),and fewer minutes completed of an exercisetest (sibling odds ratio [OR] 1·59, 95% CI 1·0to 2·5, p=0·04; community OR 1·59, 95% CI1·0 to 2·5, p=0·05).

• Community and sibling controls were morelikely to be in a higher school grade aer ad-justing for confounders (odds ratio [OR] 1·70, 95% CI 1·2–2·4, p=0·003 compared with community controls and OR 2·77, 95%CI 1·9–4·0, p<0·0001 compared with siblingcontrols).

Most of the other NCD risk factors assessed(such as lipid profile and glucose tolerance)were not significantly different between casesand controls, except for diastolic blood pressure,which was higher for cases than for sibling con-trols (adjusted difference 1·91 mm Hg, p=0·03).Amongst cases, 28% were confirmed HIV-positive (compared to 4% in sibling controlsand 3% in community controls).

e authors identified a number of limitationsto their research, including:• Survivor bias, since only 352 out of 1,024

children in the original cohort were still alivefor this follow-up (30 declined to take part);thus the study selected the fittest and healthiest survivors;

• Sibling and community controls are not fully healthy; and

• e study does not have data on potential confounders, such as exact birthweight and gestational age, which are linked to both SAM and long-term health effects.

Discussione results from the study suggest that SAMhas long-term adverse effects, especially withregard to mortality, growth and body composi-tion. SAM survivors continue to have significantlymore stunting than their siblings and other chil-dren in their community at seven years’ post-discharge from inpatient nutritional treatment.Associated functional impairments includepoorer physical strength, poorer physical capacity,and lower school achievement than controls.

Despite greater stunting among cases, sittingheight was similar to controls, suggesting thattorso growth had been preserved while limbgrowth was compromised. Other outcomes suchas head circumference were also similar in allgroups, while lung function and HbA1c wereclose to normal when compared with childrenof African-American origin in all groups. is

suggests that survivors of SAM might have un-dergone so-called brain-sparing or thriy growth,whereby the growth of vital organs has beenpreserved at the cost of less vital growth.

Large sitting-to-standing height ratio, shortlimb length, lower peripheral mass, and largerwaist-to-hip ratio have all been associated withNCDs in adulthood. e pattern of lower leanmass and preservation of fat mass seen inchildren in the case group is similar to thatseen in children born with low birthweight(LBW). is is an important predictor of physicalwork capacity in later life. e combination ofreduced lean mass and greater stunting comparedwith controls might explain the deficiencies inphysical function and strength seen in the SAMsurvivors. Weaker handgrip is also associatedwith lower bone mass, impaired cell membranepotential, and reduced muscle function, as wellas all-cause early mortality, risk of malnutritionand risk of NCDs.

However, SAM survivors did show signs ofgrowth recovery, with gain in HAZ increasingat a steeper rate in cases who were catching upto their sibling controls. e evidence for catch-

up growth, as well as the apparent preservationof vital organs, suggests the potential for recoveryfollowing SAM. Yet case study children remainrelatively small (compared with global populationfor this age), and organ damage might only be-come apparent when exposed to weight gainand unhealthy lifestyles (as seen in studies ofLBW). SAM survivors may face potentiallygreater NCD risks due to changes in dietarytrends in many African countries.

is study found high in-treatment and post-discharge mortality amongst children treatedfor SAM. e study period preceded the estab-lishment of community-based management ofacute malnutrition (CMAM) in Malawi withassociated earlier detection of SAM and outpatientcare options.

In conclusion, the study suggests that SAMhas long-term adverse effects, with survivorsshowing patterns of ‘thriy growth’ associatedwith future NCDs. Evidence for catch-up growthand preservation of vital organs suggests potentialfor rehabilitation, but future follow-ups need tofocus on how to optimise recovery and minimiseany long-term adverse outcomes.

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ResearchAdolescentnutrition inMozambique:putting policyinto practice

Location: Mozambique

What we know: Adolescents are typically not targeted in health and nutrition serv-ices; this has implications for health outcomes across generations.

What this article adds: A recent review examined the extent to which nationalpolicy on adolescent nutrition (targeting anaemia control, reduced early pregnan-cy and nutritional education) is being implemented in Manica province, Mozam-bique. It found few interventions in the province target adolescents; a gap in serv-ice implementation of the Ministry of Health’s unit for adolescents (SAAJ) servic-es; and underuse of established platforms to improve SAAJ access. Recommenda-tions to inform nutrition programming at national, provincial and district levelsinclude defining female adolescents as a separate target group; including pregnan-cy reduction in nutrition programmes that aim to reduce chronic undernutrition;designing a strategy to address early child marriage and engage men; targetingmarginalised adolescents; and using existing outreach and service provision plat-forms to full capacity.

Erin Homiak MPH is seconded to SETSAN Manicaas Nutrition Advisor. Her role is funded byUKaid/DFID. She has been working for ConcernWorldwide since January 2015 to improvecoordination across government and non-government sectors in order to reduce rates ofchronic undernutrition amongst women,adolescents and children and to address theroot causes of gender inequality to ensureimproved nutrition outcomes. Erin has workedin Mozambique since 2013, previously withHelen Keller International on their Vitamin ASupplementation Team.

The research was carried out by the TechnicalSecretariat for Food Security and Nutrition(SETSAN-P, Manica) Focal Point and the SETSANTechnical Advisor (Nutrition Advisor, ConcernWorldwide).

The author acknowledges Cosme CabselaMandu, Focal Point for SETSAN-P, Manica andDionisio Oliveira, SAAJ Focal Point for ManicaProvince for their support and participating inthis review. Thanks also to DFID and Irish Aid forfunding support.

By Erin Homiak

Global contextAdolescents are an underserved population;their needs are not reflected in services(Hainsworth et al, 2009; Save the Children,2015; Patton et al, 2014) and interventions donot define or target adolescents who are oenperceived as a healthy or low-risk group (Savethe Children, 2015). Poor care-seeking behaviourdue to individual and structural barriers (Temin& Levine, 2009) and stigma around family plan-ning and use of the health system hinder serviceaccess and delivery (Temin & Levine, 2009).Lack of evidence makes policy decisions difficult;what does exist indicates that failure to targetadolescents has major implications for healthoutcomes. Adolescent females are more likelyto give birth to babies with low birth weight orwho are small for gestational age and childrenwho are more likely to become stunted and inturn give birth to small babies, thus perpetuatingan intergenerational cycle of chronic undernu-trition (Save the Children, 2015). Neglectingadolescent health means child mortality ratesand maternal health will remain relatively un-changed (Sawyer et al, 2012).

Little is known about the micronutrient de-ficiencies at the population level in Mozambique(Korkalo et al, 2014), although we do know that54% of girls and women between the ages of 15and 49 are anaemic (Ministerio da Saúde (MIS-AU) et al, 2011). Teenage HIV infection ratessuggest that the health needs of adolescents arenot being addressed; young people (<25 years)account for 60% of new HIV infections andyoung women (20 to 24 years old) are infectedat a rate triple that of men the same age(Hainsworth et al, 2009), highlighting the needto address the root causes of gender inequality.Adolescent pregnancy rate is high in Mozambiqueat 44.4% in rural and 33.2% in urban areas(UNICEF, 2015); early marriage is one of thestrongest drivers.

Under the Scaling Up Nutrition (SUN)Movement 1,000 days window of opportunity(Black et al, 2013), the pre-conception phaseis not taken into account, which often coincideswith adolescence. While the 1,000-day frame-work encompasses adolescent pregnancies, at-tention to prevention of pregnancy and early

marriage is also needed, using a life-cycle ap-proach to inform programme design and im-plementation. Programmes that address ado-lescent nutrition will help realise the SUN ob-jective to increase exclusive breastfeeding (ado-lescents are 33% less likely to breastfeed);reduce maternal and neonatal mortality; anddecrease stunting (Save the Children, 2015;Temin & Levine, 2009).

A recent review set out to understand theextent to which national policy regarding ado-lescent nutrition is being implemented in Manicaprovince, Mozambique. e aim of the reviewwas to assist the provincial authority in advocatingfor an expansion of current delivery channelsserving adolescents and to raise their profileamong the development community as an im-portant demographic to focus on and invest in.Key findings are summarised here.

Context of Mozambiquee first objective of Mozambique’s Multi-Sec-toral Action Plan for the Reduction of ChronicMalnutrition (PAMRDC) (Republic of Mozam-bique, 2010) specifically aims to improve the

Romana Cipriano with her daughters Inês and Beatriz at theChimbadzuo primary school. Romana is the gender advisor

for the school council. She makes sure girls stay in school andprovides support for other health and sanitation needs.

Kieron Crawley, Manica, Mozambique.

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1 Dionisio Oliveira (SAAJ), conversation with author, 8 April 2015

2 Isabel Mateo (Save the Children), conversation with author, 12 June 2015..

ReferencesBlack RE, Alderman H, Bhutta ZA, Gillespie S, Haddad L,Horton S, & Victora CG (2013). Maternal and child nutrition:Building momentum for impact. The Lancet, 382(9890), 372-375.

Concern Worldwide (March 2014). Barrier Analysis Report:Linking Agribusiness and Nutrition in Mozambique (LAN).

Hainsworth G, Zilhao I, Badiani R, Gregorio D & Jamisse L(2009). From inception to large scale: The Geração BizProgramme in Mozambique.

Korkalo L, Freese R, Fidalgo L, Selvester K, Ismael C &Mutanen M (2014). A Cross-Sectional Study on the Diet andNutritional Status of Adolescent Girls in Zambézia Province,Mozambique: Design, Methods, and Population Characteristics.[The ZANE Study] JMIR research protocols, 3(1).

Ministerio da Saúde & Instituto Nacional de Estatística(2011). Moçambique Inquérito Demográfico e de Saúde 2011.Retrieved August 13, 2013dhsprogram.com/pubs/pdf/FR266/FR266.pdf

Republic of Mozambique (2010). Multisectoral Action Planfor the Reduction of Chronic Undernutrition in Mozambique2011-2015.

Roche M (2015). New Global Focus Placed on ReducingAnemia in Adolescent Girls.

Save the Children (2015). Adolescent Nutrition: Policy andprgramming in SUN+ countries.

Sawyer SM, Afifi RA, Bearinger LH, Blakemore S-J, Dick B,Ezeh C & Patton GC (2012). Adolescence: A foundation forfuture health. The Lancet, 379(9826), 1630-1640.

Temin M & Levine R (2009). Start with a girl: A new agendafor global health. Washington, DC Center for GlobalDevelopment.

UNICEF (2015). Child Marriage and Adolescent Pregnancy inMozambique: Causes and Impacts.

Researchnutritional status of adolescent girls aged 10-19 (ibid, 2010). e PAMRDC is a guidingframework designed by multiple ministries andcivil society partners and is monitored by SET-SAN at national and provincial levels. eframework includes seven objectives, all withdefined impact results, for the reduction ofchronic malnutrition.

Serviços Amigos dos Adolescentes e Jovens(SAAJ) is the unit in the Ministry of Healthproviding public health services to adolescentmales and females. e Department for Youthand Sports is the only other provincial PAMRDCpartner that targets adolescents. At provinciallevel, SAAJ consists of one Focal Point locatedin the provincial capital who is responsible forthe oversight of all the district-level service pro-vision. ere is an established, country-widemechanism of peer-to-peer activists (GeraçãoBiz), created to increase the number of adolescentswho access SAAJ services with the ultimate goalof addressing the sexual and reproductive health(SRH) needs of male and female adolescents.e activists are trained and supervised by SAAJ,the Department of Education, and the Depart-ment of Youth and Sports.

Methode study used qualitative and quantitative re-search methods, including key informant in-terviews (KIIs) and review of secondary sources,including a literature review. Participatory ob-servations of service provision of adolescent(SAAJ) health services in three district-level fa-cilities in Manica Province (Guro, Tambara andManica) and training of peer-to-peer activists(Geração Biz) in Gondola district were under-taken. KIIs were conducted with the provincialSAAJ Focal Point in Manica; SAAJ healthproviders in Guro, Tambara, and Manica districts;the provincial Focal Point for the Ministry ofEducation; and several agencies includingPathfinder International, Save the Children,FHI360, CARE, UNICEF and the UN Food andAgriculture Organization (FAO).

ResultsUnder strategic objective 1 of the PAMRDRC,there are three defined results. Evidence wasgathered on the degree to which the resultswere being met, as follows:

Result 1.1: Controlled anaemia inadolescents (10-19 years) withinand outside schoolsIn Manica province, iron supplementation isimplemented through health clinics and mobilebrigades. Mobile brigades do not specificallytarget adolescents in remote communities toreceive iron supplementations or family planning,and until 2015 the adolescent target group forhealth clinics was 15-19 year-old females (ratherthan 10-19 year-olds)1.

Result 1.2: Reduced earlypregnancy in adolescents (10-19years)Family planning for adolescents is implementedthrough the health post; again, adolescents are

not specifically targeted by the mobile brigades.SAAJ in Manica was given technical supportthrough UNFPA from 2005 until 2013 and subse-quent support from Save the Children2 from 2015in two of 11 districts in Manica Province (includingtraining of activists, service providers and teachersand materials provision) in a two-year pilot pro-gramme funded by the Norwegian Government.ere are Geração Biz activists in the districtschools, but only two districts have receivedrefresher trainings (with the support of Save theChildren). Lack of resources limits further rollout.

Result 1.3: Strengthened nutritioneducation in different educationlevels as part of school curriculum,including literacy curriculaere is a national curriculum that includes anutrition component, which is implemented atprimary school level. FAO is supporting thetraining of teachers in nutrition in three districtsof Manica province.

is snapshot from Manica shows adolescentnutrition and health is being addressed to someextent, and there are many opportunities tocontinue and increase the inclusion of adolescentsin public health interventions. At the nationallevel, several organisations, including PathfinderInternational, UNFPA and UNICEF, work inadolescent health, focusing on SRH but nottaking account of nutrition. It is important tonote that there may be interventions addressingadolescent nutrition in Mozambique that havenot been captured in this review.

Discussion andrecommendationse findings presented demonstrate a lack oftargeting and attention to adolescent nutritionwithin programmes that aim to improve nutritionin Manica province, despite national policy. ereview recognises the challenge for provincesto keep in constant connection with the nutritionand policy community that is centralised inMaputo. On a positive front, Mozambique is‘ahead of the game’ with regard to having anadolescent nutrition policy, which non-govern-mental organisations (NGOs) and partners useas a framework to align programmes. Further-more, the PAMRDC is multi-sectoral and includesthe health, education and agricultural sectors(Republic of Mozambique, 2010; Save the Chil-dren, 2015). ere are promising entry pointswith existing programmes.

Mozambique will not see a reduction in chronicundernutrition unless adolescent health and nu-trition is prioritised. A paradigm shi is neededin the way populations are targeted, taking intoconsideration the life-cycle approach, includingadolescents in target groups and not waiting foradolescent girls to become pregnant before en-gaging with them and key influencers of earlymarriage (Concern Worldwide, March 2014).

To translate this framework into the action itmerits, the following recommendations are made:• Nutrition interventions should define female

adolescents as a separate target group whose

needs are different from adult women. Interventions that define indicators specific to adolescents will generate data to inform services and interventions in the future.

• e ambition to reduce pregnancy rates in female adolescents should be mainstreamedinto nutrition programmes that seek to reduce chronic undernutrition, taking gender into account and engaging men.

• All outreach mechanisms should address early child marriage to align with Mozam-bique’s National Strategy for the Preventionand Elimination of Early Marriage adopted by the national Government in 2015. is includes engaging men, recognising that there are many determining factors that affectearly marriage.

• e current delivery platform, Geração Biz,should be utilised to full capacity in order toincrease care-seeking behaviour and ensureaccess to SAAJ services.

• Interventions should be equitable; female adolescents who are not in school and who are likely to be most marginalised require alternative community outreach programmes,such as youth care groups, youth centres andvocational training (Roche, 2015; Save the Children, 2015).

For more information, contact info@concern.net

e full report is available at: https://www.concern.net/resources/adolescent-nutrition-missing-link-life-cycle-approach.

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Robust evidence for an evidence-based approachto humanitarian action

Mike Clarke is one of thefounders of Evidence Aidand is now voluntaryResearch Director and Chairof the Board of Trustees. Hehas extensive experience inthe evaluation of health

and social care and is Director of the NorthernIreland Hub for Trials Methodology Research atQueen’s University, Belfast. He has worked onsome of the largest randomised trials in specificareas of health and on dozens of systematicreviews in a wide range of areas, with a stronginterest in increasing capacity for the conductand use of systematic reviews. He facilitatestrainings on systematic reviews for Evidence Aid.

By Mike Clarke, Jeroen Jansen and Claire Allen

Research

Jeroen Jansen is theDirector of Evidence Aid.He has been engaged in awide variety of sectors,issues and workingenvironments, mostly inmanagement positions.

He worked for Médecins Sans Frontières (MSF)in Afghanistan, Liberia, Darfur and severalother contexts. He has been successfullyemployed in the private sector, managing thedeployment of humanitarian aid and workingas a department head for MSF in the UK.Formerly an engineer, he later obtained aMasters in International Human Rights Lawand worked for Marie Stopes International.

Claire Allen is thepart-timeOperationsManager forEvidence Aid. Sheworked forCochrane for 18

years and has a B.A. (Hons) inCommunication, Media and Culture.Claire’s background is in administrationand finance. Her main tasks relate tothe overall operations of Evidence Aid,including management of informationto ensure that evidence is available in areadily accessible format.

The increasing demand for ‘value formoney’, proof of impact and effective-ness in the provision of humanitarianaid requires that decisions and activities

become more evidence-based. Reliable and robustevidence will help those making decisions andchoices, and those developing policies and stan-dards, to know which interventions work, whichdon’t work and which remain unproven. Forthose interventions that work, people need toknow how effective they are and for whom, sothat they can choose the most appropriate andeffective intervention in a specific context. Onlywith reliable and robust evidence is it possibleto maximise the impact, efficiency (‘value formoney’) and effectiveness of humanitarian actionand ensure more good than harm is done.

Evidence Aid1 engages with those guidingthe humanitarian sector to inspire and enablethem to apply a more evidence-based approachto their decisions and actions. rough this en-gagement, and by working with others who gen-erate, disseminate and apply evidence, a largeand growing audience is revealed that supportsa more evidence-based approach to humanitarianaction. A momentum is building, similar to whathas happened in the healthcare sector since thelatter decades of the twentieth century (Clarke,2015), generating a demand for robust evidence.One of the challenges is that this audience has awide range of interpretations regarding what re-liable and robust evidence entails.

When it comes to identifying and using find-ings of research to decide what is likely to domore good than harm, the healthcare sectorrecognises the need for evidence to come from asynthesis of similar studies, oen in a systematicreview. ese evidence syntheses provide userswith a critically appraised summary of therelevant research on a topic, allowing the existingstudies to be compared, contrasted and combined 1 www.evidenceaid.org/

to provide the knowledge needed to resolve un-certainties. In this way, systematic reviews providethe vehicle by which evidence from earlier researchcan be brought together in ways that minimisebias, avoid undue emphasis on individual studies,maximise the power of research that has alreadybeen done, and minimise waste from unnecessaryduplication or inadequate uptake.

Systematic reviews begin with a focused ques-tion and clear eligibility criteria, then seek outand appraise the relevant studies and compare,contrast and, where relevant and possible, combinetheir findings. ey provide decision-makers andothers making choices with a summary of theavailable evidence, which they can consider along-side other information, such as local values andresources, before taking action. An up-to-date,systematic review allows well-informed decisionsto be taken quicker and eases the evidence-gath-ering burden for people who need to take thesedecisions. e value of systematic reviews iswidely recognised in healthcare, and the conceptof drawing on the totality of evidence whenmaking decisions is neither new nor outlandishwhen explained to practitioners, patients, poli-cy-makers and the public. is should be nodifferent for disasters and other humanitarianemergencies (Gerdin et al, 2014). Just as happenedin the healthcare sector several decades ago, thegrowing need and support for an evidence-basedapproach in the humanitarian sector should resultin a growing need for robust evidence and an in-crease in the investment required to generateand disseminate this evidence.

Despite a growing momentum for an evi-dence-based approach in the humanitarian sector,progress seems limited by a strong sense of tra-dition, an antipathy to change and continuingmisapplication of ‘expert opinion’ or ‘best practice’.Key documents in the sector, such as guidelinesand policies, continue to be predominantly based

on ‘expert opinion’ and ‘best practice’, althoughthis is changing as key influencers that straddlethe humanitarian and healthcare sectors, such asthe World Health Organisation (WHO), emphasisethe need to underpin their guidance with sys-tematic reviews. (See, for example, the ongoingwork on a guideline for major radiation emer-gencies (Carr et al, 2016) and a systematic reviewof accessibility in the home for an upcomingWHO guideline on healthy housing (Cho et al,2016)). is does not imply an unthinking adop-tion of evidence synthesis as a recipe for deci-sion-making. ere are situations where the useof ‘expert opinion’ or ‘best practice’ is justified,just as an evidence-based approach, based onrobust evidence, should only be applied whenand where appropriate. Nevertheless, it is importantthat the humanitarian sector recognises the limitsof ‘expert opinion’ and ‘best practice’ and thevalue of an approach based on evidence synthesis.

Expert opinion is a valuable tool when appliedappropriately, but applied inappropriately it cancause considerable harm, getting in the way ofeffective action or promoting the use of ineffectiveor harmful actions. William J. Sutherland andMark Burgman (2015) described the pitfalls ofapplying expert opinion rather well in the journalNature. ey assert that the “accuracy and relia-bility of expert opinions is … compromised by along list of cognitive frailties (Tversky & Kahne-man, 1982). Estimates are influenced by experts’values, mood, whether they stand to gain or losefrom a decision (Englich & Soder, 2009), and bythe context in which their opinions are sought.Experts are typically unaware of these subjectiveinfluences. ey are oen highly credible, yetthey vastly overestimate their own objectivityand the reliability of their peers (Burgman et al,2011).” is does not render ‘expert opinion’ use-

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The next two courses An introduction tosystematic reviews in the humanitariansector, led by Mike Clarke, are to be held on16 November in Washington DC, USA and on30 November in Oxford, UK. The cost is£225/person. For more information, contact:Claire Allen, email: callen@evidenceaid.orgor visit http://www.evidenceaid.org/

ReferencesBurgman MA, McBride M, Ashton R, Speirs-Bridge A,Flander L, Wintle B, Fidler F, Rumpff L, Tweedy C. (2011)Expert status and performance. PLoS ONE 6(7): e22998.doi:10.1371/journal.pone.0022998.

Carr Z, Clarke M, Ak EA; Schneider R, Murith C, Li C,Parrish-Sprowl J, Stenke L, Cui-Ping L, Bertrand S, Miller C.(2016) Using the GRADE approach to support thedevelopment of recommendations for public healthinterventions in radiation emergencies. RadiationProtection Dosimetry (first published online 12 August2016) doi: 10.1093/rpd/ncw234.

Cho HY, MacLachlan M, Clarke M, Mannan H. (2016)Accessible home environments for people with functionallimitations: a systematic review. Int J Environ Res PublicHealth 13: 826. doi: 10.3390/ijerph13080826.

Clarke M (2015). History of evidence synthesis to assesstreatment effects: personal reflections on something that isvery much alive. JLL Bulletin: Commentaries on the historyof treatment evaluation. J Roy Soc Med 109:154-63. Doi:10.1177/0141076816640243.www.jameslindlibrary.org/articles/history-of-evidence-synthesis-to-assess-treatment-effects-personal-reflections-on-something-that-is-very-much-alive/)

EAPSG Evidence Aid Priority Setting Group. Prioritizationof themes and research questions for health outcomes innatural disasters, humanitarian crises or other majorhealthcare emergencies. PLoS Curr Disasters 2013 October16. Edition 1. doi: 10.1371/currents.dis.c9c4f4db9887633409182d2864b20c31

Englich B, Soder K. (2009) Moody experts – How mood andexpertise influence judgmental anchoring. Judgement and

2 www.oxfam.org.uk/hep3 www.evidenceaid.org/resources4 www.theguardian.com/global-development-professionals-

network/2015/jul/22/as-aid-gets-better-it-gets-more-boring-and-thats-as-it-should-be; last visited 15 August 2016.

5 www.alnap.org/

Researchless, but demands a certain degree of care whenengaging experts and a need for awareness of thetools available to counter these pitfalls.

An example of the appropriate use of expertopinion is in determining the gaps in the evidencebase and prioritising the filling of those gaps.e identification of gaps in evidence in the hu-manitarian sector is important for minimisingunnecessary overlap of activities and waste ofresources. Evidence Aid held a priority settingmeeting in 2013, bringing together those whoinfluence and guide the humanitarian sector, andpublished the output in the journal PLOS Currents:Disasters (EAPSG, 2013).

irty high-priority research questions wereidentified under ten themes that could be ad-dressed by systematic reviews in the area ofplanning for or responding to natural disasters,humanitarian crises or other major healthcareemergencies. Some of these gaps have alreadybeen taken up by the Humanitarian EvidenceProgramme2 and others, and relevant systematicreviews will appear in coming months and years.As these new reviews are done, they will beadded to the more than 250 systematic reviewsthat are already freely available from the EvidenceAid resources3.

Another concept frequently applied in thecontext of decision-making in humanitarian re-sponse is ‘best practice’. On e Guardian GlobalDevelopment Professionals Network page, ananonymous blogger asserts that “best practicesare those things that we’ve somehow managed tofigure out actually work, and work well” or “is

something that we know works and is worth re-peating”4 . e variety of definitions of conceptssuch as best practice is one of the common prob-lems in the humanitarian sector. However, po-tentially even more problematic is the fact thatthe blogger, like many others in the sector, doesnot reveal what their criteria are for somethingto ‘work’ and how it was established that anyparticular practice adheres to these criteria. Aswith ‘expert opinion’, the application of a trans-parent methodology to determine what ‘works’would overcome most of the hurdles, allowingspecific interventions, actions and strategies tobe proven to be effective or efficient to the satis-faction of decision-makers.

Proper evaluations can provide evidence ofthe impact of a certain project or practice. Key tothis is the application of an appropriate method-ology, such as promoted by the Active LearningNetwork for Accountability and Performance inHumanitarian Action (ALNAP)5. Nevertheless,an evaluation of one project only reveals somethingabout the impact in that particular context anddoes not allow us to derive strong conclusionsabout the likely effects of a similar project in adifferent context. Just as the successful treatmentof one patient or the positive findings of oneclinical trial in the healthcare sector do not provideany certainty that it will work for others, we needa synthesis of the evaluations of similar projectsto determine the likelihood of success in anotherplace and time. Recognition of this in the healthcaresector helped the drive towards evidence synthesisand systematic reviews as a means to bring togetherall the available evidence.

Evidence syntheses, or systematic reviews, ofreliable evaluations should be a key source ofknowledge for all decision-makers who want toanswer the question: What is likely to happen ifwe do this, rather than something else? In thehumanitarian sector, decisions, choices andpolicies impact on the health and wellbeing ofthousands, if not millions, of people and thoseresponsible have a duty to ensure that the evidencethey use is reliable and robust. is requires theuse of appropriate methodologies; firstly toevaluate humanitarian action, and then to bringtogether the findings of those evaluations. It willmean that the best possible use is made of whathappened in the past to predict what will happenin the future, and ensure that humanitarian actiondoes what those who fund it and those who im-plement it want it to do: prevent and alleviatethe suffering of people in need in humanitarianand disaster risk reduction contexts.

Decision Making Vol. 4, No. 1, February 2009, pp. 41-50.journal.sjdm.org/71130/jdm71130.pdf

Gerdin M, Clarke M, Allen C, Kayabu B, Summerskill W, etal. (2014) Optimal evidence in difficult settings: improvinghealth interventions and decision making in disasters. PLoSMed 11(4): e1001632.doi:10.1371/journal.pmed.1001632.journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001632

Sutherland WJ and Burgman M. Policy advice: Use expertswisely. Nature 2015 Oct 15;526(7573):317-8. doi:10.1038/526317a.www.ncbi.nlm.nih.gov/pubmed/26469026

Tversky A and Kahneman D. (1982) In: Kahneman D, SlovicP, Tversky A (editors) Judgement Under Uncertainty:Heuristics and Biases. Cambridge University Press pp.23-30.

Evidence in humanitarianemergencies: What does it look like?ENN was invited by Evidence Aid to share our perspective regarding evidence inemergencies in their online blog. Below is a comment posted in September 2016,www.evidenceaid.org/evidence-in-humanitarian-emergencies-what-does-it-look-like

By Jeremy Shoham and Marie McGrath, Field Exchange co-editors

Over 20 years, ENN has published FieldExchange to help achieve our purposeof strengthening the evidence andknow-how for effective nutrition in-

terventions in countries prone to crisis and highlevels of malnutrition. It provides the experiencesof those implementing nutrition programmes inacute and protracted emergencies. Most of theseexperiences and lessons learnt would not havebeen captured or disseminated without this typeof non-peer reviewed publication. Yet, for many,Field Exchange, and equivalent publications arethe ‘grey’ literature, oen seen as a source of findingsthat are ‘plausible’ but not evidenced. Hence thequestion, what is evidence and what does it looklike – especially in humanitarian contexts?

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e few reviews of evidence in humanitariannutrition programming show that there is verylittle ‘probabilistic’ evidence out there. Ran-domised trials that are held up as the “goldstandard” for assessing the effects of interventionsare particularly difficult to mount in humanitariancontexts. ey require foresight and investmentby donors; early collaboration between pragmatic,creative academics and operational agencies;and long term commitment to plan, deliver andpublish. And, many of them do not come cheap.Even where randomised trials are carried out(mostly in secure settings), they don’t necessarilytell us whether something will work or not inthe complex environment and ‘ever shiingsands’ of an emergency or, critically, how itworks. is is a key uncertainty for programmerslooking to adapt and respond to the needs ofspecific populations and contexts.

ere are also challenges around the globalcoordination of ‘robust’ research. Research agen-das are not shared between research institutionsand there is competition for scarce resources –even (shamefully) amongst research groups inthe same research consortium. e culturearound research is oen ‘secretive’ and conflictof interests are not always apparent.

However, the fact that there is a gap in the evi-dence doesn’t stop programming. Agencies on theground still need to respond, innovate and adapt,

guided by what they know or suspect works, in-fluenced by agency strengths, sometimes drivenby donor interests and sadly, oen underpinnedby the bureaucratic imperative that the implementingagency must, itself, survive. e intention thoughis always worthy – to alleviate suffering.

On the positive side, ENN has witnessed(and, through Field Exchange, has captured anddisseminated) innovation, programme devel-opment and learning. Seen as a non-governmentalorganisation with no vested interest other thanto reflect learning, multiple agencies have sharedprogramming experiences though Field Exchange,documenting perceived and measured successesand failures. is provides a collective memoryand exchange – and evidence of sorts – of whatworks and what doesn’t work. e process ofexperience capture is cathartic for many. It helpsthem unpack and reflect, enabling both personaland agency reflection and learning. It has alsohelped identify where urgent ‘robust’ researchis needed. e impact on programming and re-search of this collective experience has beensubstantial, not least on ENN’s research and re-views (www.ennonline.net/ourwork).

Should we aspire to more? Absolutely. Weneed more randomised trials, complementedby theories of change, to help explain how andwhen interventions are likely to impact nutrition.We also need institutional changes which allow

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for more of these studies to be done in challengingcontexts. e current architecture makes suchresearch very difficult. At the same time, weneed to continue to capture the kind of ‘evidence’provided by practitioners, which is critical toshining a light on programme performance,and to identify where greater institutional co-herence and joined up thinking is needed.

A great example is the special edition ofField Exchange on the Syria nutrition responsein 2014 that documented detailed case studiesof more than 60 programmes (www.ennonline.net/fex/48). is single publication has had asignificant impact on international guidancearound infant feeding in emergencies, the needfor policies on non-communicable diseases(NCDs) in emergencies and generated a con-siderable research focus on how to address highlevels of stunting in protracted crises.

In conclusion, evidence is not just generatedby academic researchers, statisticians and thelike but also by those at the sharp end of pro-gramming. Many of those at the sharp end maywell need to brush up on their epidemiology,just as many professional researchers may needto familiarise themselves with the complex cir-cumstances of humanitarian crises and theunique insights of the implementers on howthe programming they are intimately involvedin is playing out on the ground.

Recovery rate of children with moderate acutemalnutrition treated with ready-to-usesupplementary food (RUSF) or improved corn-soya blend (CSB+) Summary of research1

Location: Cameroon

What we know: A wide range of nutritional products are currentlyused to treat MAM; there is no definitive consensus on the most effec-tive products to use.

What this article adds: A controlled randomised trial compared animproved CSB (CSB+) treatment with a ready-to-use supplementaryfood (RUSF) treatment to treat MAM. Eighty-one MAM childrenaged 25-59 months were enrolled and received a daily ration (50% en-ergy) for 56 days. Fortnightly follow-up involved nutrition and gener-al health counselling, clinical assessment and anthropometry. Recov-ery was good (85% in RUSF group, 73% in CSB+ group) and was notsignificantly different between groups. Higher weight gain in theRUSF arm (similar total energy was provided to both groups) may bedue to the different nutrient contents of the products, cooking re-quirements and lower energy density of CSB. Fieen per cent ofRUSF group and 20% of SAM group did not recover aer 56 days; 3%and 5% respectively deteriorated to SAM. Nutrition education mayhave improved outcomes in this study.

Moderate and severe wasting are acute forms of undernu-trition; children suffering from them face a markedly in-creased risk of death. It is estimated that moderate acutemalnutrition (MAM) and severe acute malnutrition (SAM)

affect 52 million children under five years of age worldwide. Supplementaryfeeding programmes (SFPs) are designed to treat MAM and preventprogression from MAM to SAM, and thus have the potential to reducechild mortality and morbidity. A wide range of nutritional products arecurrently used to treat MAM. ese include fortified blended flours, es-pecially corn-soya blend (CSB) prepared as porridge; BP5 biscuits; andlipid-based nutrient supplements, in particular therapeutic and ready-to-use supplements (RUTF and RUSF). Product formulation andquantities used have varied in published effectiveness studies; thereforethere is no definitive consensus on the most effective products to use inMAM treatment.

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 (RUSF) or improved corn-soya blend (CSB+): a randomized controlled trial, Public Health Nutri-tion, 19(2), pp. 363–370. doi: 10.1017/S1368980015001238.

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Research

e purpose of this study was to compare animproved CSB (CSB+) with an RUSF programmein the treatment of MAM to test the hypothesisthat supplementary foods given at complementarydose (about 50% of the child’s energy require-ment) result in high recovery rates (assumingthe remaining energy requirements can be metthrough the usual household diet). e studywas a comparative effectiveness trial that assessedthe treatment of MAM in children for a periodof 56 days, using a controlled randomised designwith parallel assignment for CSB+ or RUSF.

Eight hundred and thirty-three childrenaged 6-59 months living in the health districtsof Mvog-Beti (urban area) or Evodoula (ruralarea) in the Centre region of Cameroon werescreened for eligibility. Children were excludedif they did not have appetite, had a chronic de-bilitating illness, or had a history of peanut al-lergy. Eighty-one children aged 25-59 monthswith MAM (WHZ <-2 and ≥ -3 without oede-ma) were enrolled in the study from Februaryto July 2012. Allocation to either CSB+ orRUSF groups was performed by caregiversdrawing from an opaque bag containing codednumbers corresponding to one of the two sup-plementary foods. The code was accessibleonly to the food distributor. Investigators andnutrition educators were blinded to the child’sassigned food group.

On enrolment, children were examined by apaediatrician to assess their health status andde-wormed (500mg mebendazole). Caregiverswere interviewed regarding the child’s socio-demographic characteristics and to assess house-hold food-consumption score. Nutrition andgeneral health counselling and informationabout the illness of their children and the benefitof supplementary feeding were provided to allcaregivers. Every child received a daily rationof 167 kJ (40 kcal)/kg body weight for 56 days,provided as two-week rations every fortnight.

Each caregiver also received nutrition and generalhealth counselling at enrolment and at everyfollow-up visit, and was instructed to continueto feed children their usual diet along with thesupplementary food as ‘medicine’. At each fol-low-up visit, caregivers reported on the child’sclinical symptoms and tolerance of the studyfood; anthropometric measurements and nu-trition education were repeated. Additional sup-plementary food was continued for those whoremained wasted. Standard methods for an-thropometric measurements were used; anthro-pometric indices (weight-for-age Z score (WHZ),weight-for-age Z score (WAZ) and height-for-age Z score (HAZ)) were based on WHO 2006Child Growth Standards.

e study found no significant differencesbetween the malnutrition profile of CSB+ andRUSF groups: all the children enrolled in thestudy were moderately wasted, moderately un-derweight and moderately stunted. No adversereactions to any of the foods were reported.Aer 56 days of treatment, 85% of children re-covered from MAM in the RUSF group (95% CI73%, 97%) and 73% in the CSB+ group (95% CI59%, 87%). e mean duration of treatment re-quired to achieve recovery was 44 days in theRUSF group and 51 days in the CSB+ group.ere was no significant difference (P=0.276) inthe recovery rate between the two groups (Fisher’sexact text). A non-response rate of 20% amongchildren in the CSB+ group and 15% in theRUSF group was observed; thus these childrenremained moderately malnourished following56 days of treatment. Of children in the RUSFand CSB+ groups, 3% and 5% respectively dete-riorated to SAM. Children who received RUSFshowed higher rates of weight gain comparedwith those receiving CSB+ (P<0.05).

e observed recovery rates suggest thatboth products were relatively successful in treat-ment of MAM in children, comparable to or

relatively higher than those found in previousstudies, despite the lower quantity of supplementprovided to children. e authors suggest thatthis could be a reflection of the investment ineducation of caregivers on how best to use foodsavailable in the house, since educational inter-ventions have been shown to improve child-feeding practices. is suggests that, in thecontext of moderate food insecurity, nutritioneducation could improve the outcomes of sup-plementary feeding and reduce the quantity ofsupplement generally provided.

e authors suggest that the higher weightgain in the RUSF arm (despite similar totalenergy provided to both groups) may be due tothe different nutrient contents of the products,the fact that RUSF does not require cooking,and the lower energy density of CSB+ (a childmust eat eight times the mass of supplementcompared to RUSF). is may have affected theglobal dietary intake of the children and mightaccount for the lower weight gain and recoveryrate in the CSB+ group. In Cameroon, as inmost African countries, national protocols forthe management of MAM recommend the useof large doses of fortified blended flours, whichare usually imported. Based on the average timerequired for treatment in both groups and thecost of both products, the overall cost to treat achild with CSB+ (3·48 euros) was relativelylower than the cost with RUSF (3·52 euros).is calculation does not include transport,storage or staffing costs. If considering the op-erational limits of CSB+ requiring preparation,RUSF could be a more cost-effective choice.

e authors conclude that both CSB+ andRUSF were relatively successful for the treatmentof MAM in children. Despite the relatively lowration size provided, the recovery rates observedfor both groups were comparable to or higherthan those reported in previous studies, aprobable effect of nutrition education.

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In South Africa, child under-five mortalitywas estimated to be 45 per 1,000 live birthsin 2012. ere has been a significant dropin reported child hunger (from 30% of all

children in 2002 to 16% in 2006), but in 2010three million children were still living in house-holds where hunger was reported. Moreover,27% of the country’s under-fives were stunted in2009, a decrease from 33% in 2003.

Existing policy responses to childhood povertyand vulnerability in developing countries includethe provision of basic services such as education,healthcare, clean water, in-kind transfers (such asschool-feeding schemes and nutritional supple-ments) and, more recently, cash transfers. eChild Support Grant (CSG) is the largest cashtransfer programme in the country and the con-tinent, reaching more than 11 million childrenfrom poor households in 2013. e grant is un-conditional, means-tested and non-contributory,with a small amount (R320/US$32 per month)transferred by the South African government tochildren of poor families. However, children livingin the poorest households target group still reporthigh rates of hunger (26%) compared with childrenin the wealthiest households (less than 1%).

MethodsA recent cross-sectional study assessed the uptakeand duration of receipt of the CSG and nutritionaloutcomes in children at two years of age (i.e.median age 22 months) during 2008. e samplingframe was participants from the sites of a multi-country, cluster-randomised, intervention trialundertaken from 2005 to 2008 (the PROMISE-EBF trial to assess the effectiveness of communi-ty-based workers in promoting and improvingexclusive breastfeeding). Aer that trial ended(2007), a new cross-sectional study (the presentone) was conducted, with participants from thetrial traced when the children were aged betweennine months and three years. A total of 871 outof 1,148 participants were traced, with 746 par-ticipants ultimately included.

e study was conducted in three diverseareas in South Africa: (i) Peri-urban Paarl, a town with a population

of about 130,000 in Western Cape Province; (ii) Rural Rietvlei, which falls under the

Umzimkhulu Municipality in KwaZulu-Natal; and

(iii)Umlazi, an urban township in Durban with a population of 550,000 inhabitants.

In terms of key child-health outcomes, Paarlfares better than the other two sites, with aninfant mortality rate of 30/1,000 live birth, com-pared with Umlazi (68/1,000 live births) andRietvlei (99/1,000 live births); and an antenatalHIV prevalence of 7% compared with Umlazi’s47% and Rietlvei’s 28%. Umlazi is the largesttownship in KwaZulu-Natal Province, with typicaltownship problems, including severe housingshortages, high rates of unemployment and crimeand little economic development. Rietvlei is apredominantly rural area where 90% of peoplelive below the household subsistence level, muchhigher than the national average of 65%.

e main outcome of interest was stunting(height-for-age z score (HAZ) <−2). Grant receiptwas defined as mother being in receipt of theCSG on behalf of the index child at any pointduring the study (12 weeks, 24 weeks and twoyears). Duration of CSG receipt, the primary ex-posure, was defined as the age of child (in months)at the two-year visit minus the child’s age (inmonths) at first reported receipt of the grant.

e researchers extracted baseline socio-de-mographic characteristics (socio-economic status,mother’s educational level, geographical area, ma-ternal age, marital status), maternal HIV statusand exclusive breastfeeding status at 12 weeks ofage from the PROMISE-EBF trial data set for the746 children traced for the present study. Regressionanalysis was used to assess confounding factors.

ResultsSocio-economic characteristics and status variedacross the three sites. e mean age of motherswas similar in Umlazi and Rietvlei (23·9 and 24·0years, respectively) and slightly older in Paarl (24·9years). e prevalence of HIV amongst motherswas 5.9% in Paarl, 8.1% in Rietvlei and 28.2% inUmlazi. Educational levels of mothers were lower

in Rietvlei. Household income also differed acrossthe three sites, with a median US$100 per monthin Paarl and Umlazi and US$78 per month in Ri-etvlei. Most of the mothers in Umlazi were single(85%), as was the case in Paarl (68%), while mostmothers in Rietvlei were married (68%). Rietvleihad the highest proportion (70%) of participantswho were in the poorest quintile; in Umlazi, noparticipants fell within that quintile and Paarl had3%. Paarl had the highest proportion of participantswho were in the least poor quintile (34%), Umlazihad 31% and Rietvlei had none.

For two years of child age, Rietvlei had thelowest rates of CSG receipt (28%) compared withPaarl (38%) and Umlazi (34%). High rates ofstunting were observed in all three sites, withUmlazi being the most affected (28%) comparedwith Rietvlei (20%) and Paarl (17%). Durationof CSG receipt had no effect on stunting, aeradjusting for confounders. Both HIV-positivestatus of the mother (adjusted OR=2·30; 95% CI1·31, 4·03) and low birth weight (adjusted OR=2·01;95% CI 1·02, 3·96) were associated with morethan double the probability of the child beingstunted. Completing high school or having a ter-tiary education was associated with a 58% and84% reduction in child stunting respectively.Being from Umlazi was associated with a nearlyfourfold increase in probability of stunting (ad-justed OR=3·89; 95% CI 2·30, 6·59).

DiscussionCSG receipt for 18 months or longer in this studypopulation was not associated with stunting aercontrolling for important risk factors such as HIV-exposure status and low birth weight, and indicatedhigher levels of education as having a protectiveeffect on stunting. e strong correlation betweenstunting and being from Umlazi is likely explainedby the high prevalence of HIV in this site. e au-thors suggest several reasons for the apparent lackof association between CSG receipt and stuntingin households. e CSG is oen introduced in thecontext of high unemployment rates, where it be-comes the only source of income in many house-holds. e value of the grant has not been keepingup with inflation rates; at US$32 per month, it is asmall amount in the context of rising food pricesand unemployment. To maximise the potentialpositive impact of cash transfers, their cash valueshould be linked to food-price movements andthe cost of essential non-food items, and theirvalue adjusted for household size.

e authors conclude that cash transfers needto work in tandem with other poverty alleviationmeasures such as education, housing and accessto quality healthcare in order to maximise theirimpact on child-health outcomes such as stunting.Findings suggest that in South Africa the effectof the cash transfer on nutritional status mayhave been eroded by food-price inflation andlimited progress in the provision of other importantsocial and environmental services. ese findingsadd weight to calls for changes in the CSG allo-cation to be pegged to the inflation rate and tobe based on the cost of raising a child.

Location: South AfricaWhat we know: Stunting is an indicator of chronic undernutrition and is oen linked topoverty-related factors. ere is mixed evidence on the impact of cash on reducing child undernutrition in low- and middle-income settings

What this article adds: In South Africa, the Child Support Grant (CSG) is the largest cash trans-fer programme targeting children from poor households. A recent paper explored predictors ofstunting, including exposure to the CSG, at a median age of 22 months among children fromthree diverse areas of South Africa. CSG receipt for 18 months or longer was not associated withstunting aer controlling for risk factors such as HIV exposure status and low birth weight;higher levels of maternal education had a protective effect on stunting. An association found be-tween mothers’ HIV-positive status and stunting supports previous research findings. Food-price inflation and limited progress in the provision of other important interventions and socialservices, in the context of high unemployment, have likely limited nutrition impact of the CSG.

Impact of child support grant inSouth Africa on child nutritionSummary of research1

1 Zembe-Mkabile W, Ramokolo V, Sanders D, Jackson D & Doherty T (2016). The dynamic relationship between cash transfers and child health: can the child support grant in South Africa make a difference to child nutrition? Public Health Nutrition, 19(2), 356-362. doi.org/10.1017/S1368980015001147.

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Public health nutritioncapacity: The quality ofworkforce for scaling upnutrition programmes

Summary of research1

Location: Global

What we know: Priority for scaling up multi-sector programmes to tackle undernutrition in LMICs is grow-ing. 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 buildingcapacity (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 isscarce, and estimates (where they exist) of PHN workforce numbers suggest they are inadequate. Applicablepre-service nutrition training is mostly clinical and/or food-science oriented; tools for in-service nutritiontraining largely relate to infant and young child nutrition and food security. Increased priority and funding forbuilding capacity for scaling up nutrition is needed to realise global targets.

IntroductionOvernutrition and undernutrition problemsaffect at least half the global population, espe-cially those in low and middle-income countries(LMICs). Programme guidance exists for un-dernutrition and overnutrition; priority forscaling up multi-sector programmes to tackleundernutrition in these contexts is growing. Aposition paper by members of the World PublicHealth Nutrition Association (WPHNA) Ca-pacity Building Task Force outlines the casefor and defines the desirable character¬isticsof a system for developing the capacity of nu-trition workforces for scaling up nutrition pro-grammes in LMICs especially. It uses evidencefrom the literature and the joint experience ofthe Task Force to describe the existing nutritionworkforce capacity and the potential mecha-nisms for building capacity. The World HealthAssembly (WHA) has urged that member statesshould include a comprehensive approach tocapacity building and workforce developmentin implementing plans for maternal, infantand young child nutrition, with the capacityindicator being the number of nutritionprofes¬sionals per 100,000 population.

Key findings on the publichealth nutrition workforceNutrition programmesNutrition-specific interventions for reducingmaternal and child undernutrition are mostlydelivered through the health sector, while nu-

trition-sensitive interventions are deliveredthrough other sectors such as education, agri-culture, water and sanitation, and social welfare.Much less consensus has been created aroundinterventions needed to reduce overnutrition.e importance of employing multi-sector ap-proaches has been widely agreed, but documentedexperience of how such programmes are imple-mented is quite rare, with little or no guidanceexisting on how to develop and manage suchprogrammes.

Many countries report having national,multi-sector nutrition plans, but very few ofthem are actually being implemented at anyscale. Community-based health and nutritionprogrammes can be very successful, especiallyif they have the essential elements ofcommu¬nity ownership, adequate populationcoverage, targeting, and central support forsupplies and training.

To achieve impact requires a cer¬tain levelof intensity of effort, with optimal ratios of notmore than 20 mobilisers, or community healthworkers (CHWs) per facilitator/ supervisor andnot more than 20 households per mobiliser.CHW volunteers typically receive some locallyorganised cascade training in order to be ableto carry out their work, oen from trainers whodo not themselves have capacity to train healthworkers; there does not appear to be any nationalor international standard for these. Recentreviews confirm that CHWs provide a critical

link between communities and health and socialservices and are effective at implementing evi-dence-based interventions.

Workforce structure An ideal PHN structure includes a pyramid(see Figure 1), where the specialist PHN managershould have oversight of the delivery of allcurative and preventive nutrition interventionsdelivered through the health system in thedistrict. e delivery of such interventions istypically done by others, including nurses, mid-wives, dietitians and doctors. ey in turn mayprovide support to other district actors, includingCHWs, teachers, agricultural exten¬sion workersand social workers.

Workforce sizeFew estimates of PHN specialist numbers exist,but all suggest that they are either insufficientand/or largely missing in most national nutri-tion/health workforces. A recent survey of 13countries in West Africa detected a criticalshortage of skilled nutrition professionals in allcountries, with limited supervision of nutritionactiv¬ities, especially at implementation levelby front-line health workers. Doctors, nursesand midwives (as well as dietitians in some

1 Shrimpton, R., du Plessis, L.M., Delisle, H., Blaney, S., Atwood,S.J., Sanders, D., Margetts, B. and Hughes, R. (2016) Public health nutrition capacity: assuring the quality of workforce preparation for scaling up nutrition programmes, Public Health Nutrition, 19(11), pp. 2,090–2,100. doi: 10.1017/S136898001500378X.

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Capacity building for theselevels of the PHN workforcethrough on-the-job trainingwith distance learning as wellas concurrent in-servicetraining

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Nutritionists/dietitians and other healthprofessionals (doctors, nurses, midwives)

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

Figure 1 Multi-layered PHN workforce development

Researchcountries) make up the majority of workerscurrently entrusted to deliver nutrition inter-ventions globally, but training is particularlypoor. For example, Asian regional country casestudies (UNICEF and the WPHNA) concludedthat the nutritional knowledge of health workerswas outdated; their nutrition competencies werelimited to more clinical and curative activities;and for nurses and midwives especially, theirjob descriptions did not include nutrition re-sponsibilities. ese findings are not surprising,since even in the USA and the UK the nutritioncontent of nurses’ and medical doctors’ trainingis also considered outdated and inadequate.

ere is a lack of a dedicated workforce (es-pecially in the health system) in most LMICs toprovide outreach for community-based nutritionservices. Scaling up CHWs was considered acrucial part of achieving the Millennium Devel-opment Goals (MDGs), but this did not happen.

Workforce organisationOrganisational difficulties are as great a hurdleto scaling up nutrition actions as the lack ofPHN specialists, although the two are interrelated.No programme guidance exists that discussesdimensions of multi-sector nutrition programmegovernance; e.g. the need for a PHN specialistat all levels – in local government districtplanning office; in the central unit of each sectorto oversee district-level implementation; and inthe central unit to help plan, budget and overseedevelopment.

None of the countries studied had in place aunified nutrition information system that could

guide decision-making processes for the doubleburden of malnutrition across the differentsectors and levels of government.

A key challenge for scaling up community-based programmes is institutionalising andmainstreaming community participation. elargest and most successful programme is theBrazilian Family Health Programme, which hasintegrated 250,000 CHWs into its health servicesand institutionalised community health com-mittees as part of municipal health services.

Workforce preparationere does not seem to be any authoritativesource of information (either regional or global)for graduate courses on nutrition. Programmesidentified in a survey of nutrition education inWest Africa found that all of them failed toprovide a comprehensive coverage of all essentialaspects of human nutrition, being heavily orientedto food science (46%), with little emphasis onPHN (24%) or overnutrition (2%).

On-the-job training to develop the workforceto act in nutrition at scale will obviously requirenew and/or unconventional methods; e.g. a mixof distance learning and periodic coming togetherwith tutors and mentors, which are both eco-nomically and logistically feasible.

Considerable material is available for in-service training of health-sector workers in thenutrition actions needed to improve maternaland child undernutrition; e.g. generic tools (suchas counselling cards) for programming and ca-pacity development of community-based infant

and young child feeding (IYCF) counselling de-veloped by UNICEF. FAO has also developed e-learning courses for professionals working infood and nutrition security, social and economicdevelopment, and sustainable management ofnatural resources.

Continuing professional development is an-other important area to be considered whendeveloping the PHN workforce. Some universitiesoffer online continuing education courses fornutrition and health-care professionals; e.g. theLondon School of Hygiene and Tropical Medi-cine’s distance learning course on multi¬-sectornutrition programming.

Improved availability of the internet has rev-olutionised the possibilities for capacity buildingin PHN. Initiatives include the Public NutritionVirtual University (still awaiting funding) andthe eNutrition Academy, a global nutrition-training platform (courses are still in develop-ment). Mentoring, defined as ‘a reciprocal,mutual and sup¬portive learning relationship’,is one more tool that should be used to strengthenworkforce development in PHN.

Conclusions Unless increased priority and funding is givento building capacity for scaling up nutritionprogrammes in LMICs, maternal and child un-dernutrition rates are likely to remain high andnutrition-related non-communicable diseasesare likely to escalate. A hybrid, distance-learningmodel for in-service training of PHN workforcemanagers is urgently needed in LMICs.

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Research priorities on therelationship betweenwasting and stuntingSummary of research1

Location: Global

What we know: ere is global momentum to bring down levels of undernutrition. Wastingand stunting frequently co-exist, but are oen considered separately.

What this article adds: A research prioritisation was conducted to investigate the relation-ships between wasting and stunting, using the CHNRI (Child Health and Nutrition Re-search Initiative) methodology. A group of 18 experts in nutrition, growth and child healthprioritised 30 research questions against three criteria (answerability, usefulness and im-pact). ere was strong support for prioritisation of research related to interventions andprogramming that can impact on both wasting and stunting. Greater commitment fromfunders, academics and implementing agencies is needed to carry out clinical trials orlarge-scale programmatic evaluations, with robust research design.

BackgroundWasting affects 52 million (19 million severewasting) and stunting affects 165 million childrenunder five years old each year. Wasting andstunting frequently co-exist in the same population(sometimes in the same child), but they areusually separated in terms of policy, guidance,programming and financing. Both forms of un-dernutrition share causal factors such as infectiousdiseases, poor diet and suboptimal infant feedingand caring practices, yet the physiological rela-tionship between them and how interventionsfor one affect the other are poorly understood.Consequently, there is a need for a closer look athow children experience both wasting and stuntingover time, and how to sharpen programmingfocus (particularly on prevention) to achieve im-pacts for both. is research aimed to establishresearch priorities to fill critical gaps in this areaand to guide future research investments.

Study methodse authors used the Child Health and NutritionResearch Initiative (CHNRI) methodology forsetting research priorities. e method enablesindividual experts to systematically develop pos-sible research questions by scoring them againstpre-defined criteria. It was agreed to use an ex-isting Technical Interest Group (TIG) facilitatedby ENN, comprising 25 individuals from a rangeof organisations (including academia and non-governmental organisations (NGOs)) with ex-pertise in research and programming for wastingand stunting.

e resulting list of possible questions wasthen refined using a recommended theoreticalframework with a set of criteria with which tojudge the questions. e criteria were reducedto three in order to encourage as many experts

as possible to complete the survey. ese were:Answerability: Was the research questionwell framed, with well defined end points, and likely to gain ethical approval?

Usefulness: Would the intervention that wouldbe developed/improved though this researchbe deliverable, effective and efficacious?

Impact: Would the research endpoints for thisquestion have high impact (i.e. the capacity toremove 5% or more of the disease burden)?

irty research questions were tabled againsteach of the three criteria, which formed anonline survey with a total of 90 queries. All TIGmembers were sent a link to the online surveyand invited to take part. Each of the 30 researchquestions received three scores, one for eachcriterion ranging between 0-100%. e overallresearch priority score (RPS) was calculated asa mean of all three priority scores so that thepriority of research questions was ranked ac-cordingly.

FindingsOf the 25 TIG members, 18 (72%) took part inthe survey, with 16 completing it in full. Mostrespondents were academics (n=10); some wereengaged in operations and programming (n=3);one worked primarily in policy; while othersdeclared involvement in a mix of these activities(n=4).

e highest ranking questions were:1. “Can interventions outside of the 1,000

days, e.g. pre-school, school-age and ado-lescence, lead to catch-up in height and in other developmental markers?” is ques-tion scored very highly against all three judging criteria.

2. “What timely interventions work to

mitigate seasonal peaks in undernutrition (both wasting and stunting)?” is scored particularly highly against ‘answerability’.

3. “What is the optimal formulation of Readyto Use erapeutic Food (RUTF) to promoteoptimal ponderal growth and also support linear growth during and aer severe acutemalnutrition (SAM) recovery?” is ques-tion scored highly against the ‘usefulness’ criteria.

4. “What is the role of pre-pregnancy nutri-tional status in determining risk of being born stunted and/or wasted?”

5. “What are the effective packages of inter-ventions for both maternal nutrition and new-born outcomes?”

Eight of the top ten questions (including thetop three) were categorised as ‘research for thedevelopment of new interventions/to improveexisting interventions’, showing that the groupprioritised research that directly related to pro-gramming and public health, rather than epi-demiological research.

Discussione strong support for prioritisation of researchrelated to interventions and programming, asfound in this CHNRI exercise, reflects the com-plexity of underlying causes of wasting andstunting; outcomes that cannot necessarily bepredicted from observational research alone.Moving this agenda forward needs greater com-mitment from funders, academics and imple-menting agencies to carry out clinical trials orlarge-scale programmatic evaluations. esemust have rigorous designs, adequate samplesizes, and follow-up for health outcomes.

Question 1: “Can interventions outside of the1,000 days, e.g. pre-school, school-age andadolescence, lead to catch-up in height and inother developmental markers?” is area has had little attention but could haveimportant implications; for example with ado-lescent girls where the evidence shows that ma-ternal stature may predict a child’s size at birth.e timing of interventions to promote catch-up growth in mid-childhood and adolescenceis not well understood, but may be important.e group identified further investigation ofother lifecycle opportunities (apart from thefirst 1,000 days), particularly those concernedwith adolescent growth, as potentially crucialfor meeting undernutrition targets.

Question 2: “What timely interventions workto mitigate seasonal peaks in undernutrition(both wasting and stunting)?”A number of countries have strong seasonalpatterns of stunting and wasting that may il-lustrate some correlation between the twoforms of undernutrition, but there are manyunanswered questions in this area. Recenttrials have shown the provision of seasonalnutritional supplementation in Niger to have

1 Z Angood C, Khara T, Dolan C, Berkley JA, WaSt Technical Interest Group (2016) Research Priorities on the Relationship between Wasting and Stunting. PLoS ONE 11(5): e0153221. doi: 10.1371/journal.pone.0153221.

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ReferenceIsanaka et al, 2008. Isanaka S, Nombela N, Djibo A,Poupard M, Van Beckhoven D, Gaboulaud V, et al. Effect ofpreventive supplementation with ready-to-usetherapeutic food on the nutritional status, mortality, andmorbidity of children aged 6 to 60 months in Niger: acluster randomized trial. Jama. 2009;301(3):277–85. doi:10.1001/jama.2008.1018 pmid:19155454; PubMed CentralPMCID: PMCPMC3144630.

Co-trimoxazole prophylaxis to prevent mortality inchildren with complicated severe acutemalnutrition Summary of research1

Location: Kenya

What we know: Children with complicated severe acute malnutrition (SAM) are at high riskof infection. Daily co-trimoxazole prophylaxis is effective in reducing mortality and prevent-ing admissions in HIV-infected children.

What this article adds: A randomised, placebo-controlled trial in four Kenyan hospitals as-sessed the efficacy of daily co-trimoxazole prophylaxis for six months on survival in childrenaged 60 days to 59 months without HIV treated for complicated SAM. Daily co-trimoxazoledid not reduce mortality (14% in co-trimoxazole group; 15% in placebo group) or improvegrowth, but did result in a lower incidence of both malaria and some bacterial infections.Mortality rate among infants aged two to 11 months was particularly high, despite follow-up.Results suggest children with complicated SAM, especially infants, remain susceptible to se-vere infections and death, despite follow-up. Findings suggest fundamental differences in theimmunopathology of malnutrition and HIV infection that require further investigation.

Children with complicated severe acutemalnutrition (SAM)2 require initialhospital treatment with antibiotics,treatment of specific medical condi-

tions, and specialised therapeutic feeding. Com-plicated SAM is associated with high inpatientmortality; even post-discharge, ‘recovered’ SAMchildren remain at increased risk of death mostlikely due to infectious disease. Daily co-tri-moxazole prophylaxis has been found to reducemortality and hospital admissions in childrenwith HIV who are susceptible to infection, pro-tecting against malaria, pneumonia and sepsis.It also prevents pneumonia in children withmeasles and recurrent urinary tract infections.A systematic review found that antimicrobials,including co-trimoxazole, had beneficial effectson ponderal and linear growth in children, pos-

sibly by reducing inflammation and preventingor treating infections. e drug is inexpensiveand widely available, with a known safety profile.However, long-term use of antibiotics can po-tentially cause toxicity and resistance.

is study tested the hypothesis that dailyco-trimoxazole would reduce mortality andmorbidity and improve nutritional recovery inchildren without HIV being treated for compli-cated SAM.

MethodA multicentre, double-blind, randomised, place-bo-controlled study was conducted in four hos-pitals in Kenya (two rural hospitals in Kilifi andMalindi and two urban hospitals in Mombasaand Nairobi) with children aged 60 days to 59

months without HIV admitted to hospital anddiagnosed with SAM. All study hospitals providedinpatient care for SAM and therapeutic andsupplementary feeding clinics.

Children were randomly assigned to sixmonths of either daily oral co-trimoxazole pro-phylaxis (given as water-dispersible tablets: 120mg per day for age <6 months; 240 mg per dayfor age six months to five years); or matchingplacebo. Assignment was done with computer-generated randomisation. Treatment allocationwas concealed in opaque, sealed envelopes; pa-tients, families and all trial staff were masked totreatment assignment. e dose regimen of co-trimoxazole was that recommended by WHOfor HIV care. Children were given recommendedmedical care and feeding and followed up for12 months.

e primary outcome was mortality duringthe 365 days of the study period. Secondary out-comes were frequency of readmission to hospitaland illness episodes treated as an outpatient.Scheduled follow-up to enrolment was once each

1 Berkley, James A, Moses Ngari, Johnstone Thitiri, Laura Mwalekwa, Molline Timbwa, Fauzat Hamid, Rehema Ali, et al. 2016. Daily Co-Trimoxazole Prophylaxis to Prevent Mortality in Children with Complicated Severe Acute Malnutrition: A Multicentre, Double-Blind, Randomised Placebo-Controlled Trial. The Lancet Global Health 4 (7) (October 4): e464–e473. doi:10.1016/S2214-109X(16)30096-1.

2 Complicated SAM is defined as children who have signs of infection or present with one or more Integrated Management of Childhood Illness danger signs (see references) or do not pass an appetite test.

Researcheffects on both wasting and stunting (Isanakaet al, 2008). The prioritisation of this questionis a call for future studies to measure bothwasting and stunting.

Question 3: “What is the optimal formulationof RUTF to promote optimal ponderal growthand also support linear growth during andaer SAM recovery?”is question reflects the fact that few studiesof SAM or moderate acute malnutrition (MAM)treatment have looked at linear growth duringor aer treatment, or compared different for-mulations of RUTF in trials of adequate size.Where such studies exist, findings suggest nopositive effect of RUTF on stunting. However,there is evidence that linear growth ceases orslows down during periods of wasting; thereforetiming of restarting linear growth and how tosupport this during treatment for wasting was

considered to be a research priority by thisexpert group.

Questions 4 and 5: “What is the role of pre-pregnancy nutritional status in determiningrisk of being born stunted and/or wasted?” and“What are the effective packages ofinterventions for both maternal nutrition andnew-born outcomes?”ere is an increasing call for research on pre-conceptual interventions for improving maternalpre-pregnancy Body Mass Index (BMI), andthat can influence adult height in order tobenefit foetal growth. Other investigations intosupport for maternal nutrition could help pro-grammers break the inter-generational cycle ofundernutrition.

e study’s main weakness was that a relativelysmall number of experts were involved in setting

the research priorities, and most of these wereacademics from Western institutions. However,given that the global pool of experts in the fieldis also small, the results were still regarded as auseful guide for research investment. High-pri-ority research questions are those where trialinterventions can inform the appropriate timingof treatment and prevention to impact on bothwasting and stunting.

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The impact of intensive counselling and a massmedia campaign on complementary feedingpractices and child growth in Bangladesh

Location: Bangladesh

What we know: In Bangladesh there has been little to no progress in improv-ing children’s diets and little evidence available on what works to improve ma-ternal knowledge and practices related to complementary feeding (CF).

What this article adds: A cluster-randomised impact evaluation compared theimpact of two ‘Alive and rive’ intervention packages (one intensive, one lessintensive) on CF practices and anthropometric outcomes, delivered at scale(1.7 million mothers in 50 sub-districts) over a four-year period. A cross-sec-tional household survey of feeding practices (6-23.9 months) and stuntingprevalence (24-47. 9 months) was conducted at baseline and endline. CoreWHO CF indicators improved over time (P < 0.0001 for all indicators) in bothgroups. For all CF indicators except timely introduction of solid, semi-solid orso foods, the increases were significantly higher in the intensive group andachieved levels were high. Stunting declined significantly in all children 24-47.9 months of age and did not differ significantly between groups. In conclu-sion, intensive intervention had substantial and significant impact on CF: evi-dence that behaviour-change interventions can be implemented at scale.

Summary of research1

1 Menon, P., Nguyen, P.H., Saha, K.K., Khaled, A., Sanghvi, T., Baker, J., Afsana, K. et al.(2016) Combining Intensive Counseling by Frontline Workers with a Nationwide Mass Media Campaign Has Large Differential Impacts on Complementary Feeding Practices but Not on Child Growth: Results of a Cluster-Randomized Program Evaluation in Bangladesh. Journal of Nutrition. Published ahead of print August 31, 2016 as doi: 10.3945/jn.116.232314.

Researchmonth for the first six months, then every twomonths for the second six months. Anthropometricmeasurements were taken at each visit and re-maining study drugs and empty blister packswere counted to assess adherence. A full bloodcount was done at enrolment, two, six and 12months. Analysis was by intention to treat.

FindingsA total of 1,778 eligible children were recruitedand assigned to treatment (887 to co-trimoxazoleprophylaxis and 891 to placebo) between 20November 2009 and 14 March 2013. Medianage was 11 months (IQR 7-16 months); 306(17%) were younger than six months; 300 (17%)had oedematous malnutrition (kwashiorkor);and 1,221 (69%) were stunted (length-¬for-ageZ score <–2).

During 1,527 child-years of observation(CYO), 257 deaths occurred (14%, 16·8 per 100CYO; 95% CI 14·9–19·0); 60 (23%) of whichoccurred during the index admission; 64 (25%)during a readmission to a study hospital; 29(11%) in other hospitals; and 104 (40%) in thecommunity. Mortality did not differ betweenthe groups: 122 (14%) of 887 children in the co-trimoxazole group died, compared with 135(15%) of 891 in the placebo group.

ere were 616 non-fatal admissions to hos-pital and 3,266 non-fatal episodes of illness forwhich children were treated as outpatients. Nosignificant differences in the overall rates of

hospital admission or outpatient illness werenoted between intervention groups. e fre-quency of pneumonia episodes was similar be-tween groups, but diarrhoea occurred more fre-quently in the group assigned to co-trimoxazole.Other infections such as skin or so tissue andurinary tract, as well as malaria, were lessfrequent in the co-trimoxazole group.

Aer 12 months, 1,209 (68%) of 1,778 childrenenrolled were alive and in follow-up with a midupper arm circumference (MUAC) above thethreshold for moderate acute malnutrition (≥12·5cm). However, this outcome varied with age,ranging from 160 (52%) of 306 infants youngerthan six months at enrolment to 154 (78%) of197 children aged 24 months or more at enrol-ment, p<0·0001.

Discussione authors conclude that daily co-trimoxazolegiven for six months to a trial group of Kenyanchildren with complicated SAM (but withoutHIV) did not reduce mortality or improvegrowth. However, it did result in a lower incidenceof malaria and some bacterial infections. Findingssuggest that children with complicated SAMremain susceptible to severe infections and deathaer discharge from hospital, despite medicalcare and follow-up, with a rate of readmissionsto hospital or death of 57 per 100 CYO. Mortalityrates among infants aged two to 11 monthswere much higher than national mortality esti-mates (22 per 100 CYO, compared to 1·7 per

100 CYO among infants aged one to 11 monthsreported in the 2014 Kenya Demographic &Health Survey).

e study results raise a number of questions:• Did low bacterial susceptibility to

co-trimoxazole contribute to an absence of protective effect against death? If so, this hasimplications for the use of co-trimoxazole prophylaxis in HIV-infected children.

• Although the bacteria found in blood and urine samples were largely non-susceptible to co-trimoxazole, the drug did prevent twobacterial conditions, namely urinary tract and skin and so tissue infections. Absenceof efficacy in this trial compared to those ofchildren with HIV suggests fundamental differences in the immunopathology of malnutrition and HIV infection, their asso-ciated infections and interaction with antimicrobials.

• Few positive blood cultures were found during the trial, despite high numbers of death and readmission and a high prevalence of antimicrobial resistance. Results raise the possibility that a substantial proportion of serious infection might not have been bacterial.

e paper concludes by suggesting that tacklingSAM requires better understanding of infections(both its causes and determinants of susceptibility),and other strategies need to be tested in clinicaltrials to reduce deaths in this population group.

Bangladesh has made dramatic health advances for itspopulation over the last two decades and is hailed asa remarkable health success story. However, rates ofstunting and wasting remain high; in 2014 an estimated

36% of children were stunted and 14% wasted. Between 2011and 2014 stunting reduced nationally by 4 percentage points(pp); wasting declined by only 1pp in the last 10 years.Appropriate infant and young child feeding (IYCF) practicesare a critical component of optimal child growth and develop-ment. is includes exclusive breastfeeding until six months ofage and the provision of safe and nutritionally rich foods insufficient quantity in addition to breastmilk from 6 to 23months of age. In Bangladesh, although rates of exclusive

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breastfeeding increased to an estimated 55% in2014, there has been little to no progress in im-proving children’s diets, with only 23% consuminga minimally acceptable diet. ere is currentlylittle evidence available on what works to improvematernal knowledge and practices related tocomplementary feeding (CF), how these changesin turn lead to positive child outcomes, andwhat factors enable successful scale-up of theseinterventions.

is paper reports on findings from a clus-ter-randomised impact evaluation of an at-scaleprogramme in Bangladesh. e objectives ofthe evaluation were to compare the impact oftwo ‘Alive and rive’ intervention packages onCF practices and anthropometric outcomes. efirst intervention package involved intensifiedinterpersonal counselling (IPC), a mass mediacampaign (MM), and community mobilisation(CM); the second package involved standardnutrition counselling, less intensive MM andnon-intensive CM. e programme modelreached a large scale, with an estimated 1.7million mothers of children under two yearsold in 50 sub-districts.

InterventionsIPC (both intensive and standard) was deliveredby a large non-governmental organisation (NGO)in 50 rural sub-districts through its existing coun-trywide essential healthcare programme. StandardIPC involved routine home visits through whichinformation on IYCF practices were delivered. Inintensive areas, a new cadre of nutrition-focusedfrontline workers conducted multiple age-targetedIYCF-focused counselling visits to householdswith pregnant women and mothers of childrenunder two years of age, coached mothers as theytried out the practices, and engaged other familymembers to support the behaviours.

e MM component, implemented in bothintensive and non-intensive areas, consisted ofthe national broadcast of seven television spots

that targeted mothers, family members, healthworkers and local doctors with messages onvarious aspects of IYCF, three of which were fo-cused on CF. In intensive areas with low electricityand limited access to television, local videoscreenings of the television broadcasts and otherIYCF films produced by the project were used.In intensive areas, CM included sensitisation ofcommunity leaders to IYCF and communitytheatre shows focused on IYCF. In non-intensiveareas, CM was less structured and coveredgeneral healthcare topics and did not includeIYCF-related information.

Evaluation methodA cluster-randomised, non-blinded impact eval-uation design was used to compare the impactof the two intervention packages. A cross-sec-tional household survey was conducted at baseline(2010) and exactly four years later (2014) in thesame communities in households with children0-47.9 months of age (n=600 children 6-23.9months of age and n=1,090 24-47.9 months ofage at baseline (2010); n=500 children 6-23.9months and n=1,100 children 24-47.9 monthsat endline (2014)). Primary outcomes measuredwere CF practices in children 6-23.9 months ofage and the prevalence of stunting in children24-47.9 months of age. Five CF indicators wereexamined using 24 hour recall of the mother/caer-giver: 1) minimum dietary diversity; 2) minimummeal frequency as appropriate for age and breast-feeding status; 3) minimum acceptable diet (de-fined as breastfeeding and achievement of num-bers 1 and 2); 4) consumption of iron-rich oriron-fortified food; and 5) timely introductionof solid, semi-solid or so foods. Anthropometricdata were collected using standard methods bytrained field staff. Difference-in-difference impactestimates (DDEs) were derived, i.e. the effect ofthe intensified versus standard programme ad-justing for geographic clustering, infant age,sex, differences in baseline characteristics, anddifferential change in characteristics over time.

Research

ResultsResults showed that the groups were similar atbaseline. e levels of all core WHO CF indi-cators improved over time (P < 0.0001 for allindicators) in both the intensive and non-in-tensive groups. For all CF indicators excepttimely introduction of solid, semi-solid, or sofoods, the increases were significantly higherin the intensive groups. e DDEs of programmeimpact were 16.3 pp, 14.7 pp, 22.0 pp, and 24.6pp for minimum dietary diversity, minimummeal frequency, minimum acceptable diet, andconsumption of iron-rich foods, respectively.All DDEs were statistically significant in adjustedmodels. Achieved levels of CF indicators in theintensive areas were high, ranging from 50.4%for minimum acceptable diet to 63.8% for min-imum diet diversity, 75.1% for minimum mealfrequency, and 78.5% for consumption of iron-rich foods. ere was also a significant differentialshi between groups from early and late intro-duction of water and other foods to a morewell-timed introduction between the ages of 6and 8.9 months. ese programme impactswere large and significant, ranging from 16 to39 pp for different foods. e shi was primarilyfrom early to timely introduction for water,rice, and semi-solid foods, and from late totimely introduction for animal source foods(ASFs) and other foods.

Stunting declined significantly in children24-47.9 months of age in both groups betweenbaseline and endline, by 5.2 pp in the non-in-tensive and 6.3 pp in the intensive group. Thedeclines in the prevalence of stunting did notdiffer between groups. A similar pattern wasobserved for the proportion of children classifiedas being underweight (decline of 5.2pp in thenon-intensive, 6.6pp in the intensive) andwasted (decline of 1.4pp in non-intensive and2.5 in intensive).

Conclusionse results show that a programme providingintensified IPC, MM, and CM (the ‘Alive andrive’ intensive intervention) at scale had asubstantial and significant impact on severalCF practices in comparison with changes ob-served with a less intensive behaviour-changeintervention in Bangladesh. Large-scale pro-gramme delivery was feasible and, with the useof multiple platforms, reached 1.7 million house-holds. Although improvements in child growthwere observed in both groups and for all agegroups over time, the DDEs for linear growthand stunting at 24-47.9 months were not statis-tically significant and therefore cannot be at-tributed to the intensified interventions. eauthors suggest that non-differential impactson stunting were likely due to rapid positivesecular trends in Bangladesh and the furtheracceleration of linear growth requires accom-panying interventions. e authors concludethat this study offers compelling evidence thatbehaviour-change interventions can be imple-mented at scale to deliver impact on whatremains a substantial global challenge: improvingchildren’s diets.

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Direct procurement from familyfarms for national schoolfeeding programme in Brazil

Claudia Rodriguez is a researcher at the School of Public Health atUniversidade de São Paulo (USP), Brazil. She is a nutritiongraduate of the Universidad Industrial de Santander in Colombia.In 2013 she joined a research project on the impact of familyfarming in a school feeding programme at USP under thesupervision of Professor Betzabeth Slater.

Claudia Rodriguez

Flavia Schwartzman has a PhD in Public Health Nutrition from theUniversidade de São Paulo. She has worked as an internationalconsultant for the Food and Agriculture Organization of the UnitedNations (FAO) since 2011, supporting the strengthening of school-feeding programmes in Latin America and the Caribbean.

Betzabeth Slater is a professor and researcher at the School of PublicHealth at USP. A nutrition graduate from the National University ofSan Marcos, Peru, she has a PhD in Public Health. In 2012, sheinitiated a research project on the impact of family farming in schoolfeeding programmes at USP, reflected in this article.

Flavia Schwartzman

Betzabeth Slater

Iris Emanuelly Segura, Ana Paula Cantarino Frasão de Carmo, Daniela Bicalho andVanessa Manfre Garcia Souza are nutritionists and postgraduate students at the Schoolof Public Health at Universidade de Sao Paulo. They research family farming and schoolfeeding under the supervision of Professor Slater.

This article describes the preliminary investigation directed by Professor BetzabethSlater. The authors gratefully acknowledge the Foundation for Research of the State ofSão Paulo (FAPESP) for funding this work.

Location: Brazil

What we know: Brazilian legislation obligates minimum purchase levels of food fromfamily farms to supply the National School Feeding Programme (PNAE) when using fed-eral funds.

What this article adds: A cross-sectional study of 40 municipalities in São Paulo, Brazil,suggested an upward trend in the proportion of municipalities procuring family-farmedfood for the PNAE from 47% to 67.5%. Purchases are largely local, from individual farm-ers, farming associations and cooperatives. Challenges remain when it comes to the suc-cessful implementation of policy; political will, government support and the organisa-tional efficiency of the family farmers involved may impact on the success of local pro-curement.

In June 2009, the Federal Government of Brazilpassed legislation (Law 11,947/2009) which reg-ulates the National School Feeding Programme(PNAE) and consolidates its links with family

farms (FFs). Under the legislation, at least 30% of allfunds which the federal government transfers toStates and municipalities must be used to buy foodfrom FFs, and a bidding process is not required . Arecent study found that 47% of municipalities in theState of São Paulo had bought food from FFs at leastonce between June 2009 and August 2011 (Slater etal, 2013). is confirms that local procurement forthe PNAE had not yet been implemented in all themunicipalities analysed. e implementation of localprocurement is known to be a complex process in-volving different sectors and levels of governmentand demands coordinated action. Consequently, theaim of this study was to check the percentage ofdirect procurement from FFs for the PNAE in theState of São Paulo in 2012 and describe the mainfeatures of the process.

MethodA cross-sectional survey was conducted in São Pauloin 2012 as part of a research project to assess thelevel of implementation of direct procurement fromFFs for the PNAE (Slater, 2011). e survey wasbased on a probability sample of 40 municipalities.A structured questionnaire was completed (telephoneor email) by a civil servant in the school meals man-agement department of each municipal council.

The direct procurement of food from FFs forthe PNAE was the dependent variable. The inde-pendent variables were: PNAE management method,value of the municipality contribution, value offunds transferred by the federal government forthe PNAE, and provenance of the farmers whosold food for the PNAE. Proportions and averageswere used for the descriptive analysis; to analysethe correlation between variables, these were di-chotomised and Fisher’s exact test was used with astatistical significance level of p≤0.05.

Resultse percentage of direct procurement from FFs forthe PNAE in 2012 was 67.5%. In the same year, theaverage funds in US dollars which the central govern-ment transferred to the municipalities was $317,910.87,ranging from $14,733 to $2,103,721, while the averagemunicipality contribution for the PNAE was $680,746,ranging from $0.00 to $8,785,240. Of the 40 munici-palities analysed, four did not make any contributionand six did not respond. PNAE management wascentralised in 80% of municipalities; decentralised in10%; mixed in 7.5%; and outsourced in 2.5%.

Of the 27 municipalities that had implementeddirect procurement from FFs for the PNAE, 59%used FFs in the actual municipality. ese comprised44 individual farmers, 23 farming associations and16 farming cooperatives.Analysis of the correlation between direct procure-ment from FFs for the PNAE (dependent variable)and the existence of municipality contribution andcentralised PNAE management method (independentvariables) did not reveal any correlation when they

1 Brazil. Presidency of the Republic. Law No. 11,947 of 16 June 2009. Articles 12 and 14.

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ReferencesBandoni et al 2014 – Bandoni DE, Stedefeldt E, AmorinALB, Barbosa Gonçalves HV, De Rosso VV. Healthregulation challenges for the safety of food acquired fromfamily farms for School Meals. Vigilância Sanitária emDebate: Sociedade. Ciência & Tecnologia. v 2, n 4, p. 107–14. 2014.

Bezerra OM, Bonono É, Da Silva CAM, Da Silva Correa M,De Souza AA, Dos Santos PCT, Da Silva ML et al. Promotingthe purchase of family farm products for school meals inMinas Gerais and Espírito Santo States, Brazil. Revista deNutrição. v 26, n 3, p. 335–42, 2013.

Researchwere dichotomised, (p-value 0.63; 0.68, respec-tively). Similarly, no correlation was found be-tween the remaining variables examined.

Discussion Since the enactment of Law 11,947/2009, thePNAE has played two crucial roles: as a publicpolicy vehicle for guaranteeing the human rightto adequate food, and as a key food safety andnutrition strategy affecting both schools andfamily farmers. e results suggest an upwardtrend in the percentage of municipalities thathave implemented direct procurement from FFsfor the PNAE, rising from 47% (Slater et al,2013; Saraiva et al, 2013) to 67.5%. e findingsare consistent with a similar analysis of 63 mu-nicipalities in the State of São Paulo, where76.2% bought products from FFs for the PNAE

between January 2012 and November 2013 (Ban-doni et al, 2014).

It is encouraging that purchases are largelybeing made in the same municipality; this pre-supposes that there is not only a dialoguebetween the various players involved in theprocess, but the political will to implement it(Bezerra et al, 2013; De Camargo et al, 2013).

The minimum purchasing power of the mu-nicipalities that did not buy products fromFFs was US$4,419, a sum that would supportat least one family farm per year. The maximumsale value by a family farm in 2012 wasUS$4,404.

In conclusion, although the percentage ofmunicipalities that have implemented local pro-

curement has increased, when it comes to thesuccessful implementation of public policieschallenges remain which go beyond economicresources. Political will, government supportand the organisational efficiency of the familyfarmers involved may well impact on the successof local procurement, but these factors must beconfirmed by more extensive studies.

For more information, contact: Claudia An-drea Rodriguez Mora, email: clauromo@usp.br

For more experiences from Latin America andthe Caribbean, including detailed case studies,see FAO, 2014. School feeding and possibilitiesfor direct purchases from family farms. Casestudies from eight countries. www.fao.org/3/a-i3413e.pdf

De Camargo RAL, Baccarin JG, Silva DBP. The role of theFood Acquisition Program (PAA) and the National SchoolFeeding Programme (PNAE) in strengthening familyagriculture and promoting food security. Temas deAdministração Pública. v 8, n 2, 2013.seer.fclar.unesp.br/temasadm/article/view/6846

Saraiva et al, 2013 – Saraiva EB, Ferreira da Silva AP, Araújode Sousa A, Cerqueira Fernandes G, Chagas dos SantosCM, Toral, N. Panorama of purchasing food products fromfamily farmers for the Brazilian School Nutrition Programme.Ciênc. saúde coletiva. v 18, n 4: p. 927-35, 2013.

Slater et al, 2013 – Slater BV, Januario BL, Jamile FR,

Schwartzman F. Situation of the Municipalities of São PauloState in relation to the purchase of products directly fromfamily farms for the National School Feeding Programme(PNAE). Revista Brasileira de Epidemiologia v 16, n 1, p.223-26, 2013.www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2013000100223

Slater, 2011 – Slater BV. The National School FeedingProgramme (PNAE) and family farming: evaluation of theimplementation process and the possible effects of localpurchases, under Law 11.947 / 2009. São Paulo; 2011.Technical-scientific report presented to Fundação deAmparo à Pesquisa do Estado de São Paulo.

Relationships between wasting and stuntingand their concurrent occurrence in Ghanaianpre-school children Summary of research1

Location: GhanaWhat we know: Wasting is a short-term health issue, but repeated episodes may lead to stunt-ing (long-term or chronic malnutrition). is may occur in resource-poor settings, wherepoor dietary intake and infectious disease are highly prevalent and persistent.

What this article adds: A reanalysis of the 2014 Ghana Demographic and Health Survey(DHS)2 assessed the magnitude of and relationship between concurrent wasting and stuntingamong 2,720 pre-school children aged 0-59 months, along with factors associated with bothconditions. Results found children who had low WHZ scores were at higher risk of stunting,especially children aged less than three years. e study confirms that wasting relates to lineargrowth, moderated by child age. Wasting and stunting share many common risk factors.

BackgroundGhana’s most recent Demographic and HealthSurvey (DHS) found a fall in stunting amongpre-schoolers (28% in 2008 to 19% in 2014),though masking great regional disparities, withthe highest prevalence of 33.1% in NorthernRegion. Many countries, including Ghana, haveinformation on the prevalence and factors as-sociated with chronic and acute undernutrition,but lack knowledge of the factors that contribute

to the development of their concurrence withinthe same children and the magnitude of thesefactors. is study investigated the relationshipsbetween wasting and stunting and associatedfactors in the Ghanaian population.

Methodse study involved reanalysis of the 2014 GhanaDHS dataset of 2,720 pre-school children aged0-59 months. e main outcome variable wasthe nutritional status of the child measured as

stunting (height-for-age z score (HAZ)), wasting(weight-for-age z score (WHZ)), and concurrentwasting and stunting. e independent variableswere maternal weight and height, reproductivefactors (parity, level of education, place ofdelivery, and prenatal care utilisation), childcharacteristics (e.g., sex and birth weight),malarial infection, child dietary intake, andhousehold wealth index. e analyses includedother household characteristics such as householdwealth, region of residence, urban/rural, sourceof drinking water, type of toilet facilities, andeducational level of the mother/caretaker. ewealth variable categorised respondents intoquintiles according to the household score onthe DHS wealth index, which is based on house-hold amenities, assets and living conditions.

1 Mahama Saaka and Sylvester Zackaria Galaa, Relationships between Wasting and Stunting and Their Concurrent Occurrence in Ghanaian Preschool Children, Journal of Nutrition and Metabolism, vol. 2016, Article ID 4654920, 11 pages, 2016. doi:10.1155/2016/4654920.

2 dhsprogram.com/pubs/pdf/FR307/FR307.pdf

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Local spatial clustering of stunting and wastingamong children under the age of five yearsSummary of research1

Location: EthiopiaWhat we know: e prevalence of stunting and wasting in Ethiopia has fallen but remains aconsiderable burden. Effective nutrition strategies must target where there is greatest burden.

What this article adds: A recent study in the Meskane Mareko District of Ethiopia used a spa-tial point process to investigate whether undernutrition indicators (stunting and wasting) havea tendency to cluster in order to determine the physical location and scale of clustering anddiscover risk factors for the observed clustering. A total 2,371 children under five years of agewere anthropometrically assessed in 1,744 households. Overall stunting prevalence was 40.2%(19.1% severe); wasting prevalence was 9.8% (5.3% severe). Older children, poorest childrenand male children were more likely to be stunted; male children were more likely to be wasted.Only wasting and severe wasting clusters were observed in two of the six kebeles surveyed (4xand 10x more likely to be wasted/severely wasted within clusters). Across all six kebeles, likelysignificant clusters for stunting (1.5x risk) and severe stunting (1.7x) were identified. For stunt-ing, household locations (elevation of the house and place of residence) were risk factors. Forsevere stunting, household dietary diversity, food-security status and latrine availability wererisk factors. Spatial locations of high-risk areas for stunting could be an input for geographical-ly targeting and optimising nutritional interventions.

1 Gebreyesus SH, Mariam DH, Woldehanna T and Lindtjørn B. (2016) Local spatial clustering of stunting and wasting among children under the age of 5 years: implications for intervention strategies. Public Health Nutrition, 19(8), pp. 1,417–1,427. doi: 10.1017/S1368980015003377.

Research

Ethiopia has documented a significantdecline in the prevalence of both stunt-ing and underweight between 2000and 2014; 31% decrease in stunting

(58% to 40%) and 39% decrease in underweight(41% to 25%) (CSAE & ICF, 2012; CSAE &ORC, 2006; CSAE & ORC, 2001; CSAE, 2014).However, prevalence remains considerable (WHOclassification: medium to high grade). Effectivenutrition strategies in Ethiopia, as elsewhere,require targeting on the basis of nutritional vul-nerability and burden to maximise benefit. isrequires the identification of specific locations

All data were coded for weighted analysis totake into account the complex design of multi-stage cluster surveys, and to ensure the sampledata were statistically valid. Effect modification(where wasting and stunting is moderated bythe age of the child) was identified and adjustedfor effect through multiple regression analyses.

ResultsResults showed that malnutrition prevalenceamong the study population was 17.9% stunting(HAZ <-2); 4.7% wasting (WHZ <-2); and 10.8%underweight (weight-for-age z score (WAZ)<-2). National prevalence of concurrent wastingand stunting was low at 1.4%, but with geo-graphical variations. e Upper East Region hadthe highest prevalence of 3.2%; the lowest preva-lence was in the Volta Region, with 0.5%. Furtheranalysis of undernutrition according to age group,gender and geographical location indicate that:both wasting and stunting frequently occur asearly as 0-5 months; levels of global acute mal-nutrition (GAM) were highest among the 6-11months age group, and in the Upper East Region;and stunting was highest among children aged24-35 months in the Northern Region and lowestamong children aged 0-5 months.

e study confirmed that the relationshipbetween wasting and stunting is moderated bychild age; a 1-unit increase in WHZ was associatedwith a 0.07 standard unit increase in HAZ [∂=0.071 (95% CI: 0.03, 0.15)].

Predictors of stunting andwastingPredictors of stunting were more common thanwasting, with some factors associated with both.e greatest predictors of stunting (accountingfor 17.8% variability) were: low maternal height,

low birth weight (LBW), whether child is wastedor not, child age, low utilisation of antenatal care(ANC) services, poverty, and increased parity. eonly amenable behavioural variable was utilisationof ANC services. Key predictors for wasting wereLBW, age of child, wealth index and living in ruralareas (accounting for 10% variance). Low percentageof variance accounted for in stunting and wastingsuggests that there are a larger number of possiblevariables that were not measured in the study.ree variables – LBW, age of child and householdwealth index – were found to be significant commonpredictors of wasting and stunting. Children whosebirth weight was less than 2.5kg were about 2.0times more likely to be wasted and 2.7 times morelikely to be stunted than children with normal birth weight (>2.5kg).

Discussions andrecommendationse authors discuss and compare their findingswith other research and make recommendations.

Low national prevalence of concurrent wastingand stunting (1.4%) among the Ghanaian studypopulation may partly be due to seasonal varia-tions in wasting prevalence, depending on whenthe data was collected.

WHZ relates to linear growth, but the natureand strength of the association was moderatedby child age. e association was strongest amongchildren aged 0-5 months and 12-23 months.Consistent with other studies, the study foundthat increasing child age is associated positivelywith stunting but negatively with wasting.

Cross-sectional studies at the populationlevel have demonstrated conflicting views onthe relationship between wasting and stuntingin childhood. Some have found little or no as-

sociation, whereas others have found evidencethat ponderal growth faltering can increase therisk of linear growth faltering. Findings in thisstudy confirm this.

ere is no clear mechanism by which wastingmay lead to stunting. Some studies suggest thatgrowth in height only takes place when thebody has a minimum level of energy reserves.Body fat plays a critical role in regulating bonemass, but although fat stores are needed to pro-mote linear growth, they are not sufficient, sincestunting and overweight can co-exist in somepopulations (and individuals). e relationshipbetween fat stores and stunting requires furtherinvestigation.

is study shows that predictors of stuntingwere more common than those for wasting, butthis may be due to the lower prevalence ofwasting compared to stunting in the same pop-ulation, therefore statistical power to detect sig-nificant associations between wasting and othervariables was low. All the risk factors for wastingwere also associated with stunting, apart fromrural/urban residence.

Low maternal height and household wealthindex were strongly associated with child nutri-tional status. Household wealth index was acommon predictor of both stunting and wasting,confirming that child undernutrition is stronglyassociated with poverty. Low maternal height(below 45cm) increased the risk of stunting butnot wasting; interventions should focus equallyon children and mothers to improve child health.

LBW was the most consistent risk factor forboth WHZ and HAZ for all ages, which concurswith other research from birth cohorts and lon-gitudinal studies. LBW infants should be a focusfor intervention.

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of at-risk populations in a given geographicalarea, a process that is aided by the use of spatialanalytical approaches.

is paper attempts to use such an approach,spatial point process, to investigate the localspatial structure of stunting and wasting amongchildren under the age of five years (U5s) in aparticular area of Ethiopia. e study aimed toevaluate whether undernutrition indicators(stunting and wasting) have a tendency to clusterin order to determine the physical location andscale of clustering and discover risk factors forthe observed clustering.

A community-based, cross-sectional studywas conducted between December 2013 andApril 2014 in the Meskane Mareko District ofEthiopia (around 513.65km2 in size) in theGurage Zone South of Addis Ababa. e studydistrict houses the Butajira Rural Health Pro-gramme (BRHP) run by Addis Ababa University,a health and demographic surveillance systemthat collects data on vital events and demographicpatterns in the district. e BRHP includes oneurban and nine rural communities (kebeles)and is divided into three agro-ecological zones,each containing three kebeles. e study ran-domly selected two out of three kebeles fromeach agro-ecology zone. Data were then collectedfrom the six kebeles, totalling 4,077 households.Out of these, 737 households were excluded(vacant or inhabitants very old and unable torespond), leaving 3,340 eligible households.From these households, weight and length/heightwere measured in all U5s. A team of 20 local re-search assistants was used to take anthropometricmeasurements, all of whom had initial trainingand evaluation of performance.

e survey collected a range of socio-demo-graphic and health data of children and respon-dents; e.g. child’s age, sex, morbidity, mother’seducation, religion, marital status and occupation,and household data; e.g. ownership and size ofland, type of house and construction materialsand possession of certain items. Household foodsecurity was measured using the HouseholdFood Insecurity Access Scale (HFIAS) tool.Household food intake was qualitatively capturedthrough 24-hour recall on food group con-sumption. Interviews were conducted by the 20research assistants, overseen by two supervisors.Household geographic locations and elevationswere determined using a hand-held GPS (GarminGPSMAP®). EpiData version 3.1 was used fordata entry. e statistical soware package Stataversion 11.0 was used for data cleaning andanalysis. Anthropometric indices (Z-scores)were calculated using the WHO Anthro sowareversion 3.2.2; analysis of spatial clustering wascarried out using Kulldorf ’s spatial scan statisticsand SaTScanTM version 9.1.

ResultsA total of 3,340 households was visited, of which53.4% (1784) households had one or more U5s.Response rate was 97·8 % (1,744 households),resulting in anthropometric assessment of 2,371U5s. Sixty-nine houses were not surveyed aerrepeated visits because of unavailability or refusal.

e overall prevalence of stunting amongU5s was 40·2%; 19.1% were severely stunted.e highest prevalence of stunting was in childrenaged 24-35 months (49·9 %). e lowest was inchildren below the age of six months (14·6 %);prevalence increased with the age of child. Malechildren (42·9 %) were more stunted than femalechildren (37·9%) and children in the poorestwealth stratum (45.1%) were more stunted thanthose in the richest (35·2 %). e prevalence ofstunting varied considerably among the six ke-beles. e highest prevalence (52%) was docu-mented in Dobena kebele (1,853m above sealevel). e prevalence of wasting and severewasting was 9·8% and 5·3% respectively. Asmaller difference in wasting prevalence wasfound between male children (10·7 %) andfemale children (8·9 %). e highest prevalenceof wasting was documented in Shershera Bido(13·5 %) and Dirama (11·7%) kebeles (≥1977mabove sea level). Concurrence of wasting andstunting in children was not reported.

Spatial scan statistics were applied separatelyfor the six kebeles to find out whether there wasa distinct spatial cluster in the distribution ofstunting and wasting at a smaller scale. Resultsshowed most likely significant clusters only forwasting and severe wasting in two of the six ke-beles. In Dirama, a single cluster of 31 cases(18.2 expected) in 129 households was identified.Children in this cluster were four times more atrisk of wasting than children outside the cluster.In Bati Lejano, a smaller cluster of seven cases(0.88 expected) in 15 households was identified;cluster children were ten times more at risk. epresence of significant clusters of undernutritionon a higher scale across the six kebeles was alsoexamined; this indicated a most likely significantcluster for stunting and severe stunting. Forstunting, a single large cluster size of 390 cases(304.19 expected) in 756 households was identi-fied; cluster children were 1.5 times more at riskof stunting than children outside the cluster. Forsevere stunting, a single cluster size of 106 cases(69.39 expected) in 364 households was identified;cluster children were 1.7 times more at risk.

ReferencesCSAE & ICF, 2012 – Central Statistical Agency of Ethiopia &ICF International (2012) Ethiopia Demographic and HealthSurvey 2011. Addis Ababa and Calverton, MD: CSA and ICFInternational.

CSAE & ORC, 2006 – Central Statistical Agency of Ethiopia& ORC Macro (2006) Ethiopia Demographic and HealthSurvey 2005. Addis Ababa and Calverton, MD: CSA andORC Macro.

CSAE & ORC, 2001 – Central Statistical Agency of Ethiopia& ORC Macro (2001) Ethiopia Demographic and HealthSurvey 2000. Addis Ababa and Calverton, MD: CSA andORC Macro.

CSAE, 2014 – Central Statistical Agency of Ethiopia (2014)Ethiopia Mini Demographic and Health Survey 2014. AddisAbaba: CSA.

Seifu Hagos, Ethiopia

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e authors found no difference between casesof stunting within and outside the cluster withregard to child and household dietary-relatedfactors such as child morbidity, household dietarydiversity and food-security status, nor householdsocio-economic conditions and latrine availability.e only factors that continued to be differentwere household locations (elevation of the houseand place of residence). Stunted children withinan identified spatial cluster were positioned atlower elevations than those outside a cluster(P<0.05). For severe stunting, significant differenceswere found between cases within and outside thecluster with regard to household dietary diversity,food-security status and latrine availability. Inthese cases, no differences were found with regardto the elevation of the house and place of residence.

e authors conclude that the distribution ofwasting and stunting was partly spatially structuredin the communities analysed. Distinct areas wereidentified within and between villages that havea higher risk than the underlying at-risk population.is indicates that the spatial distribution ofwasting and stunting may not be a completelyrandom process, but could be determined beyondthe individual or household level. Spatial locationsof high-risk areas for stunting could therefore bean input for geographically targeting and opti-mising nutritional interventions.

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Carbohydratemalabsorption in acutelymalnourished children andinfants: A systematicreview Summary of research1

Location: Global

What we know: Diarrhoea is commonly associated with SAM; carbohydrate malabsorptionmay be a contributing factor.

What this article adds: A recent systematic review finds a consistently reported reduced ca-pacity for carbohydrate absorption in severely malnourished children. Evidence is lacking onthe extent of malabsorption, the impact on clinical outcomes and the relationship with infec-tions. Malabsorption of monosaccharides and disaccharides is common (most observed islactose malabsorption); this has implications for current SAM treatment since therapeuticproducts tend to be high in carbohydrates. Intervention studies are needed to determinewhether different therapeutic food carbohydrate profiles affect outcomes of SAM complicatedby carbohydrate malabsorption, and how.

Severe acute malnutrition (SAM) accountsfor approximately one million child deathsper year. SAM is associated with multipleco-morbidities that may contribute to an

increased risk of death, a prominent one beingdiarrhoea. A common cause of diarrhoea in de-veloping countries is enteric infection, which,when associated with underlying malnutrition,can lead to villous blunting and, as a result, im-paired carbohydrate absorption. In turn, significantdecreases in carbohydrate absorption can lead tosevere osmotic diarrhoea. To inform future mod-ification of therapeutic feeds, it is necessary todetermine the prevalence of carbohydrate mal-absorption and to understand the possible impactof carbohydrate malabsorption on the recoveryof malnourished children. is systematic reviewaims to evaluate the research to determine theextent to which carbohydrate malabsorptionoccurs in children with SAM, to find out whattypes of carbohydrate are malabsorbed, and tofind out if carbohydrate malabsorption in childrenwith SAM is associated with osmotic diarrhoea.

A comprehensive literature search was per-formed in PubMed and Embase and referencelists of selected articles were further screenedfor additional relevant publications. All obser-vational and controlled intervention studies in-volving children with SAM in which direct orindirect measures of carbohydrate absorptionwere analysed were eligible for inclusion. Atotal of 20 articles were selected for this review.

Some of the included studies performeddynamic tests of carbohydrate absorption in

children with malnutrition. The most commontechnique was blood glucose rise after carbo-hydrate tolerance tests using a glucose responsecurve after an oral carbohydrate load. For anoral tolerance test, generally 2g of carbohydrateper kilogram of body weight dissolved in a10% solution was given orally after a six-hourfast and capillary blood was then sampledevery 30 minutes for two hours. If the bloodglucose rises less than 30mg/100ml after oralcarbohydrate is administered, intolerance isconsidered likely; increments of less than20mg/100ml are considered diagnostic of mal-absorption. When compared with controls,children with SAM showed a decline in theaverage maximum glucose rise. Other studiescompared malnourished children before andafter treatment. One study (Viteri et al, 1973)reporting a significant improvement in car-bohydrate absorption after treatment and an-other (James, 1972) showing no significantimprovement after treatment in lactose or su-crose absorption.

Other studies, instead of comparing treatedsubjects with control subjects, investigated plasmaglucose increments in children with SAM to in-dicate malabsorption aer administration of acarbohydrate load. Rothman et al (1980) showedthat glucose increments in eight of 12 childrenwith SAM fell below the cut-off value of20mg/100ml, while increments in the remainingfour were less than 30mg/100ml. ese findingsindicate that carbohydrate malabsorption isprevalent in children with SAM. Comparison

of absorption of different types of carbohydrateswas also done in several studies, which revealedthat lactose intolerance is a concern for childrenwith SAM. One study in particular looked atlactose malabsorption in different types of SAMand found that the proportion of children withlactose malabsorption was highest in those withkwashiorkor, second highest in those with maras-mic kwashiorkor, and lowest in those withmarasmus (James, 1972).

Some studies measured faecal pH and outputof water and carbohydrate as markers of car-bohydrate malabsorption. A pH of less than5.5 (normal pH values range between 7 and7.5) and the presence of reducing substancesin the faeces are indicative of carbohydrate in-tolerance and malabsorption as a result ofvillous atrophy. A higher mean stool weightand a higher lactic acid content are also consistentwith carbohydrate malabsorption. Reducedfaecal pH was observed in children with SAMcompared with controls in the studies that con-ducted carbohydrate tolerance tests, althoughthe average pH was still more than 5.5 in allmalnourished cohorts studied. Four studiesdemonstrated a significant reduction in meanstool weight in children on a disaccharide-freediet compared with children on a lactose-con-taining diet. For example, Maclean and Graham(1975) demonstrated that children with SAMon a low-lactose diet had a mean stool weightnearly three times lower than that of convalescentchildren. Overall, the data from faecal exami-nation in included studies suggests the prevalenceof carbohydrate malabsorption in children withSAM, as determined by increased mean stoolmass, the presence of reducing substances, andan acidic faecal pH.

e other indirect method used for assessingcarbohydrate absorption is the measurement ofmetabolic enzymes, namely lactase, sucrose andmaltase in jejunal mucosal biopsy samples. Mu-cosal disaccharidases, specifically, are essentialfor disaccharide absorption. Different studiesobserved reduced levels of disaccharides in mal-nourished children. James (1972) further illus-trated a rise in disaccharidase levels aer treatmentof both children with moderately acute malnu-trition and children with SAM. In another study,two children with SAM showed normal lactase,sucrose and maltase activities; one child withSAM had low sucrose and maltase activities andborderline low lactase activity, and eight childrenwith SAM had low lactase and sucrose activities,six of whom also has low maltase activity.

Measurement of anthropometric markerscan be indirectly related to carbohydrate mal-absorption and is harder to control for influencingfactors. A study conducted in a cohort of 20male children with SAM indicated that, despitethe increased incidence of diarrhoea in the

1 Kvissberg, MA; Dalvi, PS; Kerac, M; Voskuijl, W; Berkley, JA; Priebe, MG; Bandsma, RH (2015) Carbohydrate malabsorption in acutely malnourished children and infants: A systematic review. Nutrition reviews. ISSN 0029-6643 DOI: 10.1093/nutrit/nuv058

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References Eichenberger JR, Hadorn B, Schmidt BJ. A semi-elementaldiet with low osmolarity and high content of hydrolyzedlactalbumin in the treatment of acute diarrhea inmalnourished children. Arq Gastroenterol. 1984;21:130–135.

James WP. Comparison of three methods used in assessmentof carbohydrate absorption in malnourished children. ArchDis Child. 1972;47:531–536.

MacLean WC Jr and Graham GC. Evaluation of a low-lactosenutritional supplement in malnourished children. J Am DietAssoc. 1975;67:558–564.

Prinsloo JG, Wittmann W, Pretorius PJ, et al. Effect of differentsugars on diarrhoea of acute kwashiorkor. Arch Dis Child.1969;44:593–599.

Rothman D, Habte D, Latham M. The effect of lactose ondiarrhoea in the treatment of kwashiorkor. J Trop Pediatr.1980;26:193–197.

Viteri FE, Flores JM, Alvarado J, et al. Intestinal malabsorptionin malnourished children before and during recovery.Relation between severity of protein deficiency and themalabsorption process. Am J Dig Dis. 1973;18:201–211.

Nutrition among menand household foodsecurity in an internallydisplaced personscamp in KenyaSummary of research1

Location: Kenya

What we know: Internally displaced persons (IDP) arevulnerable to nutrition and food insecurity.

What this article adds: A 2013 study investigated thenutritional status of 251 men and their householdfood-security status during a pre-harvest period in anestablished IDP camp in Kenya. Nutritional status wascomparable to non-displaced men in Kenya (the ma-jority (68.9%) were of normal body mass index; onequarter (23.9%) were undernourished). Householdfood insecurity, measured using three assessmentscales, was relatively high. e most common source offood was own production (63.2%). Each had access toland; a minority depended on food aid. Recommenda-tions to improve food security include initiatives to im-prove access to credit and enabling investment and ca-pacity development in agriculture.

In 2007, disputed election results led tothe outbreak of ethnic violence in Kenya,centred on the Ri Valley Province wherethe Kikuyu minority, among others, was

targeted. Up to 600,000 people were displacedfrom their homes and eventually settled in In-ternally Displaced Persons (IDP) camps. Reportssuggest that access to basic needs, includingfood, water, sanitation and healthcare, continuesto be irregular throughout these camps. To date,no study has been published on nutrition andfood security among Kenya’s IDPs. e purposeof the present study was to determine the nutri-tional status of men and their household food-security status in an IDP camp in Kenya.

Methode study was conducted in 2013 within anIDP resettlement camp in Rongai District,Nakuru County, for those displaced from theRi Valley. Currently there are over 400 familiesresiding in the study camp who have each beenallocated two acres of land for agriculture and

0.25 acres of land for housing. e study wasundertaken over one week in June 2013 duringthe pre-harvest season of high food insecurity.e study was descriptive and cross-sectional,using a questionnaire and biometric measure-ments. A total of 267 men aged ≥ 18 yearsresiding within the camp were recruited via re-spondent-driven sampling. e questionnairecomprised 72 questions divided into three mainareas: demographic characteristics, nutrition,and food security. e nutrition and food securitysection incorporated three assessment scales:Individual Dietary Diversity Score (IDDS) (using24-hour recall of the consumption of differentfood groups); Household Food Insecurity AccessScale (HFIAS), involving recall over the previousfour weeks; and Household Hunger Scale (anewly emerging measure of hunger in regionswhich may already be experiencing significantfood insecurity, calculated using HFIAS data).e questionnaire was self-completed by par-ticipants in either English or Kiswahili with theoptional use of an interpreter. Both body mass

index (BMI) and mid-upper arm circumference(MUAC) were measured.

ResultsA total of 251 responses were included in theanalysis. e mean age of participants was 37years, 84·5% were of Kikuyu ethnicity and 82·1%had resided in the former Ri Valley Provinceprior to displacement. ree fihs of participantshad completed up to or more than primary ed-ucation; half were married and the mean house-hold size was seven. Half were employed, pre-dominantly in agriculture, and the medianmonthly household income was 2,500 KES(US$32).

During the previous 12 months, most par-ticipants (95·2 %; n=239) consumed at least one

1 Singh KP, Bhoopathy SV, Worth H, Seale H and Richmond RL (2015) Nutrition among men and household food security inan internally displaced persons camp in Kenya, Public Health Nutrition, 19(4), pp. 723–731. doi: 10.1017/S1368980 015001275.

Researchcohort on a lactose-containing diet comparedwith the cohort on a lactose-free diet, bothcohorts recovered well and in a similar fashionwith regard to anthropometric characteristics(Prinsloo et al, 1969). In contrast, two studiesshowed a decreased weight gain in children ona lactose-free diet. In one study in 20 malnour-ished children placed on a semi-elemental dietcontaining glucose and maltodextrin as the car-bohydrates, the average weight gain aer 21days was 420g, while in the 18 malnourishedchildren on the cow’s milk-based diet, the averageweight gain aer 21 days was 110g (Eichenbergeret al, 1984).

is review finds a consistently reported re-duced capacity for carbohydrate absorption inseverely malnourished children. e extent ofcarbohydrate malabsorption, the impact of mal-absorption on severe diarrhoea, dehydration and

other adverse clinical outcomes, and the rela-tionship between malabsorption and infectionare unclear owing to the lack of conclusivestudies. Most of the observational studies reviewedby the authors suggested a prevalence of lactosemalabsorption and an increase in diarrhoea andreduced weight gain in children on a lactose-containing diet. e consistent observation ofmalabsorption of both monosaccharides anddisaccharides could have profound implicationsfor current treatment of severe malnutrition,since the therapeutic foods in most treatmentprotocols have a relatively high carbohydratecontent. Additional well-designed interventionstudies are needed to determine whether outcomesof SAM complicated by carbohydrate malab-sorption could be improved by altering the car-bohydrate/lactose content of therapeutic feedsand to explain the precise mechanisms involved.

A typical camp setting wherethe research was conducted

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How to engage across sectors:Lessons from agriculture and nutrition inthe Brazilian School Feeding ProgrammeSummary of research1

Location: Brazil

What we know: Historically, successful collaboration between agriculture, nutrition and health sectors hasproved 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. elessons 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 nutri-tion 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.

1 Hawkes C, Brazil GB, Castro IR, Jaime PC (2016). How to engage across sectors: lessons from agriculture and nutrition inthe Brazilian School Feeding Program. Rev Saude Publica. 2016 Aug 11;50:47. doi: 10.1590/S1518-8787.2016050006506.

Brazil’s National School Feeding Pro-gramme, Programa Nacional de Ali-mentação Escolar (PNAE), is a universaland free programme that began in

1954 and that currently serves 45.6 million publicschool students. In June 2009, a law was signedin Brazil requiring that 30% of the food budgetof the national school feeding programme shouldbe used to purchase foods directly from family

Researchmeal every day. e most common food sourcewas from own production (63·7%; n=160); fol-lowed by purchase (28·3%; n=71); food fromfriends/relatives (4.4%; n=11); and governmentfood aid (3·6%; n=9). e majority (86·1 %;n=216) reported poor access to household fuel.

HFAIS Scale responses revealed that the ma-jority (80.5%; n=202) of participants had to eata limited variety of foods and reported missingout on preferred foods (79.3%; n=199). Onefih of respondents experienced limited foodvariety (22.3%; n=56) or missed preferred foods(21.1% (n=53) more than ten times in the pastfour weeks. Half of respondents (49·0%; n=123)reported going a whole day and night withouteating anything. e HFIAS score was 11.6 (po-tential range 0-27).

HFIAS score was associated with income.ose earning less than 2,000 KES (US$25) permonth had a significantly (P< 0.001) highermean HFIAS score (14·26), suggesting greaterfood insecurity. e majority of participants(71·7%) were from severely food-insecure house-holds; 13·5% were moderately food insecure;4·8% were mildly food insecure; while only 4·8%were food secure.

e median HHS score was 2 (SD 1·5) out ofa maximum possible score of 6. e most com-

mon condition of household hunger reportedwas going to sleep hungry at least once in theprevious four weeks (62·5 %; n=157). e con-dition experienced most was having no food ofany kind in the household: 7.2% (n=18) experi-enced this more than ten times. e majority ofparticipants were from households with moderatehunger (46·6%), followed by little or no hunger(40·2%) and severe hunger (10·0%). Men agedover 45 years and from households earning lessthan 2,000 KES (US$25) per month were morelikely to report being in the severe householdhunger category.

IDDS results show that starchy staples (e.g.thick maize porridge (ugali) and thin maizeporridge (uji) were eaten by 92% of participants.Organ meat (e.g. liver, heart and kidney) wasthe least common (21·9%). e mean IDDS was6 out of a possible 9 (SD 1·8). Low dietarydiversity (score ≤4) was associated with income,food insecurity and household hunger.

e mean BMI of respondents was 20·3 (SD2·5). e majority (68·9 %) had a normal BMI.One quarter (23·9%; n=60) were underweight,of whom 85% had mild thinness (BMI=17·0-18·4); 13·3% had moderate thinness (BMI=16·0-16·9); and a single participant had severe thinness(BMI ≤15·9). Being underweight was associated

with being older, having less income and beingmarried or living with a partner. e meanMUAC was 26·4cm (20.5-36.5).

Anthropometry was similar to other studiesamong non-displaced men in rural Kenya, whichcontrasts with other findings, suggesting IDPshave poorer nutritional status than comparablenon-displaced populations. is may be due tothe study being undertaken in a relatively stableand well-developed camp, five years post-dis-placement, among households with access toagricultural land and low reliance on food aid.However, levels of food insecurity among camphouseholds are worse than those in averagerural settings in the region. is may in part bedue to the lack of household capital to supportagriculture; community conversations suggestlack of income means that fertiliser, agriculturalimplements and seeds are difficult to access.

Recommendations: Recommendations to im-prove food security include registering land allo-cations under the name of the owner to provideaccess to credit and encourage investment inagricultural implements, as well as agriculturaleducation programmes. Such steps will be essentialto address severe food insecurity and minimiseits impact on mental health, disease profiles andfamily wellbeing documented in other IDP settings.

farms. is study examines integrating familyfarming and nutrition into a legal framework inBrazil to identify lessons on how to successfullyshi other sectors toward nutrition goals.

Information and perspectives on the devel-opment of Article 14 were obtained from in-terviews with 18 leading actors involved, duringFebruary and July 2010. Questions explored

the nature of the inter-sectoral approach,interests and values involved, and factors bothfacilitating and presenting barriers to the ap-proval of Article 14. Documentation on thehistory of the development of the law and key

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ReferencesUNSCN 2015 – United Nations Standing Committee onNutrition. A road map for scaling-up nutrition (SUN).[Place unknown]: Scaling Up Nutrition Road Map TaskTeam; 2010 [cited 2015 Mar 27]. Available from:scalingupnutrition.org/wp-content/uploads/pdf/SUN_Road_Map.pdf

antecedent actions from published documentswas also examined.

e study provided five key lessons for pro-moting inter-sectorality for nutrition, based onthe Brazilian experience of linking family farmingwith the National School Feeding Programme,as follows:

Lesson One: Identify or create a triageof spaces to bring together differentsectors – political, philosophical, andgovernance spacesIn 2003, food security moved to the centre ofthe political stage with the develop-ment of a new programme, FomeZero. is emphasised the need forstructural reform to address incomepoverty and encourage the productionof lower-cost food, including by sup-porting family farmers. A large, cross-sectoral government civil societygroup, CONSEA, was established toadvise the President on policies andactions needed to promote food andnutrition security. e new Govern-ment also created the Programa deAquisição de Alimentos (PAA – FoodAcquisition Programme), which pur-chases food directly from family farmsand distributes it to institutions andfamilies at risk of food and nutritionalinsecurity by social programmes.

e addition of nutrition into theconcept of food security was forgedduring this process and formally ap-proved at the second ConferênciaNacional de Segurança Alimentar eNutricional (CNSAN – National Con-ference on Food and Nutrition Secu-rity) in 2004. According to this broaderconcept, as a way of ensuring the hu-man right to adequate food, publicpolicies on food and nutrition securityshould not only encompass actionsto improve availability of and accessto food, but also promote and protectsustainable and healthy diets. isconcept links the nutritional dimen-sion of food security that puts allsectors and their priorities and agen-das in the same space.

Crucial to this was an inter-sectoral frameworkof food and nutrition security that provided thephilosophical space to put the two problems offood security and nutrition together, the policyspace provided by the new Government for thisjoint issue, and the governance provided byCONSEA to make it happen.

Lesson Two: Forming coalitions withmore powerful sectors focused onachieving a common political goalthat can help move them towardnutrition and health goalsSuccessful lobbying for Article 14 was strengthenedby three overlapping advocacy coalitions. efirst was between the relevant government min-

istries and agencies who had first discussed familyfarming-PNAE links. e second coalition consistedof food security advocates, Frente Parlamentarde Segurança Alimentar e Nutricional (Parlia-mentary Front on Food and Nutrition Security),comprising over 230 deputies and senators in2007, led by an influential politician who partneredwith civil society. e third coalition was a groupof family farming advocates, which providedstrong mobilisation and extensive, well-organisedadvocacy activities.

Improving nutritional outcomes was not theprimary goal of Article 14. e stated aim was

to support local economic development, not toimprove nutrition. Nutrition interests were rep-resented within the various groups, but notcentral to discussions, and the process lacked aclearly distinguishable coalition formed aroundnutrition and health interests. Nutritionists didadvocate to ensure that, by law, a nutritionistshould design the menus for the PNAE and toinclude specific nutritional standards for schoolmeals within the final Bill. e authors arguethat politically it served the nutrition interestnot to focus on the nutrition technicalities buton a common goal: to change the PNAE. En-gagement of nutritionists with a clear nutritionobjective was important; however not focusingon that goal as the foundation of the coalitionwas politically advantageous.

ese experiences suggest that the politicalprocess of identifying and participating in astrong coalition that is able to cause change inthe right direction, and that is focused onfighting for a common goal into which nutritionand health can fit, is more important than anexplicit nutrition goal, which is oen called forby the international nutrition community innutrition-focused development (UNSCN, 2015).

Lesson ree: Positioning nutritionand health goals as a solution thatmeets the interests of other sectors

Article 14 explicitly met the interestsof family farmers through new mar-kets and income generation, whichsecured the backing of family farminginterests. us the incentive for in-ter-sectorality came from a solution,rather than a problem. Article 14met the interests of a more powerfulsector, family farmers, and nutritionand health goals were met as a by-product.

Lesson Four: Obtainingevidence that the inter-sectoral approach can workArticle 14 was not the first initiativein Brazil linking family farmers withmarkets. Most notable was the FoodAcquisition Programme (PAA) es-tablished in 2003. is group had acrucial role in the approval of Article14 by providing evidence that familyfarming works; specifically and no-tably that the pricing and procurementmechanism could work and familyfarmers could supply sufficient food.

Lesson Five: Not beingafraid of bold ideas whenworking with other sectorsArticle 14 was a bold and appealingidea. It not only had the political ap-peal of supporting family farmersand economic development, but “itwas an important political force inthe minds of the population, thesocial imagination and the enhance-ment of self-esteem of the farmers

because it will nourish the children”. Principles,language, assumptions and approaches changewhen working with other sectors: they can beexploited for mutual advantage.

is study on policy processes shows how aconvergence of factors enabled a link betweenfamily farming and school feeding in Brazil. Ithighlights key strategies in engaging other sectorson working towards nutrition goals to benefitall sectors involved.

WFP/Isadora Ferreira

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

Location: Global

What we know: Child malnutrition has lifelong consequences for heath, human capital,economic development, prosperity and equity. Global nutrition targets (2012) focus onstunting, anaemia, low birthweight, childhood overweight, breastfeeding and wasting; thecost of achieving this is unknown.

What this article adds: A recent comprehensive analysis by the World Bank estimates anadditional investment of $70 billion (£62 billion approx) over ten years is needed toachieve global targets for stunting, anaemia in women, exclusive breastfeeding and scaled-up treatment of severe wasting. is would avert 3.7 million child deaths; every dollar in-vested would yield between $4 and $35 in economic returns. Investment in a subset of pri-ority interventions would cost $23 billion (£19 billion approx); global targets would not bereached, but 2.2 million lives would be saved. Achieving global goals is feasible but con-certed efforts in financing, scale-up and sustained commitment are needed. Research pri-orities include scalable strategies for delivering high-impact interventions, how to improvethe technical efficiency of nutrition spending, and costs and impacts of nutrition-sensitiveinterventions.

In 2015, 159 million children under theage of five were chronically malnourishedor stunted, underscoring a massive globalhealth and economic development chal-

lenge (UNICEF, WHO, and World Bank 2015).In 2012, in an effort to rally the international

community around improving nutrition, the176 members of the World Health Assemblyendorsed the first-ever global nutrition targets,focusing on six areas: stunting, anaemia, lowbirthweight, childhood overweight, breastfeedingand wasting. Some of the targets (stunting and

wasting) are further enshrined within the UnitedNations Sustainable Development Goal 2 (SDG2), which commits to ending malnutrition inall its forms by 2030.

Nutrition targets: Investmentcase and constraintsEnding malnutrition is critical for economicand human development. Childhood stuntinghas lifelong consequences not just for health,but also for human capital and economic de-velopment, prosperity and equity. Reductionsin stunting may increase overall economic pro-ductivity. Nutrition interventions are consistentlyidentified as one of the most cost-effective de-velopment actions. However, although the in-vestment case for nutrition is strong, factorslimiting achievement of nutrition SDG targetsinclude insufficient financing, complexity ofimplementation, difficulty determining themethods and costs involved in monitoringSDG targets, and the resources required forscale-up. There is little evidence on the estimatedcosts of achieving the global nutrition targets,including the SDG targets. No previous studyhas systematically linked the costs with thepotential for impact and the interventions’ re-turns on investment, nor assessed the financingshortfall between what is required and globalspend. Finally, no prior study has presented acomprehensive global analysis of domestic fi-nancing from governments and official devel-opment assistance.

This report aims to close these knowledgegaps by providing a more comprehensive es-timate of costs as well as financing needs,linking them both to expected impacts, andlaying out a potential financing framework.An in-depth understanding of current nutritioninvestments, future needs and their impacts,and ways to mobilise the required funds, areincluded.

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

Figure 1 2025 target

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ReferencesUNICEF, WHO, and World Bank (United Nations Children’sFund, World Health Organization and World Bank). 2015.Joint Child Malnutrition Estimates: Levels and Trends. GlobalDatabase on Child Growth and Malnutrition.www.who.int/nutgrowthdb/ estimates2014/en/ (accessedOctober 2015).

Advancing Early Childhood Development:From Science to Scale

Location: Global

What we know: ere have been major improvements in childsurvival over the last 30 years. A major focus of the 2030 Sustain-able Development Goals (SDGs) is now on early childhood devel-opment (ECD) to ensure that every child can achieve their full hu-man potential.

What this article adds: e 2016 Lancet Series Advancing EarlyChildhood Development: From Science to Scale, has just been re-leased. It estimates that 250 million (43%) of children under fiveyears of age in low- and middle-income countries (LMICs) are atrisk of poor development outcomes. Risks to health and wellbeinggo beyond stunting and extreme poverty to include factors such aslow maternal education and physical maltreatment. is Serieshighlights emerging scientific evidence and proposes pathways forimplementation of ECD programmes at scale. ‘Nurturing care’ isemphasised, especially of children below three years of age, andmulti-sector interventions starting with health.

Introductione 2016 Lancet Series Advancing Early Childhood Development: FromScience to Scale has just been released, comprised of six comments andfive papers. Building on the findings and recommendations of the previousLancet Series, this highlights new scientific evidence for interventions andrecommends pathways for scaling up ECD programmes.

Focus of the 2030 Sustainable Development Goals (SDGs) is on earlychildhood development (ECD) to ensure that every child can achievetheir full human potential. e first three years of life offer a window toamplify ECD interventions if stimulation through parenting, educationalsupport and adequate health and nutrition are provided. Despite thedecrease in child mortality over the past 30 years, the extremely highburden of risk for poor developmental outcomes remains, affecting an es-timated 250 million (43%) of children under five years of age in low- andmiddle-income countries (LMICs). Sub-Saharan Africa’s burden is evengreater, with two thirds of children affected. e burden of poor child de-velopment has been underestimated because risks to health and wellbeinggo beyond stunting and extreme poverty to include factors such as low

Researchbillion approx) over ten years is needed toachieve the global targets for stunting, anaemiain women, exclusive breastfeeding and scaled-up treatment of severe wasting. e expectedimpact of this increased investment is the pre-vention of 65 million cases of stunting and 265million cases of anaemia in women in 2025, ascompared with the 2015 baseline . In addition,at least 91 million more children under fiveyears of age would be treated for severe wastingand 105 million additional babies would be ex-clusively breastfed during the first six monthsof life over 10 years . Such investment wouldalso result in at least 3.7 million child deathsbeing averted. Every dollar invested in this pack-age of interventions would yield between $4and $35 in economic returns.

In an environment of constrained resources,prioritisation of a subset of interventions is nec-essary – scaling-up of interventions with thehighest returns, that are scalable now, with thestrong caveat that global targets would not bereached. Costing $23 billion (£19 billion approx)over next 10 years, when combined with otherhealth and poverty reduction efforts, an estimated2.2 million lives would be saved and there wouldbe 50 million fewer cases of stunting in 2025than in 2015.

A mix of domestic on-budget allocationsfrom national governments, oversees developmentaid (ODA), newly emerging innovative financingmechanisms and household contributions couldfinance the remaining gap. A society-wide effortis needed for financing the achievement of thenutrition targets; this mix of financing is also inline with other SDG challenges. Not only do in-vestments in nutrition make one of the best

value-for-money development actions, they alsolay the groundwork for the success of investmentsin other sectors.

Recent country experiences suggest that meet-ing global nutrition targets are feasible, althoughsome, especially those for reducing stunting inchildren and anaemia in women, are ambitiousand will require concerted efforts in financing,scale-up and sustained commitment. On theother hand, the target for exclusive breastfeedinghas scope to be much more ambitious.

Priority research areas include: Research on scalable strategies for delivering high-impact interventions, including how to addressbottlenecks to scaling-up.

e assessment of allocative efficiency, i.e.identifying the optimum funding allocationamong different interventions or an allocationthat maximises the impact under a specificbudget constraint.

Research to improve the technical efficiencyof nutrition spending, including identifying newstrategies for addressing complex nutritionalproblems such as stunting and anaemia, as wellas technologies to help take these solutions toscale more rapidly and at lower cost.

Strengthening the quality of surveillance data,unit cost data for interventions in different countrycontexts, and building stronger data collectionsystems for estimating current investments in nu-trition (from both domestic governments andODA). Further research is needed on the costsof interventions and significant resources willbe required to build a living database of currentinvestments, including closely monitoring spend-

ing and ensuring accountability, and to undertakenational-level public expenditure reviews.

Research on which interventions preventwasting is urgently needed. It is also essential tolearn more about cost-effective strategies formanaging moderate acute malnutrition, andwhether or not these can contribute toward theprevention of wasting.

Costs and impacts of nutrition-sensitive in-terventions; i.e. interventions that improve nu-trition through agriculture, social protectionand water and sanitation sectors, among others.It is evident that stunting and anaemia havemultiple causes and can be improved throughincreasing quality, diversity and affordability offoods; increasing the control of income bywomen farmers; and reducing exposure to faecalpathogens by improved water, sanitation, andhygiene practices. However, the attributablefraction of the burden that can be addressed bythese interventions is unknown.

e authors end with a call to action. Invest-ments in the critical 1,000-day window of earlychildhood will pay lifelong dividends, not onlyfor the children directly affected but also for usall in the form of more robust societies that willdrive future economies.

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maternal education and physical maltreatment.Multi-sector policies and funding for ECD haveincreased, but few countries have institutionalisedthe implementation of these policies. Servicesfor ECD remain fragmented and programmesat scale are rare and poorly evaluated.

is Series provides compelling new evidencein two areas. First, new research on early humandevelopment shows that adaptations (e.g. epigeneticand psychological) to the environment begin atconception and affect development throughoutlife, with implications for targeted interventions.Second, evidence is presented on long-term out-comes in LMICs. For example, a programme toincrease cognitive development in stunted childrenin Jamaica 25 years ago resulted in a 25% increasein average adult earnings.

Key messages from the Seriese burden and cost of inaction ishighA poor start in life limits children’s abilities tobenefit from education, resulting in lower pro-ductivity and social tensions. Consequences areinter-generational: poor ECD leads to a cycle oflost human capital and perpetuation of povertyfor both the individual and future generations.Predicted losses are 25% average adult incomeper year; nationally, this could mount to twicecurrent GDP spend on health.

Early means earlyChild development starts at conception and de-pends on good nutrition and certain types of

experience. A young child’s developing brain ispatterned by the ‘nurturing care’ of adults, in-cluding age-appropriate learning experiences.Many families cannot provide these due tostresses and conditions that affect their abilityto parent, including extreme poverty and familyand societal conflict. Families need support toprovide nurturing care; e.g. material and financialresources, knowledge, time and skilled assistance.Support should be provided through policiessuch as paid parental leave, time at work forbreastfeeding and the provision of free pre-pri-mary education.

A start can be made throughhealthe health sector has unique advantages, sinceit has existing maternal and child health servicesthat can be expanded to feasibly and affordablyinclude evidence-based nurturing care inter-ventions; most important are those strengtheningthe growth and health of mothers and youngchildren. Other essential services are child pro-tection for violence prevention, social protectionfor financial stability, and education for qualityearly-learning opportunities.

Scale up what we know worksSmall-scale civil society initiatives can be scaledup to effective and sustainable national pro-grammes. Government leadership and politicalprioritisation are prerequisites, but differentpathways may be followed to achieve ECD targets,from staged enhancement of existing strategiesto transformative, whole-government initiatives.

ReferencesBlack MM, Walker SP, Fernald LCH, Andersen CT,DiGirolamo AM, Lu C, … Grantham-McGregor S (2016).Early childhood development coming of age: sciencethrough 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: promotingearly childhood development. The Lancet.doi:10.1016/S0140-6736(16)31390-3

Chunling L, Black MM, Richter LM (2016). Risk of poordevelopment in young children in low-income andmiddle-income countries: an estimation and analysis atthe 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 thefoundation of sustainable development: pathways toscale up for early childhood development. The Lancet.doi:10.1016/S0140-6736(16)31698-1

Shawar YR & Shiffman J (2016). Generation of globalpolitical priority for early childhood development: thechallenges of framing and governance. The Lancet.doi:10.1016/S0140-6736(16)31574-4

Overview of papersObjectives of the first paper (Black et al, 2016) areto update the estimates of children at risk of not at-taining their developmental potential and to presenta life-course, conceptual ECD framework. epaper also examines current access to, and describesopportunities to implement, centre-based andhome-based cross-sector ECD programmes.

e second paper (Britto et al, 2016) providesa comprehensive, updated analysis of ECD inter-ventions across the five sectors of health, nutrition,education, child protection and social protection.

e third paper (Richter et al, 2016) presentsnew analyses showing that the burden of poordevelopment is higher than estimated, takinginto account additional risk factors. Nationalprogrammes are needed with greater politicalprioritisation key to scale-up of available effectiveprogrammes to support ECD. All sectors, par-ticularly health, education and social and childprotection, must play a role to meet the holisticneeds of young children.

e fourth paper (Shawar & Shiffman, 2016)describes multiple opportunities to advancepolitical priority for ECD, including an increas-ingly favourable political environment, advancesin ECD metrics, and the existence of compellingarguments for investment in ECD. However,proponents will need to overcome the framingand governance challenges to leverage theseopportunities.

e fih and final paper (Chunling et al,2016) updates the 2004 estimates (published in2007) of children exposed to stunting or extremepoverty with the use of improved data andmethods and generated estimates for 2010. e2007 study underestimated the number of chil-dren at risk of poor development. Progress hasbeen made in reducing the number of childrenexposed to stunting or poverty, but it has beeninsufficient: targeted interventions are urgentlyneeded.

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Role of nutritionin integratedearly childdevelopment Summary of research1

Location: GlobalWhat we know: Early child development (ECD) is a key predictor of future social capitaland national productivity. Worldwide, 250 million children under five years old may failto reach their developmental potential due to extreme poverty and social injustice.

What this article adds: A special issue of Maternal and Child Nutrition that compiledpreviously published articles on ECD related to nutrition shows that nutrition-specificinterventions, though essential, are not sufficient for children to reach their full develop-mental potential. Non-nutrition factors such as social determinants of health, parentingstyle and early childhood stimulation affect other ECD dimensions (psychosocial, cogni-tive and educational); poverty and social exclusion limit access. Multi-sector pro-grammes are needed at scale that consider responsive parenting, learning stimulation,education and social protection, in addition to health and nutrition.

IntroductionChild development has multiple dimensions, in-cluding physical, sensorimotor, social, emotional,language and cognitive. Children develop rapidlyduring the first five years of life from being unableto speak and walk to having fairly advancedmotor, social and cognitive skills. e importanceof the first 1,000 days (from gestation to twoyears) in helping a child develop healthy growthis well established. e brain grows very rapidlyduring the same period; between three and fiveyears of age its development continues with newabilities building on those already acquired.

Early child development (ECD) is recognisedas one of the most important predictors of futuresocial capital and national productivity, yet therecent ECD Lancet Series reports that about 250million children under five years old are at riskof not reaching their developmental potential(see summary in this edition of Field Exchange).is special issue of Maternal and Child Nutritionbrings together important, previously publishedarticles on ECD (with priority given to the lasttwo years) to identify how the nutrition sectorcan contribute to ECD in the context of multi-sector interventions. is is crucial given thecentrality of ECD indicators as part of the 2030Sustainable Development Goals (SDGs).

e 14 papers in the series are identified underfour headings:

Nutrition and child developmentacross the life-courseAuduchon-Endsley et al (2016) found that ex-cessive maternal weight and gestational weightgain was associated with poorer neurobehaviourin infants via hormonal pathways, highlightingthe importance of peri-conceptual nutrition.

e positive association between breastfeed-ing and academic ability at 12 years of age wasfound to be independent of socioeconomicstatus and parenting behaviours, according toa prospective study by Huang, Vaughn and Kre-mer (2016).

Crookston et al (2011) found concurrentstunting (stunted at 4.5-6 years of age) to havea greater impact on cognitive skills than earlystunting (6-18 months of age) in Peruvian chil-dren participating in the Young Lives study.Another cohort study in Malawi found thatimproved height gain between two and 15years of age, but not between birth and two

years of age, was independently associated withcognitive development (Teivaanmäki et al,2016), strongly suggesting the importance ofpromoting linear growth post-1,000 days forlong-term cognitive development.

Liu and Raine (2016) found that malnourishedchildren in a large sample of three-year-olds inMauritius had impaired social functioning, witha dose-response relationship; i.e. increased mal-nutrition was associated with more impairedsocial behaviour.

Findings from studies investigating the asso-ciation between micronutrients and ECD remaininconclusive. Makrides et al (2011) confirmedthat the effect of maternal fatty acid supplemen-tation on global neurobehavioural outcomes forchildren remains unclear, although fatty acidsupplementation of women expressing milk fortheir pre-term infants appears to improve infantneurodevelopmental performance.

Social and behavioralmediatorsMallan et al (2015) found that maternal postpartumdepression, assessed at four months postpartum,had a negative association with the mother’sability to feed her two-year-old children respon-sively (i.e. pressure to eat, restrictive feeding styleand emotional feeding). Such practices may un-dermine child self-regulation of intake, which isassociated with increased risk of overweight.

InterventionsA meta-analysis by Larson and Yousafzai (2015)concludes that the mental development of childrenunder two years in low and middle-income coun-tries (LMICs) is more strongly influenced bytheir motor development than their growth statusresulting from postnatal nutrition interventions.is important finding underscores the need tointegrate child psychosocial stimulation with nu-trition as part of ECD interventions.

e Baby-Friendly Hospital Initiative (BHFI)Ten Steps were found to have a positive impacton short, medium and long-term breastfeedingoutcomes, with a dose-response relationship be-tween the number of BFHI steps women are ex-posed to and breastfeeding outcomes (Pérez-Es-camilla et al, 2016). Such findings have major im-plications for ECD, since strong and consistentevidence supports the impact of breastfeeding ona child’s intellectual development, an effect whichcarries on into adulthood (Victora et al, 2016).

A randomised controlled trial in India (Vaziret al, 2013) found that responsive feeding edu-cation of caregivers improved dietary intake,growth and mental development among toddlers,underlining the need for integration of parentingskills as part of nutrition interventions targetingyoung children.

Fabrizio et al (2014) identified key componentsof effective behaviour-change interventions toimprove complementary feeding practices asidentifying barriers and enablers and delineatingprogramme-impact pathways, pointing to theneed for inter-disciplinary partnership in ma-ternal-child nutrition.

In a review of water, sanitation and hygiene(WASH) interventions, Cumming and Cairncross(2016) add to the strong evidence that malnu-trition and infectious diseases are interrelatedand that WASH should be part of multi-focalECD interventions.

Policy Subramanian et al (2016) call for a rethinking ofpolicies to address child stunting in South Asia,the region most affected, and conclude that up-stream social determinants of health must beurgently addressed to tackle the problem.

Conclusionsis collection of papers shows that nutrition-specific interventions, though essential for childdevelopment, are not sufficient for children toreach their full developmental potential. is isdue to the many non-nutrition factors, such associal determinants of health, parenting styleand early childhood stimulation that affect otherECD dimensions (psychosocial, cognitive andeducational). Poverty and social exclusion limitthe access of families to most, if not all, of thesefactors. Multi-sector programmes need to con-sider including responsive parenting (includingresponsive feeding), learning stimulation, edu-cation and social protection, in addition tohealth and nutrition. Programme scale-up by-governments to adress multiple factors in anintegrated way is crucial. Research is needed tobetter understand if and how childhood obesityaffects the different dimensions of ECD.

All references and papers are free to access on-line at onlinelibrary.wiley.com/journal/10.1111/(ISSN)1740-8709/homepage/virtu-al_issue_integrated_early_child_development

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By Jeanette Bailey, Rachel Chase, Marko Kerac, AndréBriend, Mark Manary, Charles Opondo, MaureenGallagher and Anna Kim

Jeanette Bailey is the Project Director for ComPAS,based at the International Rescue Committee (IRC)in New York. She has an MSc in Public HealthNutrition and is undertaking her PhD at theLondon School of Hygiene & Tropical Medicine. Shehas more than 10 years’ experience of working in

nutrition programmes in humanitarian contexts.

Dr Rachel Chase received her PhD from theDepartment of International Health at JohnsHopkins Bloomberg School of Public Health. Shecurrently works as a qualitative and quantitativedata analyst for universities and non-governmentalorganisations.

Dr Marko Kerac is a lecturer in Public HealthNutrition and the course director for the MSc inNutrition for Global Health at the London School ofHygiene & Tropical Medicine. He is a medicaldoctor with a PhD in nutrition and many years ofexperience in leading research on malnutrition in

developing countries.

Dr André Briend is an Adjunct Professor in theDepartment of International Health, University ofTampere and Affiliated Professor in Child Nutritionat the Department of Nutrition, Exercise and Sportsat the University of Copenhagen. He is a medicaldoctor with a PhD in nutrition and has more than

30 years of experience in research in paediatric nutrition indeveloping countries.

Dr Mark Manary is the Helene B. RobersonProfessor of Paediatrics at the WashingtonUniversity School of Medicine in St. Louis. He is amedical doctor with many years of experienceleading research on the treatment of acutemalnutrition.

Dr. Charles Opondo is a Research Fellow at theLondon School of Hygiene & Tropical Medicine,and a Researcher in Statistics and Epidemiology atthe University of Oxford. He is a pharmacist with anMSc and PhD in Medical Statistics from the LSHTM.

Maureen Gallagher is the Senior Nutrition & HealthAdvisor for Action Against Hunger U.S., based inNew York. She is a public health specialist with anMSc in Social Policy and Planning, specialising inhealth policy. She has been working in nutritionprogramming for the last 15 years in Niger, East

Timor, Uganda, Chad, DRC, Burma, Sudan and Nigeria.

Anna Kim is a Senior Health Communications andAdvocacy Officer at the IRC in New York. She hasan MA in International Relations and Journalism

The ComPAS study

Combined protocol forSAM/MAM treatment:

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 FundFoundation (CIFF); particularly Claire Harbron.

anks to MSF-France and MSF-Spain for sharing data and to IRC, ACF-USA, ACF-UK and the London School of Hygiene & Tropical Medicine col-leagues for their collaboration and input during the development of thiswork, particularly Angeline Grant, Bethany Marron, Lara Ho, Silke Pietzsch,Ruwan Ratnayake, Viddah Owino, Bijoy Sarker, Sophie Woodhead, SaulGuerrero, Amy Mayberry, Kerstin Hanson, Nuria Salse, Candela LaNusse,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,Diane Holland, Grainne Moloney and Tewoldeberha Daniel.

A more detailed version of this article will be prepared for publication in apeer-reviewed journal.

Location: Chad, Kenya, Yemen, Pakistan, SouthSudan.What we know: Different protocols, products and servicesystems are used to treat severe and moderate acutemalnutrition, which complicates management of theconditions.

What this article adds: Stage 1 of the three-year CombinedProtocol for Acute Malnutrition Study (ComPAS)retrospectively analysed treatment data (growth, energyrequirements) from acutely malnourished children to develop(by expert committee) a simplified MUAC-based dosing chartto treat both SAM and MAM (Combined Protocol). Thestudy found that growth trends in MUAC mirror those ofproportional weight gain during treatment. Rates of gain inMUAC and weight slow with increasing MUAC and as theydo, proportional energy needs decrease. Total energy needs of95% of all children with a MUAC <125mm can be met with1,000 kcals/day. Given this, a Combined Protocol is proposedthat admits children with MUAC<125mm and/or oedemaand treats as follows: MUAC <115mm - 2 sachets RUTF/d;MUAC 115mm- <125mm -1 sachet RUTF/d). The next phaseof ComPAS aims to examine the effectiveness and cost-effectiveness of this simplified protocol.

The Combined Protocol for Acute Malnutrition Study (ComPAS)aims to simplify and unify the treatment of uncomplicatedsevere and moderate acute malnutrition (SAM/MAM) for chil-dren aged 6-59 months into one protocol in order to improve

the global coverage, quality, continuity of care and cost-effectiveness ofacute malnutrition treatment in resource-constrained settings. Buildingon a number of studies (see Box 1), the Combined Protocol proposes touse only one product (ready-to-use therapeutic food (RUTF)), at dosestested to optimise growth and minimise cost at each stage of treatment.Admission, progress and discharge will be assessed using mid upper armcircumference (MUAC) and oedema only. It is hypothesized that this ap-proach will eliminate the need for separate products/infrastructure/ad-ministrative procedures for MAM treatment; enable earlier treatment ofcases before deterioration into more costly SAM treatment; enable bettercontinuity of care; and lead to more positive community perceptions ofthe programme.

ComPAS began in October 2014 and completed its first stage ofsecondary data analysis in January 2016. e second stage will consist ofa multi-country cluster randomised trial in two countries and is expectedto be completed by December 31, 2017. It is guided by a scientificcommittee of global experts in paediatrics and nutrition and comprisedof partnerships between the International Rescue Committee (IRC),Action Against Hunger-USA (AAH-USA), Action Against Hunger-UK(AAH-UK) and the London School of Hygiene and Tropical Medicine

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Field Article

(LSHTM). It is funded by USAID’s Office ofU.S. Foreign Disaster Assistance (OFDA) andChildren’s Investment Fund Foundation (CIFF).

Stage 1 of ComPAS retrospectively analysedtreatment data from acutely malnourished childrenaged 6-59 months to assess growth trends andenergy requirements and develop a simplifieddosing chart based on MUAC. Preliminary findingsare summarised in this article; a more detailedfinal analysis is planned for future peer-reviewedpublication. Further initial findings, Figures 1-4and Table 3 are available online at: http://www.ennonline.net/fex/53/thecompasstudy

Objectivese objectives of Stage 1 of ComPAS were to:1) Assess rate of growth and

a. Calculate energy requirements for ob-served growth in children recuperating in Outpatient erapeutic Programmes (OTPs) and Supplementary Feeding Pro-grammes (SFPs);

b. Evaluate differences in the response to treatment according to geography, age, anthropometric status on admission, andtreatment outcome;

2) Calculate energy requirements by MUAC category; and

3) Propose a physiologically appropriate dosage table based on MUAC that could be used in a simplified and unified protocol.

MethodA secondary analysis of data from children re-covering from SAM in OTP and from MAM inSFP programmes was used to evaluate growthtrends in response to treatment, using registrationbook/patient card data from the following pro-grammes and countries: • International Rescue Committee (IRC):

Chad, Kenya, Yemen.• Action Against Hunger-USA (AAH-USA):

Pakistan.• Médecins Sans Frontières-France (MSF-

France): South Sudan.

Data from 10,070 acutely malnourished childrenbetween the ages of 6 and 59 months were avail-able (see Table 1); 8,233 were retained for analysis(Table 2). Most patients from each country were

retained in the analysis, ranging from 75% inKenya to 90% in Chad. Reasons for exclusionincluded uninterpretable or unfeasible data thatlimited interpretation of individual course ofrecovery.

To balance the contributions of each of thefive countries in the analysis when using localpolynomial estimation (described below), 1,300visits were randomly selected from each countryfor a total of 6,500 visits (from, at most, 2,798children) in a sub-sample used for the visualanalysis of growth. is visual analysis of thelocal polynomial estimation of growth by MUACat last visit guided the decision to assess energyneeds over ranges of MUACs at last visit inmeaningful but theoretical groups.

Method for objective 1: Assess rate of MUACand proportional weight gain and energy requirements of children and valuate differences in the response to treatmentUsing local polynomial smoothing, we visuallyassessed the relationship between:(1)One-week MUAC growth (mm); and (2) Proportional weight gain (g/kg/day) compared

to last-measured MUAC among children discharged as “recovered”.

One-week MUAC growth was calculated as thedifference between two MUAC measurementswhen a child’s visits are one week apart. Whena child’s visits were recorded as being two weeksapart, the difference between the first and secondvisit MUAC is divided by two to estimate weeklyMUAC growth. Proportional weight gain wascalculated as the weight gain (in grams) dividedby weight at last visit (in kg) divided by numberof days since the last visit prior to the referencevisit (hereaersimplyreferredtoasthe“last visit”).

is analysis was performed for all data to-gether (unweighted), by region (Africa andAsia), by country, and by age group. Exceptwhen compared by country, reported valuesand figures reflect results from the n=6,500 sub-sample described above.

Method for objective 2: Calculate energy requirements by MUAC categoryDaily energy needs were estimated as:

Current weight (in kg) * resting energy needs(82 kcal/kg) + weight gain (in grams) * energycosts of weight gain (5 kcal/g) (FAO, 2001)

Changes in energy needs were calculated foreach child as kcal/day as per the above formulaand as kcal/kg weight. Both values are reportedby MUAC at last visit. As an example, considera child who weighed 7.1 kg, had a MUAC of116mm on their 5th visit to the clinic, andweighed 7.4 kg on their 6th visit 7 days later.is means that the child gained, on average,42.9 g in weight per day between visits. To esti-mate the child’s daily energy needs to achievethat growth, we calculate:

7.1 kg * 82 kcal/kg + 42.9 g * 5 kcal/g = 796 kcal.Because the child’s MUAC was 116mm at their5th visit, this energy need estimate is reportedalong with other children’s calculated energyneeds who had a MUAC of 116mm at theirprior visit.

Method for objective 3: MUAC dosage tableAn expert scientific committee reviewed the re-sults of objectives 1 and 2 and proposed aMUAC/RUTF dosage table that would coverthe total energy needs of >95% of children aged6-59 months with a MUAC <115mm, and halfthe energy needs of >95% of children aged 6-59months with a MUAC 115-<125mm.

ResultsGrowth trends in MUAC mirror those ofproportional weight gain and rates of MUACand weight gain slow with increasing MUACAmongst children with similar MUACs at agiven visit, MUAC and proportional weightgain show roughly the same growth trend.Proportional rate of growth tends to be lowerfor children with higher MUACs, and rates ofgrowth appear to plateau over ranges ofMUACs (see Figure 1 online).

The current SAM treatment protocol basesRUTF dosage on 175-200 kcal/kg/day untilchildren are discharged as cured. However,research indicates food intake drops(Ashworth, 1969) and growth rate (weightand MUAC-based) slows (Goossens et al,2012) towards the end of treatment. Similarcured/death/defaulter results have beenfound where RUTF dosage was reduced atthe end of SAM treatment (Cosgrove et al,2012); this observation is being furtherexplored through ACF research . A recenttrial in Sierra Leone suggests that anintegrated SAM/MAM programme usingRUTF had more favourable outcomes oncoverage and is an acceptable alternative tostandard treatment (Maust et al, 2015).

Box 1 What is known? Researchunderpinning ComPAS

Table 1 Summary of data provided by three agencies from five countries

Country(organization)

Source Total patientcount

Admitted toOTP facility

Admitted toSFP facility

Admitted withSAM MUAC orWHZ*

Admitted withMAM MUAC orWHZ**

Yemen (IRC) Patient registers 1,099 315 784 317 782Kenya (IRC) Patient cards 1,685 421 1,260 527 1,158Chad (IRC) Patient cards 2,054 639 1,415 529 1,525Pakistan (ACF-USA) Patient cards 2,619 551 2,068 661 1,958South Sudan(MSF-France)

Patientdatabase

2,613 2,613 0 2,407 162

TOTALS 10,070 4,539 5,527 4,441 5,585

Table 2 Counts of patients excluded from the analysis by country

Kenya Pakistan Chad Yemen South Sudan TotalPatient retained in analysis 1,259 2,260 1,849 853 2,012 8,233

75% 86% 90% 78% 77% 82%Patient removed from analysis 426 359 205 246 601 1,837

25% 14% 10% 22% 23% 18%TOTALS 1,685 2,619 2,054 1,099 2,613 10,070

* SAM defined as MUAC < 115mm and/or WHZ <-3z** MAM defined as MUAC 115-< 124mm and/or WHZ-3- <-2z

Note on Table 2: Most patient from each country were retained in the analysis, ranging from 75% in Kenya to 90% in Chad. Reasonsfor exclusion included uninterpretable or unfeasible data that limited our ability to interpret a patient’s course of recovery

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No significant difference was observed ingrowth trends across MUAC at last visit by agegroup (under two years and over two years) orby stunting status (greater/equal to or less thanheight for age (HAZ) <-2 z-scores).

When comparing children enrolled in pro-grammes in the three African countries (SouthSudan, Chad and Kenya) and children enrolledin programmes in the two Asian countries(Yemen and Pakistan), a notable difference inweekly MUAC gain is observed between 111mmand 123mm MUAC at last visit (1.4 mm vs 0.7mm). New plateaus in MUAC gain might beseen at 115mm and 126mm among children inAfrica, whereas only one new plateau appearsto form among children in Asia over MUAC atlast visit, starting at around a MUAC of 110mm(see Figure 2 online).

As the rates of MUAC and weight gain slow,proportional energy needs decreaseComparisons of MUAC and proportional weightgain to MUAC at last visit indicate that averageproportional energy needs (that is, energy neededper kg of weight to achieve observed growth)follow a similar step-down pattern (see Figure3 online), although total energy needs increasedue to greater total body weight. Among childrenwith MUAC <125mm, the children with thegreatest energy needs to achieve observed growthare those with the lowest MUACs; approximately150-160 kcal/kg/day would be enough to supportthe growth observed in 95% of visits amongchildren with the lowest MUAC. In these data,energy needs never exceed 190 kcal/kg/day (seeFigure 3 online).

Total energy needs of 95% of all childrenwith a MUAC <125mm can be met with1,000 kilocalories a daye 95th percentile line indicates the number ofkilocalories that would be sufficient to cover thetotal energy needs of 95% of children with 100mm≤ MUAC < 115mm, 115mm ≤ MUAC < 125mm,or 125mm ≤ MUAC ≤ 140mm. Minor differenceswere observed between estimated energy needsfor children in Africa and Asia when MUAC wasbelow 115mm (909 kcal in Africa vs 731 kcal inAsia), and no practical difference when 115mm≤ MUAC < 125mm (1,013 in Africa, 1,011 inAsia) (see Figure 4 online).

MUAC dosage tablee ComPAS expert panel met to review theseresults from January 26-27 2016. ey agreedthat MUAC was a suitable alternative to weightto determine the dosage of RUTF as childrenprogress through treatment. e Combined Pro-tocol will admit all children who have aMUAC<125mm and/or oedema, and treat themaccording to the following simplified dosageprotocol:• Children with a MUAC <115mm or oedema

(+) to receive two sachets of RUTF per day (1,000 kcal);

• Children with a MUAC 115mm- <125mm to receive one sachet of RUTF per day (500 kcal).

is protocol remains in line with globally ac-cepted practice, with children recovering fromSAM receiving enough therapeutic food to covertheir total energy needs (as a replacement forthe family diet), whereas children with MAMreceive a food supplement to complement theirfamily diet. Most SFP protocols provide 500-550 kcal/day of ready-to-use supplementaryfood (RUSF). e advantage of using one productis simplicity (currently procurement of RUTFand RUSF involves separate UN agencies) andphysiological appropriateness, considering acutemalnutrition on a continuum of severity ratherthan as separate SAM/MAM conditions.

When tested in a theoretical comparison(Table 3 online), the protocol performs as de-signed (i.e. meets the total energy needs for>95% of children with a MUAC <115mm, andmeets approximately half the energy needs for>95% of children with a MUAC 115-<125mm)for all major sub-divisions of children (by sex,country, continent, weight and admission type).Of note:• At 95% of visits, children with MUAC <

115mm in the specified category have 100%of their energy needs covered by two sachetsof RUTF (1,000 kcal) per day. Two categoriesof children fall slightly short of this goal: children aged 25 months or more (93%) and children who weigh 8.0kg or more (83%). Even in these two groups, only at 5%of visits do children have less than 96% of their caloric needs covered by two sachets of RUTF per day.

• At 95% of visits, children with a MUAC of 115mm -< 125mm have 50% or more of their total energy needs met by the provi-sion of one RUTF sachet (500 kcal) per day.In both Asia and Africa, we estimate that 49% of total energy needs or more are met at 95% of visits. Children aged 25 months or over and children who weigh 8.0kg or more again fall short of this goal, but not bya startling amount: only 5% of children aged25 months or more and children who weigh8.0kg or more have 40% and 42% respec-tively (or fewer) of their energy needs covered to achieve observed growth. How-ever, the provision of RUTF 500kcal per daymatches the current global MAM manage-ment practice of providing 500 kcal of RUSF per day, so the same gap exists with the existing SFP protocol. e nutrient compositions of RUTF and RUSF are not exactly the same (RUTF has more dairy and RUSF has a higher content of macro-minerals, important for linear growth), but RUTF has been proven effective in the treatment of MAM (Maust et al, 2015).

Overall, 97% of children with MUAC < 115mmin the observational data would have their totalenergy requirements to achieve observed growthmet or exceeded by the proposed protocol. emedian percentage of their energy needs coveredwould be 170% (i.e., they would receive 70%more calories than needed to achieve observedgrowth), and 95% of children with MUAC <

115mm would have at least 111% of their energyneeds covered by the protocol.

Consistent with the design, 95% of childrenwith 115mm-< 125mm would have 49% ormore of their energy needs covered by the pro-posed protocol, with a median of 74% of theirenergy needs covered. In both Africa and Asia,this simplified dosage protocol meets or exceedsthe vast majority of children’s energy needswhen children have MUAC < 115mm and isaligned with the current practice of SFP pro-grammes of providing at least 50% of children’senergy needs when children have a MUAC be-tween 115-<125mm.

Supporting figures and tables for results areavailable online at: www.ennonline.net/fex/spe-cific reference.

Conclusionis study considered the rate of weight andMUAC gain and energy needs of children withacute malnutrition as defined by MUAC status.Our findings concluded that two 92g sachets ofRUTF (1,000 kcal) meet the total energy require-ments for >95% of children with a MUAC<115mm,and one 92g sachet of RUTF (500 kcal) meetshalf the energy requirements for >95% of childrenwith a MUAC of 115-<125mm, and serves tosimplify and streamline the treatment to betested in a combined protocol.

e next phase of ComPAS aims to examinethe effectiveness and cost-effectiveness of thissimplified protocol. Stage 2 will pilot the com-bined protocol in a cluster randomised controllednon-inferiority trial in two countries to assessthe effectiveness of the combined protocolagainst the standard protocol (OTP + SFP) interms of recovery (with enrolment and dischargebased on MUAC), coverage, length of stay, andaverage daily weight gain and weekly MUACgains. A comprehensive cost-effectiveness analysiswill be included as part of the field trial.

For more information, contact: Jeanette Bailey,email: Jeanette.bailey@rescue.org

ReferencesAshworth A. Growth rates in children recovering fromprotein-calorie malnutrition. British Journal of Nutrition.(1969), 23,835

Goossens S, Bekele Y, Yun O, Harczi G, Ouannes M,Shepherd S (2012). Mid-Upper Arm Circumference BasedNutrition Programming: Evidence for a New Approach inRegions with a High Burden of Acute Malnutrition. PLoSONE 7(11).

Cosgrove N, Earland J, James P, Rozet A, Grossiord M,Salpeteur C. Qualitative review of an alternativetreatment of SAM in Myanmar. F. Exch. [Internet].2012;42:6. Available from:www.ennonline.net/fex/42/qualitative

Maust A, Koroma A, Abla C, Molokwu N, Ryan K, Singh L,Manary M. Severe and Moderate Acute Malnutrition CanBe Successfully Managed with an Integrated Protocol inSierra Leone. Journal of Nutrition. 2015.

FAO. Food and Agriculture Organization. Human energyrequirements: Report of a Joint FAO/WHO/UNU ExpertConsultation. FAO Food Nutr. Tech. Rep. Ser. [Internet].2001;0:96. Available from:www.fao.org/docrep/007/y5686e/y5686e08.htm

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Field Article

By Mustafa Ghulam andMohammed H Alshama’a

Mustafa Ghulam is aFood Security andLivelihoodsProgamme Mangerwith Save theChildren, based inYemen. He has 20

years of experience in programme designand implementation in both natural andman-made disasters.

MohammedAlshama’a is MEALTechnical Advisorwith Save theChildren, based inYemen. Mohammedhas extensive

experience in emergency and developmentprogramming in different contexts. He isexperienced in programme design,programme monitoring, research andassessment in complex emergencyresponses in fragile state contexts.

The authors would like to acknowledgeKarl Frey, Save the Children and Brian Kriz,Consultant for their technical input andcontributions to this article.

Experiencesfrom Yemen

Adapting aresilienceimprovementprogrammein conflict:

Beneficiaries on thesite of redemption

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Location: YemenWhat we know: Emergency response in fragile state contexts is complex;Yemen is currently in a state of acute crisis against a backdrop of long-termpolitical and nutritional volatility.

What this article adds: A three-year Save the Children programme in Yemenwas designed to strengthen household resilience and improve infant and youngchild feeding (IYCF) and care and hygiene practices in an insecure (thoughstable) context. Two years of programming involved a food-for-assets scheme(vouchers in exchange for community-identified assets development) andmother-to-mother support groups. Community feedback mechanisms andimpact monitoring were established. Communities reported high coverage ofbenefits from roads and water projects (assets). Deterioration to a crisissituation in year three led to needs reassessment and adaptation to anunconditional voucher programme that served almost twice as manybeneficiaries compared to the conditional transfers. Household DietaryDiversity Score rose and Household Hunger Score fell. The electronic food-voucher programme, established in the community assets scheme, was key tothe feasibility of scale-up.

ContextIn 2013, the United States Agency for Interna-tional Development (USAID) Office of Foodfor Peace (FFP) provided three years of fundingto Save the Children International (SCI) toimplement a programme with the objectivesof strengthening household resilience and im-proving infant and young child feeding (IYCF)and care and hygiene practices in Dhamar andSana’a governorates. e original programmestrategy sought to layer and integrate activitiesso that the short-term food security needs ofvulnerable households were met with conditionalfood vouchers, while establishing long-termresilience through rehabilitating or improvingcommunity-level assets and improving IYCFpractices at the community level.

However, with the outbreak of fighting inMarch 2015, the project was forced to adapt toa rapidly changing context. As a result, theprogramme adjusted its programme objectivesand activities to meet immediate humanitarianneeds. is article recounts how a resilience-building programme successfully adapted to arapidly emerging humanitarian crisis.

Programme rationale anddesignWhen the programme was designed in 2013,Yemen was facing a different set of challengesto the one it faces today. While the politicaland security climate was still volatile andpockets of humanitarian need existed in thecountry, development policies were focusedon resilience-building programmes. e focusof many development agencies and funderswas on solving issues of dwindling water re-sources, child health, nutrition and educationand seizing opportunities for livelihood security.In that context, this programme was originallydesigned with two immediate results (IR) inmind. e first IR focused on improvement of

community-level resilience through food-for-asset (FFA) activities. e second IR focusedon the adoption of key IYCF, care and hygienepractices in the community.

e project targeted a part of the countrywhere communities were largely rural and scat-tered across mountain tops and valleys, withlimited market access. Most households reliedon various seasonal labour options for income,supplementing these incomes with the sale ofsmall animals and/or support from the govern-ment social protection programme. e projectsought to work with 150 communities over threeyears. To optimise operations, clusters of villagesand households took part in asset-improvementactivities for six months, aer which the pro-gramme would move on to another village. Inits first two years, the FFA programme benefitted7,350 households and built or rehabilitated 436community assets in Dhamar and Sana’a. But inthe third year alone, the programme drasticallyramped up operations and managed to nearlydouble the number of households served.

IYCF and hygiene-promotion activities wereexpected to continue across all programme areasfor the whole three years of the programme.e programme also organised training forMinistry of Public Health and Population staff(MoH) on referral systems and nutrition servicesat health facilities. With the support of theMoH, SCI established 169 mother-to-mothersupport groups (MTMSGs) in target villages.ese are groups of women helping new motherscare for their children through model-optimalbreastfeeding practices and sharing informationand experiences, and by offering support toother women in an atmosphere of trust and re-spect. Group leaders create awareness amongmembers about exclusive breastfeeding practicesand complementary feeding for infants andyoung children during regular meetings.

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Field Article

Mobilisation and targetinge mobilisation and targeting process tookplace in partnership with district-level leaders.It began by ranking districts based on vulnerabilitycriteria, including proximity to markets, incomeoptions, access to water and access to previousassistance. At the sub-district and village level,another round of mapping, ranking and targetingusing the same set of criteria was completedwith local authorities and community leaders.e geographic and administrative targetingprocess not only ensured that vulnerable com-munities were targeted, but also enabled com-munity buy-in before the village and beneficiaryselection process.

Community Resilience Committees (CRCs)were formed in each village and acted as theprimary interface between the programme andthe community. eir key responsibilities wereto advise on community-specific programmedecisions, identify target beneficiary households,and communicate programme messages to thecommunity (i.e. work and distribution schedules).A Memorandum of Understanding (MOU) out-lining roles and responsibilities was signed be-tween SCI and CRC before the start of the as-set-improvement project. Village committeesincluded men, women and youth. CRCs wereless involved with the IYCF activities, but helpedcommunicate the intention of this part of theprogramme to the community.

e CRCs were trained on targeting criteriaand generated lists of beneficiaries that met thecriteria developed by SCI (see Box 1). SCI wouldaudit the list by randomly selecting 15% ofhouseholds on each list to visit and verify eligi-bility. If there was evidence of systematic errorsin targeting, CRCs were required to start theprocess again. In addition, beneficiary selectioncriteria were displayed throughout the village,which also helped make the process transparent.

Targeting vulnerable households to participatein the FFA project was conducted with the aidof village poverty-ranking indicators in additionto SCI-developed criteria. Roughly 80% of house-holds were selected from each village. Uncon-ditional transfers were provided to those whowere very poor and had no labour to enablethem to participate in the asset-improvementproject. About 10% of the total beneficiary listwas made up of this group. Typically, womenfrom female-headed households did not workon the FFA activities, instead sending male sur-rogates in their place, or were included in theunconditional food-assistance transfers. In somecases, women assisted in providing food andwater during workdays. is practice was inline with local traditions and customs. Roughly18% of beneficiaries were women (see Table 1).

FFA and skills developmentAssets built or rehabilitated by the programmewere identified through broad-based communitymeetings facilitated by CRCs and SCI staff. Eachasset-improvement project, which was endorsedby a majority of the participants and was in linewith the programme’s mandate, was documentedin a village resolution.

One family member from each of the 7,350households was engaged in the asset-improve-ment project. ese family members workedfor ten days a month (four hours a day) toreceive a monthly food voucher for their family.Many of the target population were rural, de-pendent on local, temporary, seasonal incomes;the asset work was another income strategyavailable to them. e value of the voucher wasdesigned to provide a food basket to cover ap-proximately 70% of an average-size family’s foodneeds and could be exchanged with vendors atthe local market at a time of their choosing. Forsome difficult-to-reach villages, vendors wouldhold a market day at a designated distributionsite in the village. e cash value of the voucherwas between US$66 and US$72, depending onthe exchange rate and local commodity prices.Every registered household was entitled to sixtransfers, as per the design of the programme.e six-month period of FFA activities coincidedwith the seasonal lean period, a time when in-come-earning activities are limited; thereforethe effort required of participants to receive as-sistance added to income-earning strategies ata time when the household had excess time toparticipate.

In the first year, the project utilised paper-based commodity vouchers, which were ex-changed for a predetermined food basket by

vendors in local markets. ese vendors werevetted and entered into an agreement with SCIprior to the distribution. In the second andthird years, the programme took part in a pilotMasterCard e-voucher solution. is provideda chip-enabled card loaded with a token that al-lowed beneficiaries to access the same prede-termined food basket as the paper vouchersfrom local vendors. Vendors were equippedwith and trained in the use of tablets and donglesthat worked much like a point-of-sale system.Once beneficiaries satisfied their work require-ments under the FFA programme, a token wasdeposited in their account that could later beexchanged with a vendor for their food items ata time convenient to them. A back-end accountingsystem reconciled the token exchange, whichinformed quantity of payment to vendors. esystem was designed to work on or offline,though most of the time data was synchedoffline. is consisted of SCI programme stafftravelling to vendors to synchronize the trans-action history with another device before re-turning to the field office to upload. e pilotstarted with 100 households and scaled up to6,050 households per month. If necessary, thee-voucher programme could add other tokenswith different vendors to meet the need of otherprogrammes.

With the support and guidance of CRCs,SCI engineers designed asset-rehabilitation spec-ifications. Once the project’s specifications andwork plan were finalised, a bill of quantity de-tailing necessary materials and labour require-ments was signed with CRCs. While the assetproject was underway, SCI engineers providedtechnical backstopping to the CRCs, who mon-itored attendance and quality of work performed.

Quality monitoringTo ensure programme quality, the SCI Moni-toring, Evaluation, Accountability and Learning(MEAL) team followed the project and measuredprogress against pre-identified output indicators.e use of Indicator Performance TrackingTables (IPTT) and Budget versus Actuals (BVA)management tools allowed the programme totake corrective action when projects veeredfrom their plans.

Accountability to the beneficiaries was a keycomponent of the SCI monitoring and qualityassurance system. It involved giving beneficiariesthe opportunity to influence key programmedecisions and highlight problems with pro-gramme activities. In addition to participatingin CRCs, beneficiaries could provide feedbackto SCI on any aspect of the programme througha complaints mechanism. is initially consistedof comment boxes, which were promoted during

1. Households with two or more children under the age of two years

2. Households with more than seven members

3. Households with no livestock4. Households with no or small parcels

(maximum 0.5 acres) of arable land 5. Female-headed households6. Households with a high number of school

dropouts

Box 1 FFA Beneficiary Targeting Criteria

Table 1 Profile of participants in theFFA project

Description 2014 2015

Governorate Male Female Male Female

Dhamar 2,862 800 2,918 511

Sana’a 154 34 69 2

Total 3,016 834 2,987 513

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Vocational skills traineeswith their kits

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the community mobilisation process. In thethird year, SCI introduced a national, toll-freehotline to the complaint mechanism that allowedbeneficiaries another avenue to provide feedback.Each method allowed a person to provide inputanonymously if they so wished. ese mechanismsnot only enabled SCI to deliver a quality pro-gramme; they also empowered the communitiesto participate and address their concerns withthe programme at any time. e complaint mech-anism produced three key issues: inclusion errors,request of information for date and time of dis-tributions, and concerns about food quality. Be-cause these mechanisms were in place, the SCIteam could quickly learn about beneficiary com-plaints and rapidly find a resolution to the issue.

In addition to complaint mechanisms, SCIalso conducted Post Distribution Monitoring(PDM) surveys for all target villages. e surveysinquired about beneficiary’s perception of thedistribution process, security concerns, andknowledge of complaint mechanisms. EachPDM also measures the Household Dietary Di-versity Score (HDDS) and Household HungerScore (HHS). In order to ensure quality in thedelivery of programme outputs, SCI developedquality benchmarks that drew on internationalstandards, such as Sphere, as well as the organ-isation’s global expertise. Regular field visitswere conducted to measure the project’s per-formance against these standards.

Adapting to a changing contextWith the outbreak of fighting in March 2015,Yemen faced large-scale displacement, civil con-flict, food insecurity, high food prices, diminishingresources, and an influx of internally displacedpersons (IDPs). In addition to airstrikes through-out the country, ports, which are crucial for im-porting key commodities such as wheat, cookingoil and petrol, were blockaded by the Saudi-led

coalition. As a result, market supplies quicklydwindled, pushing food prices higher.

Aer the conflict began, Dhamar governoratewas categorised as Integrated Food SecurityPhase Classification (IPC) level 3 (crisis). Nearlyhalf the population in Yemen was food-insecureprior to March, and the situation significantlyworsened as a result of the conflict. At the timeof writing, it is estimated that more than 21.4million people, including three million IDPs,are in need of humanitarian assistance in Yemen.Emergency food assistance became a top priorityin the programme area.

e deteriorating situation in the secondand third year of the programme posed massiveoperational challenges. First, the security situationrequired senior leadership for most internationalorganisations to evacuate to Amman in Jordan,which slowed decision-making processes. Yemenistaff were regularly forced to shelter in placeand unable to visit programme areas due tosafety concerns. With staff periodically immobile,

there was a limited flow of assessment informationfor decision-making purposes. Finally, field op-erations were challenged with shortages of fueland other commodities and destabilisation ofthe Yemeni currency, the rial.

Despite these barriers, rapid assessmentswere still able to take place in accordance withsecurity advisories. Once gathered, informationwas compiled and disseminated in Yemen andAmman. Information was regularly shared withinthe United Nations (UN) cluster system. Fieldteams were frequently tasked with following upon information related to their area of operation.Management provided remote technical back-stopping and addressed all issues as quickly aspossible to ensure the programme moved forward.

It was clear from the assessment informationthat the programme would need to shi itsfocus towards addressing immediate humani-tarian needs and away from resilience-buildingactivities. In order to adapt to growing food-as-sistance needs and the changing operationalcontext, the community asset projects weredropped. It was determined that continuing theFFA portion of the programme would put staffand beneficiaries at risk. As a result, the pro-gramme was redesigned to scale up unconditionalfood assistance to meet the growing need. SCIplanned to reach IDPs and local host communitiesto address their immediate food needs throughelectronic voucher transfers. e resources savedby dropping the FFA component of the pro-gramme allowed the beneficiary caseload to in-crease by about 75%; from 3,500 householdsper year to 6,050 households in the third yearalone. Figure 1 shows the number of householdsthat were assisted before and aer the decisionto change the design of the programme wasmade, in consultation with the donor.

Cash transfers were considered, but the pro-gramme retained the e-voucher scheme becauseit was considered more appropriate with sharpfluctuations in market prices, supply chain dis-ruptions and depreciation of the rial. To facilitatefood assistance in the target programmes, SCIbegan to negotiate directly with national fooddistributors to ensure local vendors were providedwith the required food and timely delivery. eprogramme continued to use the MasterCardsystem, which proved to be agile enough to

Figure 1 Beneficiary household caseload over three years

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Redememption of points

IYCF training - preparationof different types of food

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meet the demands of a rapid scale-up of benefi-ciaries. In fact, having an established electronicfood-voucher programme in place was key tothe programme’s ability to scale up assistance.

Impactrough paper and electronic vouchers, 13,400households (around 93,800 individuals) wereable to receive wheat (50 kg), beans (12 cans),cooking oil (4 litres) and rice (20 kg) on a monthlybasis for at least six months. Perhaps the mostinteresting insight from the programme endlinesurvey is how household vulnerability and hungerchanged during the course of the programme.Endline data showed that the mean HDDS, whichis used as a proxy measurement of household so-cio-economic status, increased by 31% comparedto the baseline. Using the HHS, households withno or little hunger increased by 76%, while severehunger fell to zero. ese improvements in food-security outcomes came despite a major conflictand disruptive markets.

e mean HDDS trend throughout the thirdyear of the programme clearly illustrates howthe emergency assistance supported beneficiaryhouseholds during the course of the programme(see Figure 2). At the time of the baseline, meanHDDS for the beneficiaries in the third year ofthe programme was 3.88. While households re-ceived food assistance (January to June 2016),HDDS scores temporarily elevated to between47% and 51% of the baseline. e endline HDDSmeasurement, which took place one month aerthe last distribution in July 2016, fell to 5.07. Itis unknown how far the HDDS has fallen sincethe end of the programme. While there is noclear cut-off for this measure, the increase inmean HDDS while households were receivingassistance and some lingering effects of elevatedHDDS aer the assistance stopped indicatesthat the food assistance relieved economic pres-

sure and reduced vulnerabilities for the targethouseholds.

It is important to note that each measurementwas taken with a new cross-sectional randomsample of the beneficiary population; thereforesome changes in mean HDDS between eachround of measurements are likely due to samplingvariance. Additionally, the programme wasunable to capture non-beneficiary HDDS scoresto understand the likely impact of the programme.Despite those limitations, a Welch approximationtest showed that mean HDDS between the base-line and endline were not equal: t (1074.4) =13.285; p = 0.001. e boxplot in Figure 3 showsthe difference in the HDDS distributions betweenthe baseline and endline. It is clear from thisplot that the central tendency for the endlinemeasurement of HDDS shied upwards andthe variance was reduced. Levene’s test indicatedthe variance was not equal between the twogroups; p<0.001.

In the first two years, prior to the outbreakof conflict, the community asset-improvementprojects contributed to increased access to waterassets, improved market access through repairedroads, and improved water harvesting throughrepair of agriculture and rehabilitation of terraces.More than 430 asset projects were successfullyimplemented (see Table 2).

During years one and two of the programme,80% of year one beneficiaries and 95% of yeartwo beneficiaries sampled indicated they benefitedfrom the community assets projects, especiallythose related to water and road projects. Sur-prisingly, some beneficiaries from the third yearof the programme who were not in villages thatdirectly benefited from the FFA activities alsoreported that they benefited from the communityasset-improvement projects from previous years.is most frequently happened when roads were

able to link multiple communities to marketsand highways. Eighty-six per cent of those whowere provided with some type of road asset sawan improvement in travel time. All those whoreceived some type of water asset saw improve-ments in agricultural and livestock production.Some beneficiaries asserted that working oncommunity assets gave them an opportunity torecognise the value of cooperation and that theycan replicate similar activities in the future.Finally, both hygiene and breastfeeding educationwere mentioned as an intervention with lastingeffects; 77% of the respondents expect theMTMSGs to continue to function1.

ConclusionsIn March 2015, the conflict in Yemen forcedSCI’s USAID-funded, resilience-strengtheningprogramme in Dhamar and Sana’a governoratesto reassess beneficiary needs and adapt the pro-gramme design to meet a growing humanitariancrisis and changing operational environment.Key challenges during this period included adeteriorating security situation for programmestaff and beneficiaries, rapidly increasing prices,limited commodity supplies and devalued localcurrency. Further, the outbreak in violence re-quired senior management to evacuate the coun-try and limited field staff movement within op-erational areas.

In the face of these challenges, there was stilla window of opportunity to adapt the programmeto the context and provide much-needed foodassistance. As a result, the community asset-improvement activities were replaced with anemergency food-assistance programme thatserved almost twice as many beneficiaries. Mon-itoring data collected throughout this periodshowed a measurable increase in HDDS fortarget beneficiaries and a decrease in the HHS.

Key to the programme’s success was the fieldstaff ’s willingness to leverage its experience andcommunity network to mobilise and gear upbeneficiary selection. e use of MasterCard’selectronic food-voucher programme in the firsttwo years also provided the infrastructure thatallowed for new activities to easily scale up tomeet the programme’s need.

For more information, contact: Mustafa Ghulam,email: Ghulam.mustafa@savethechildren.org1 While baseline and endline IYCF assessments were made,

different methods were used, which has limited comparison.

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Table 2 Assets improvement projects by year

Assets improved Year 1 Year 2 Total

Rehabilitation of terraces (by village) 139 120 259

Road linkages established 2 18 20

Water points established and rehabilitated 0 29 29

Road sections rehabilitated 8 73 81

Water-harvesting channels rehabilitated 2 12 14

Surface water pools rehabilitated 2 31 33

Total 153 283 436

Beneficiaries recievingfood vouchers

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News ......................................................................

Grand Bargain: Reform or business as usual?

Location: Global

What we know: Inadequate resources are a severeand increasing constraint on humanitarian action inthe face of increasing emergencies due to conflicts,natural disasters and disease.

What this article adds: The ‘Grand Bargain’ is apackage of reforms to humanitarian fundinglaunched in May 2016 at the World HumanitarianSummit. It comprises 51 ‘commitments’ to makeemergency aid finance more efficient and effective,endorsed by 34 agencies. It requires innovation,greater efficiencies, more resources and enhancedcollaboration between existing and new partners. Itis estimated to produce annual savings of US$1 bil-lion within five years (5% of current spending). Bothopportunities and limitations have been raised.

IntroductionThe ‘Grand Bargain’ is the name given to a pack-age of reforms to humanitarian funding,launched in May 2016 at the World HumanitarianSummit. A group of 34 representatives of donorsand aid agencies (which together provide the‘lion’s share’ of global emergency aid funding)produced 51 ‘commitments’ to make emergencyaid finance more efficient and effective. TheGrand Bargain is presented as a collective actionto address the shortcomings of under-resourcedhumanitarian response which requires innova-tion, greater efficiencies, more resources andenhanced collaboration between existing andnew partners across the humanitarian ‘ecosystem’.It identifies a need to move from the presentsupply-driven model dominated by aid providersto a demand-driven model more responsive tothe people being assisted. Commitments arepackaged under ten measures/areas for reform.It is estimated that the Grand Bargain agreementwill produce annual savings of US$1 billionwithin five years, which equates with 5% ofcurrent spending.

A recent IRIN3 report suggests the package hashad a mixed reception. Some, like Dutch devel-opment minister Lilianne Ploumen, feel the bu-reaucracies involved did well to agree on somuch in a few short months, given the com-plexities of budgeting and contracting emer-gency aid. Others point to a lack of more specificactions tied into timelines and targets: “It couldbe the Grand Bargain for business-as-usualunless there are more specific actions” (ChristinaBennett, Overseas Development Institute). Theauthor of the review outlines some opportunitiesand limitations around the ten key areas of re-form, including:

1. Greater transparency The pledge is to “publish timely, transparent,harmonised and open high-quality data on hu-manitarian funding within two years”. The In-ternational Aid Transparency Initiative (IATI)data model is likely to be the agreed format.Several major donors already publish at leastsome of their information in this format, whichshould help accountability both upwards tothe donor and downwards to aid recipients.

2. More support and funding tools for local and national responders

Only 0.4% of emergency funding currently goesdirectly to local and national operators, so thetarget of 25% by 2020 is high. Southern NGOswill likely receive more funding, on better terms,but will not easily ‘shake off’ the sub-contractingrelationship with the United Nations (UN) agen-cies and large, international, non-governmentalorganisations (NGOs).

3. Increase the use and coordination of cash-based programming

There are no firm targets for the expanded useof cash, despite studies saying it is now beyondquestion that it works4. According to the author,the Grand Bargain text is contradictory: it claimsthat “using cash helps deliver greater choiceand empowerment to affected people andstrengthens local markets, but remains under-utilised”, while at the same time calling forfurther research to better understand its risksand benefits.

4. Reduce duplication and management costswith periodic functional reviews

The agreement states that “reducing manage-ment costs depends upon reducing donors andaid organisations’ individual reporting require-

ments and oversight mechanisms”. There is ten-sion between donors wanting their granteesto trim costs, and recipient aid agencies blamingdonor bureaucracy for adding to those costs.Donors should ‘harmonise’ boilerplate grantagreements. Aid agencies should commit tobeing more open about their real costs “by theend of 2017” and meanwhile find savings fromsharing costs such as transport, logistics, infor-mation technology (IT) and insurance.

5. Improve joint and impartial needs assessments

Significant efforts have been made to strengthenthe quality and coordination of humanitarianneeds assessments used for strategic decision-making, but critics claim that aid agencies toooften get to define the scale of the problem,pick where they wish to intervene and set theirprice tag. The Grand Bargain tackles only a partof the problem of overlapping and duplicativeassessments; donors and aid agencies are to“provide a single, comprehensive, cross-sectoral,methodologically sound and impartial overallassessment of needs for each crisis to informstrategic decisions on how to respond and fundthereby reducing the number of assessments.”

Summary of commitments1 and review2

1 The Grand Bargain – A Shared Commitment to Better Serve People in Need. Istanbul, Turkey. 23 May 2016. consultations. worldhumanitariansummit.org

2 Is the Grand Bargain a Big Deal? A deal to sort out emergencyfunding meets with a mixed response. By Ben Parker, Head of Enterprise Projects, IRIN. www.irinnews.org/analysis/ 2016/05/24/grand-bargain-big-deal

3 Originally the Integrated Regional Information Networks, IRIN left the United Nations in January 2015 to relaunch as an independent, non-profit media venture. See www.irinnews.org/

4 www.odi.org/projects/2791-humanitarian-cash-cash-transfers-high-level-panel-humanitarian-cash-transfers

President of Turkey Recep Tayyip Erdogan and Secretary-GeneralBan Ki-moon pose with children during the closing ceremony ofthe World Humanitarian Summit, Istanbul, Turkey 2016.

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De-linking assessment from response, for ex-ample by commissioning independent assess-ments, was proposed in earlier drafts but notincluded in the final text.

6. A participation revolution: include people receiving aid in making the decisions which affect their lives

The end customers of aid often have little choiceor influence in the services they get, and feedbackmechanisms so far have had little impact inchanging programme delivery. The agreementinvokes two different sets of guidelines for this,the Core Humanitarian Standard and the Inter-Agency Standing Committee (IASC) Commit-ments to Accountability to Affected Populations.Donors will have to agree that programmescan change as a result of community feedback,while aid agencies have to show how they in-corporate it into their programmes.

7. Increase collaborative, humanitarian, multi-year planning and funding

Aid agencies often find themselves presentingsimilar programmes to donors year after yearthat have no longer-term goals; a process thatwastes time and effort. Most humanitarian find-ing is issued on a 12-month cycle. The GrandBargain target is for five countries to trial multi-year planning and funding by the end of 2017.

8. Reduce the earmarking of donor contributions

Donors typically earmark funds to specific proj-ects, but this can become wasteful and encour-age micro-management. The Grand Bargainsuggests that various types of pooled fundingmechanisms will expand; e.g. the UN’s CentralEmergency Response Fund (CERF) is likely to

rise to US$1 billion a year5. The goal to reduceearmarking is worded without much promiseof enforceability: “The aim is to achieve a globaltarget of 30% of humanitarian contributionsthat are non-earmarked or softly earmarked by2020.” Measurable progress on this will dependheavily on classifications of earmarking.

9. Harmonise and simplify reporting requirements

The text puts more onus on the donors: “simplifyand harmonise reporting requirements by theend of 2018 by reducing [their] volume, jointlydeciding on common terminology, identifyingcore requirements and developing a commonreport structure”.

10. Enhance engagement between humanitarian and development actors

Combining emergency and development fundsand agendas is a hot topic. The text addressesthis: ‘it is about working collaboratively acrossinstitutional boundaries on the basis of com-parative advantage”. The general intent is broad:“use existing resources and capabilities betterto shrink humanitarian needs over the longterm with the view of contributing to the out-comes of the Sustainable Development Goals(SDGs)”. This will need to be the focus not onlyof aid organisations and donors, but also of na-tional governments at all levels and civil societyand the private sector.

ConclusionAccording to the author, two of the ten areascovered – transparency and funding of localand national aid agencies – have gone furtherthan others. On transparency, the Grand Bargain‘group’ committed to publish their financial

data in a common open format within twoyears. Major reform on cash-based aid andneeds assessments did not materialise.

The following donors and aid organisations endorsethe Grand Bargain: Australia, Belgium, Bulgaria, Canada, Czech Re-public, Denmark, European Commission, Germany,Italy, Japan, Luxembourg, The Netherlands, Norway,Poland, Sweden, Switzerland, United Kingdom,United States of America

Food and Agriculture Organization of the UnitedNations (FAO), InterAction, International Committeeof the Red Cross (ICRC), International Council ofVoluntary Agencies (ICVA), International Federationof Red Cross and Red Crescent Societies (IFRC), In-ternational Organization for Migration (IOM),Steering Committee for Humanitarian Response(SCHR), United Nations Children’s Fund (UNICEF),United Nations Development Programme (UNDP),United Nations Entity for Gender Equality and theEmpowerment of Women (UN Women), UnitedNations High Commissioner for Refugees (UNHCR),United Nations Population Fund (UNFPA), UnitedNations Office for the Coordination of Humani-tarian Affairs (OCHA), United Nations Relief andWorks Agency for Palestine Refugees in the NearEast (UNRWA), World Bank, World Food Programme(WFP)

The World Health Organization (WHO) will lead adiscussion on the Grand Bargain commitmentswith its Member States.

5 2015 CERF funding amounted to US$469,650,008. Source: www.unocha.org/cerf/cerf-worldwide/funding-sector/funding-sector-2015

Call for experiences on mothersmeasuring MUAC

Action Against Hunger, in partnership withALIMA, is compiling a lessons-learned docu-ment detailing the use of this approachworldwide, building on the existing evidence(Alé et al, 2016) and guidance (ALIMA, 2016).Evidence from Niger has shown that care-givers are able successfully to measure MUACand are not inferior to community healthworkers (CHW), with children being admittedto care earlier and requiring fewer hospitali-sations. Additionally, this approach has been

shown to cost less to implement than the tra-ditional CHW-led approach.

Since this evidence has been published, mul-tiple implementers have adopted it world-wide. We would like to collect all theexperiences to date from different contexts:how the evidence has been implemented,what works, and the challenges, supportedby case studies. This will be used to guide oth-ers on how to implement the approach andovercome any associated challenges.

If you can contribute to this or know any-one who can, please contact Eleanor Rogersat e.rogers@actionagainsthunger.org.uk byNovember 15 2016.

ALIMA (2016). Mother-MUAC. Teaching moth-ers to screen for malnutrition. Guidelines for

training of trainers. ALIMA. Available in Eng-lish (alima-ngo.org/empowering-mothers-prevent-malnutrition) and French (alima-ngo.org/fr/les- meres-meilleur-atout-pour-prevenir-la-malnutrition).

Alé et al (2016). Franck GB Alé, Kevin P.Q. Phe-lan, Hassan Issa, Isabelle Defourny, GuillaumeLe Duc, Geza Harczi, Kader Issaley, SaniSayadi, Nassirou Ousmane, Issoufou Yahaya,Mark Myatt, André Briend, Thierry Allafort-Duverger, Susan Shepherd and Nikki Black-well/Mothers screening for malnutrition bymid-upper arm circumference is non-inferior tocommunity health workers: results from alarge-scale pragmatic trial in rural Niger.Archives of Public Health (2016) 74:38. arch-publichealth.biomedcentral.com/articles/10.1186/s13690-016-0149-5

Are you using the mothers measuringmid upper arm circumference (MUAC)approach or do you know someone whois? If so, we want to hear from you!

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AuthorAID: A global network forearly career researchersfrom low and middle-income countriesBy Jennifer Chapin

Jennifer Chapin is Programme Manager, Research andCommunications at INASP, an international developmentcharity based in Oxford, UK. INASP works with a globalnetwork of partners in Africa, Latin America and Asia tosupport individuals and institutions to produce, share and useresearch and knowledge. Projects are running in 28 countries.

“…being an AuthorAID mentorgoes beyond a conventional

teacher-student relationship – it isa really stimulating and

worthwhile learning process forboth mentee and mentor”

Dan Korbel, UK

“My experience with AuthorAIDhas been great! rough the

AuthorAID website, I met mymentor, a PhD student at the

University of Michigan. She hasbeen very dedicated in offeringme guidance on how to improve

my writing skills”Rhoune Ochako, Kenya

Researchers in the developing worldhave long been under-representedin published research. This is not ahuge surprise. They face many of

the same intense pressures to publish as aca-demics in the UK, yet they lack access to thefundamental resources needed to communi-cate their research: information and training,writing support and mentorship. How canthey manage the pressure of publishing rig-orous scientific research and communicatingfindings in a way that meets publisher expec-tations?

In order to address some of these issues, theAuthorAID programme (www.authoraid.info)was launched in 2007 by the Oxford-based or-ganisation INASP (www.inasp. info) to supportresearchers in low and middle-income coun-tries to publish and communicate their work.It also serves as a wider global forum to dis-cuss and disseminate research.

One of the cornerstones of AuthorAID is apopular online mentoring system (www.au-thoraid. info/en/mentoring) that allows vol-unteer mentors to use their crucial skills andexperience to guide less experienced re-searchers through the challenges of publish-ing and communicating their research. Sincethe platform was set up in 2008, requests formentoring assistance have intensified, andmentors are in demand. The platform is opento researchers from all subject areas and cur-rently comprises almost 2,000 active mentorsand mentees. Support is available in a num-ber of languages, including English, Frenchand Spanish.

The mentoring system helps pair togetherexperienced mentors with researchers whoneed support at any stage of their writingproject. It is easy to make contact with men-tors or mentees: we have a ‘find a researcher’search facility and our mentoring dashboardwill automatically suggest suitable ‘matches’based on subject and skills – rather like a dat-ing website for researchers!

Fifteen of the most common types of sup-port needed by new mentees include:• Writing

• Article planning• Proofreading• Grant proposal development• Language editing or proofreading

support• Career mentoring• Theses and dissertation writing• Literature reviews• Study design• Statistics• Presentation planning• Responding to peer review• Publication ethics• Technical reports• Dealing with the publishing process

Over the years, AuthorAID has amplified itsscope to provide support to researchers in anumber of other ways: • One primary aim is to embed research

writing skills training in universities and re-search institutes, with the objective of building local training capacity face-to-face and online. We are currently workingwith ten partners in four countries: Ghana, Tanzania, Sri Lanka and Vietnam.

• In recent years, AuthorAID has launched free Massive Open Online Courses (MOOCs) in research writing. So far, thesecourses have attracted over 2,800 re-searchers from 76 countries (www.authoraid.info/en/e-learning).

• Small grants to host workshops and travel

to conferences are offered twice annually (www.authoraid.info/en/funding).

• Over the last year, AuthorAID has focusedon supporting women in research to ad-dress gender inequalities they face in progressing in their careers. AuthorAID has recently produced a Gender Main-streaming in Higher Education Toolkit(available online soon), which is hoped will be a valuable resource for universitiesand institutions tackling gender inequal-ity in academia.

• AuthorAID also provides training materi-als and resources free of charge online. Resources are available in English, Arabic,Chinese, French and Spanish(www.authoraid.info/en/resources).

• An increasing number of our members also provide informal mentoring, advice and support by replying to questions about publishing on the Discussion Group, now numbering over 2,300 members.

Whether you’re an early career researcher ina developing country who could benefit fromsupport and mentoring, an established aca-demic with a strong track record who wantsto give something back to the research com-munity, or are just keen to get involved insome stimulating discussions, you can easilyregister now on the AuthorAID website atwww.authoraid.info.

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Indonesian researchers involved in theAuthorAid programme

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Saul Guerrero is the Director of Nutrition atAction Against Hunger UK (ACF UK). Prior tojoining ACF, he worked for ValidInternational supporting UN agencies, NGOsand national governments in the design,implementation and evaluation ofcommunity-based management of acute

malnutrition interventions in over 16 countries in Africa andAsia. In 2012 he co-created the Coverage Monitoring Network(CMN), an inter-agency initiative to evaluate the reach ofnutrition services worldwide.

Erin Boyd is a Nutrition Advisor andinstructor with experience in emergencynutrition response and covers policy,programme management, monitoring andevaluation, coordination and operationalresearch. She has worked in nutritionsurveillance, emergency nutrition

interventions, and coordinated responses in locations such asDarfur, Ethiopia, Haiti and Pakistan. She has also worked withdonors and at the Friedman School of Nutrition Science andPolicy at Tufts University.

Claire Harbron is a Manager at the Children’sInvestment Fund Foundation. She overseesCIFF’s strategy and programme portfolio onthe prevention and treatment of severe acutemalnutrition.

Diane Holland is Senior Nutrition Advisor atUNICEF New York and has a focus on scalingup programming to treat severe acutemalnutrition and addressing nutritionemergencies. She has over ten years’experience in public nutrition, includingsupport to nutrition surveillance in Sudan,

nutrition policy in Afghanistan, and technical support in large-scale emergencies such as Typhoon Haiyan in the Philippines.

Abigail Perry is acting Nutrition Team Leaderat the Department for InternationalDevelopment, UK. A nutritionist withextensive experience in development andemergency work, Abi has previously workedin a variety of technical roles for differentNGOs and as a Research Associate at UCL.

Sophie Whitney is working as a GlobalNutrition Expert for the EuropeanCommission Humanitarian Aid and CivilProtection (DG ECHO). She has extensiveexperience in nutrition, having worked forover 15 years in both headquarters and fieldpositions in programme design, monitoring

and implementation. In her current role she is monitoringinnovation and informing the nutrition policy to ensure aidefficiency in humanitarian crises.

The last decade has been one of the most exciting in the global ef-forts to treat Severe Acute Malnutrition (SAM) at scale. In that pe-riod, we have seen a community-based model to treat SAM gofrom a small-scale but innovative pilot to a large-scale intervention

in over 70 countries worldwide. We have seen the availability of revolution-ary, ready-to-use therapeutic foods (RUTF) increase, with reductions in costand a wider range of producers at global, national and regional levels. Thishas led to a rise in the number of SAM children accessing life-saving treat-ment worldwide from just over one million in 2009 to over three million in2014. And all of these changes have occurred against a backdrop of increas-ing political support for addressing malnutrition worldwide, through plat-forms like the Scaling-Up Nutrition (SUN) movement and the formal inclusionof wasting as a key target in both World Health Assembly (WHA) and Sus-tainable Development Goals (SDG).

When we take stock of these and other achievements, we feel optimisticabout the future. But we also know that the job is far from over. Nutrition-sensitive investments and programmes are on the rise, yet the evidence basefor the prevention of acute malnutrition, in particular, remains limited andoften inconclusive, hampering efforts to effectively link prevention and treat-ment efforts. The number of children accessing treatment has tripled in justfive years, but is beginning to stagnate; today only one in every five childrensuffering from SAM has access to treatment, leaving the large majority ofthose affected at increased risk of mortality from associated illnesses.

This has to change, and the nutrition community, together with col-leagues across health and other sectors, needs to do whatever it takes to en-sure that a higher proportion of children have access to effective treatment.No single approach or solution will be sufficient and critical challenges acrossnutrition programming, policy and financing will need to be addressed.

Programmatically, community-based approaches for treating SAM mustcontinue to be integrated into health systems and basic emergency pack-ages. To do so, the specific measures required for these efforts to fully suc-ceed need to be identified. For us, there are five key elements that must beat the heart of these efforts:1. Ensure that prevention and treatment of wasting is situated in all

child survival packages. As the drive to address childhood illnesses together continues, SAM cannot continue to be addressed in isolation. Its prevention and treatment must be formally and officially integrated in child survival packages once and for all.

2. Maintain the focus on home-based models of care. Outpatient approaches need to be formally integrated into national guidelines in all countries. The boundaries of service delivery models need to be pushed to ensure that services are accessible and equitable, includingfor those living in hard-to-reach areas.

3. Modify and expand the ways in which SAM is diagnosed. The way children suffering from SAM are identified must be simplified to enable a wider range of individuals (starting with the caretakers themselves) to find them and do so early.

Accelerating thescale-up oftreatment for severeacute malnutritionBy Saul Guerrero, Erin Boyd, Claire Harbron,Diane Holland, Abi Perry and Sophie Whitney

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Girls at a clinic inBossaso, Somalia

WFP/Laila Ali

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4. Optimise the specifications and dosage ofspecialised nutritious foods. To make sig-nificant improvements in the cost-effective-ness of treatment, efficiencies and im-provements in the way these products are made, what they contain and how much of it is used in the treatment of SAM must continue to be pursued.

5. SAM information must be consolidated and made widely available. Today, critical information about the context-specific fac-tors that lead to acute malnutrition, the scale of the problem and the performance of the services dealing with acute malnutri-tion is either missing or inaccessible. As theGlobal Nutrition Report has high-lighted, greater investments in SAM information, and the right platforms to make this infor-mation easily accessible to those who needit, are urgently needed.

Addressing these and other questions will re-quire investment in innovative and bold ideas,and the capacity to generate evidence andidentify what works in a timely manner, so thatinnovations can be mainstreamed in years, notdecades.

The challenge of SAM treatment scale-upmight often be defined in programmatic terms,but the solutions are, more often than not, po-litical. At a time when the nutrition movement

is gathering pace, the issue of SAM is often lostin policy debates at a global level and fails to beincluded in national nutrition targets. To makeSAM a political and public health priority, thenutrition community must do what we haverecognised for years: get out of the echo cham-ber and start engaging consistently and activelywith the wider public health community. Doingthat will require us to be clear about what wewant to see happen, in concrete terms, and toensure that the benefits of putting SAM intochild survival policy and practice are made ex-plicit. This conversation is particularly critical atnational level, for it is there that the impact ofscaling-up SAM treatment will ultimately bemost profound. Repositioning SAM as a key as-pect of accelerating child survival will be abouthigh-level dialogue, but it will ultimately beabout translating dialogue into action andmeasurable commitments.

Delivering SAM treatment at scale will comeat a cost. The recent projections made by theWorld Bank, Results for Development, 1,000Days and others, have generated valuable in-sights into exactly how much will be needed todeliver SAM treatment at scale ($1.8 billion ayear) and how much is currently being madeavailable ($450 million in 2014). Addressing thedeficit will require a step-change and the ca-pacity to integrate SAM treatment into non-emergency, long-term funding streams

including (but not limited to) health financing.It will also require a gradual but sustained com-mitment from national governments to includeSAM treatment costs into multi-year healthbudgets. Business, private sector companiesand foundations also have a critical role to play,but in different ways to national governmentsand bilateral donors. Determining the addedvalue of each in covering different componentsof treatment services (e.g. commodities, re-search & development and health system-re-lated costs) will be the key to optimising thecontributions of each actor and getting uscloser to the mark.

And when all is said and done, that is ourlasting answer: to unlock the global and na-tional challenges we will need to bring our dif-ferent skills, knowledge, geographical reachand diverse networks to bear on this very press-ing problem. Only if efforts are coordinatedand dialogue sustained on the opportunitiesand challenges we face, will we maximise theinfluence and impact we can leverage, andbring others on board to drive change. In this,the UN-designated Decade of Nutrition, weneed to ramp up and coordinate our collectiveefforts to tackle severe acute malnutrition,thereby unlocking the wider benefits for childhealth and global development.

Watch this space…www.nowastedlives.org

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Global School Feeding Sourcebook: Lessons from 14 countries

The Global School Feeding Sourcebook: Lessons from 14countries was produced in response to demand from gov-ernments and development partners for guidance on de-signing and implementing large-scale, sustainable,

national school-feeding programmes that can meet globally ap-proved standards. The Sourcebook documents and analyses gov-ernment-led school-feeding programmes to providedecision-makers and practitioners worldwide with the knowledge,evidence and good practice they need to strengthen their nationalschool-feeding efforts.

Based on high-level collaboration with government teams from14 countries (Botswana, Brazil, Cabo Verde, Chile, Côte D’Ivoire,Ecuador, Ghana, India, Kenya, Mali, Mexico, Namibia, Nigeria andSouth Africa), the Sourcebook includes a compilation of concise andcomprehensive country case studies. Programmes are examined interms of Five Quality Standards that are needed for school-feedingprogrammes to be sustainable and effective. These standards in-clude: design and implementation; policy and legal frameworks; in-stitutional arrangements; funding and budgeting; and communityparticipation. The review highlights the trade-offs associated withalternative school-feeding models and analyses the overarchingthemes, trends and challenges that run across them.

The Sourcebook is free to download at www.hgsf-global.org andwww.wfp.org

School feedingprogramme in

Odisha, India

WFP

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The missing ingredients: Are policy-makers doing enoughon water, sanitation and hygieneto end malnutrition?

IntroductionEvidence shows that scaling up interventionsthat tackle the immediate causes of malnutri-tion is insufficient to overcome the challenge.A more comprehensive ‘recipe’ requiring a mixof ‘ingredients’ from multiple sectors is criticalto address both the immediate and underlyingcauses of malnutrition.

A report from SHARE (Sanitation and Hy-giene Applied Research for Equity) and Wat-erAid highlights why water, sanitation andhygiene (WASH) are essential for nutrition. Anestimated 50% of undernutrition is associatedwith infections caused by poor WASH, con-tributing to 860,000 preventable annualdeaths in children under five years of age. Evi-dence from a number of trials and observa-tional studies has identified three biologicalmechanisms linking WASH to undernutrition,including repeated bouts of diarrhea, intes-tinal parasitic infections and environmentalenteric dysfunction (EED). There may be otherimportant WASH-related social and economicpathways.

Growing evidence of the links between nu-trition and WASH has contributed to buildingmomentum for better coordination, collabo-ration and integration. However, the defini-tions that different sectors, individuals andorganisations use for ‘integration’ vary consid-erably along a continuum. This ranges fromvery minimal coordination and collaborationon one side through to a more closely inte-grated and jointly delivered programme onthe other.

Through an analysis of both nutrition andWASH plans and policies in 13 Scaling Up Nu-trition (SUN) countries (Bangladesh, Kenya,Liberia, Madagascar, Malawi, Mozambique,Nepal, Rwanda, Sierra Leone, Tanzania, Timor-Leste, Uganda and Zambia), the report evalu-ates the degree to which national strategies inboth ‘sectors’ are integrated. It identifies gapsin coordination and ways of working, andwhere and how improvements must be made.

MethodCountries selected for analysis were based onSHARE’s focus countries and WaterAid’s countryprogrammes, for which national, multi-sectornutrition action plans or strategies were freelyavailable online. National, multi-sector nutritionaction plans were the primary focus of analysis,

although national nutrition policies were alsoreviewed for a comprehensive picture. Pre-de-fined criteria used for reviewing action plans in-cluded: • Is WASH recognised as an underlying and

important factor in nutrition?• Are all three components of WASH

mentioned? • Is there a budget outlined for WASH

activities?

In addition, a keyword search of nutritionterms in the national WASH plans and policiesof the 13 countries was conducted to allow fora basic assessment of whether the plans in-clude nutrition considerations.

Key findingsWASH into nutrition varies widely. All the nu-trition plans and policies that were analysedrecognise the importance of WASH; however,the degree to which WASH is embeddedwithin plans varies significantly across coun-tries in terms of objectives, targets, interven-tions and indicators (Nepal and Timor-Lestehave the strongest plans in terms of embed-ding WASH components).

Nutrition into WASH is limited. Very fewWASH plans reference nutrition or identify op-portunities to integrate with nutrition andhealth programmes and campaigns (with theexception of Liberia).

Limited budget informationOf the plans analysed, a detailed budget foractivities was not generally included in thesame document, limiting the ability to capturethe budget for WASH activities. Where budgetwas available, this was provided at the level ofthe objectives or priority areas and not by ac-tivity; thus a detailed costing analysis was notpossible within the scope of this research.

One size does not fit all. There is no singleblueprint for how WASH should be embeddedin nutrition plans, nor for how WASH pro-grammes can be made more nutrition-sensi-tive. However, consideration of some keyprinciples and approaches could help driveprogress. For example, designing WASH pro-grammes to target populations most vulnera-ble to nutrition and/or identifying opport-unities to integrate activities such as those re-lated to behaviours (e.g. personal and food hy-giene and breastfeeding) could result in morejoined-up approaches.

Continuum approach. Working togethershould be considered along a continuum, withdifferent degrees or approaches to collaboration.is may range from simply sharing informationand targeting different programmes to the samepopulations to a more integrated programme,involving the same staff and a single budget.

Challenges in working together. Inherentdifferences in the objectives, outcomes of in-terest and people involved in delivering nutri-tion and WASH programmes present a numberof challenges to working together. Unlikethose responsible for nutrition, the WASH sec-tor is not dependent on nutrition action forachieving its primary objectives. However,both nutrition and WASH policy-makers sharea common vision and goal of improvinghealth, and evidence shows that public healthaims have been a key driver of investments inWASH, particularly sanitation. Working to-gether can also leverage investments acrossthe two sectors to maximise health impact andimprove cost-effectiveness. Plans and policiesare a core part of the process of outlining themechanisms and systems required to allowmore cohesive working to advance nutritionand WASH goals.

The report uses findings from the analysis,along with existing evidence and lessonslearned to date, to provide insights into thedifferent ways of working to enhance nutritionand WASH coordination and collaborationacross different stages of the policy cycle.

RecommendationsAccording to the report, comprehensive na-tional nutrition plans are a critical first step to-ward ending malnutrition by 2030, but theymust include all three WASH ‘ingredients’.Moreover, these plans should be underpinnedby sufficient financing, effective coordination,timely tracking of results and stronger institu-tions. The report makes specific recommenda-tions on how partners – governments, UNagencies, donors, technical agencies and inter-national NGOs and academics – can play theirpart to ensure an integrated approach to end-ing malnutrition.

An infographic on how well water, sanitationand hygiene are integrated into national pro-grammes is available at: www.wateraid.org/uk/what-we-do/policy-practice-and-advo-cacy/research-and-publications

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Nutrition funding: The missing piece of the puzzle

The 2016 N4G summit in Rio de Janeiro didnot turn out to be a pledging summit, as hadoriginally been envisaged. The Generation Nu-trition campaign is calling for the next high-level nutrition funding summit to beannounced immediately and for all stakehold-ers to step up and pledge ambitious andSMART (Specific, Measurable, Achievable, Rele-vant and Time-bound) financial commitments.At this next summit, they want donors to agreeto a doubling of global aid to nutrition by 2020,and for southern governments to agree to in-crease their budget allocated to nutrition, start-ing with (but not restricted to) the health sector.

RecommendationsRecommendations made in the report are inline with priorities from states and other donorswho are part of the N4G initiative. They relateto measures which, if implemented, would helpeither to increase nutrition funding or to im-prove the impact of existing programmes.

All international donors• To identify quickly a date and occasion for

a new, high-level, pledging summit on nu-trition, working together with southern countries.

• To ensure that the promises made at N4G 1are fulfilled by keeping spending up to 2020 ‘on track’.

• To go further and commit to a doubling of global aid for nutrition, to be achieved by 2020 and based on a verifiable baseline fig-ure (for instance, 2014 spending). A signifi-cant share of the increase should be for life-saving, nutrition-specific interventions.

• To improve the nutritional impacts of aid channelled to agriculture, education, health, water and sanitation, and social protection. This can be done by ensuring

that programmes include objectives on, and intended outcomes for, nutrition and that aid is targeted towards those most at risk of undernutrition.

For southern countries• To support the inclusion of dedicated

budget lines for nutrition within national health budgets.

• To raise the level of government expendi-ture in key nutrition-sensitive sectors, such as health, education, agriculture, water andsanitation, and social protection, and con-tinue developing systems that can guaran-tee a minimum level of investment in nutri-tion (3% of national budgets).

For all stakeholders• To announce measures to strengthen inter-

national, innovative, financing mechanismsand funds for nutrition. One example is UNITLIFE, an initiative for combating un-dernutrition, based on small-scale levies in the extractives sector (www.unitlife.org). The initiative is expected to generate US$115 million a year in its initial phase. Mali was the first country to contribute, with a levy of 10% per gram of gold sold. Another example is the Power of Nutrition (www.powerofnutrition.org); allocations totalling US$200 million have been made.

• To ensure that any new financial pledges are developed in a way that is SMART and makes their delivery easy to assess. For instance, all the money committed should represent additional spending.

1 Nutrition Funding: the missing piece of the puzzle. A Generation Nutrition briefing paper. June 2016. www.generation-nutrition.org/sites/default/files/editorial/ missing_piece_of_the_puzzle.pdf

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Arecent report by Generation Nutri-tion, a coalition of 85 civil society or-ganisations, describes both whyfunding matters to nutrition and

the current situation with regard to donor fund-ing and domestic resources. The report calcu-lates that, at the current rate of progress,countries will miss the 2025 World Health As-sembly (WHA) targets on stunting and acutemalnutrition by a significant margin (see Table1), let alone the more ambitious Sustainable De-velopment Goals (SDGs). Increasing funding isessential if these and the other global nutritiontargets are to be met on time. Progress in meet-ing the WHA stunting and wasting targets arerespectively 20 and five years behind schedule.

In 2013, the UK hosted the Nutrition forGrowth (N4G) event, a high-level summit result-ing in over US$23 billion pledged to improvenutrition up to 2020. This was a substantialcommitment, but ultimately not enough to endmalnutrition in all its forms, as promised byworld leaders. The report by Generation Nutri-tion describes the ‘London Legacy’ as present-ing challenges in relation to theimplementation of the deal; for example, of theeight donors who supplied data on nutrition-specific and nutrition-sensitive aid spending in2013, only 64% of the aid pledged for that yearwas actually disbursed. Moreover, the 2015Global Nutrition Report, which tracks N4G com-mitments, revealed that 13 donors were spend-ing either less than US$1 million per annum ornothing at all on nutrition-specific pro-grammes. Furthermore, only a relatively smallshare of donor budgets in supposedly nutri-tion-sensitive sectors is being targeted directlyat improving nutrition – 3% out of 21% spendon health agriculture, WASH (water, sanitationand hygiene) and education.

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Breastfeeding advice session, Ethiopia

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News

Biofortification:Helping meet nutritionneeds worldwideBy Dr Erick Boy, Nutrition Head, HarvestPlus

Dr Erick Boy is a public health practitioner and has a doctoral degree innutrition from University of California, Davis. He currently heads theHarvestPlus nutrition programme, overseeing dietary intake andnutritional status surveys, as well as food science and epidemiologicresearch required to assess the nutritional merits of biofortification inSub-Saharan Africa and South Asia. Before joining HarvestPlus he workedas chief scientific adviser at the Micronutrient Initiative (1999-2008).

Content for this article was secured by Charulatha Banerjee, ENN Regional KnowledgeManagement Specialist (Asia).

Location: Global, India

What we know: Micronutrient deficiency is common in populations that relyprimarily on staple foods; poor, rural communities are particularly affected.

What this article adds: Biofortification is the process of increasing the density ofvitamins and minerals in a crop through plant breeding and agronomic practices, sothat when consumed regularly the crops will generate measurable improvement invitamin and mineral nutritional status. HarvestPlus is a global partnershipprogramme that leads the global development and promotion of biofortified crops,involving crop development, work with policy-makers and engagement withcommunities. Biofortified crops can provide 30% to 80% of a woman’s or child’s dailyneeds of vitamin A, zinc and iron (key focus nutrients). Evidence is emerging onnutrition and health impact. Developments in India are promising for biofortificationat scale. Biofortification now reaches more than 15 million people in Africa and Asia;new crop varieties are available/pending release in 55 countries.

Micronutrient deficiency is usuallythe result of consumption of mo-notonous plant-based diets com-posed predominantly of a starchy

staple food (cereal, roots/tubers), which resultsin a lack of essential minerals and vitamins re-quired for proper growth and development ofthe body. When large segments of a populationare affected by micronutrient deficiency, theirhealth and economic development are curtailed.

Biofortified staple crops rich in micronutri-ents are most beneficial to groups who are vul-nerable to micronutrient deficiencies, especiallyinfants, young children and pregnant andbreastfeeding women. Deficiencies in micronu-trients such as zinc, iron and vitamin A cancause profound and irreparable damage to thebody, including blindness, growth stunting,mental retardation, learning disabilities, lowwork capacity and even premature death.

Biofortification can help in the prevention ofmicronutrient deficiencies. Biofortified crop va-rieties will eventually provide from 30% to 80%of a woman’s or child’s daily needs, dependingon the nutrient and the amount of the bioforti-

fied food consumed regularly. Biofortificationtargets in particular the rural poor, who aremore vulnerable to the underlying causes ofundernutrition and consume large quantities ofstaple foods, often with little else.

HarvestPlus is a global partnership pro-gramme that leads the global developmentand promotion of biofortified crops (see Box 1).Together with local farmers and researchers,HarvestPlus develops and promotes staplecrops that are climate-smart, high-yield andpacked with micronutrients. HarvestPlus alsoworks with policy-makers to develop pro-grammes to promote the crops, and with com-munities to take the crops ‘from fields to meals’.

Origins of biofortification:Intersection between nutritionand agricultureTraditionally, economists believed that energyintake was the primary dietary factor constrain-ing better nutrition outcomes in developingcountries. This was the underlying premise ofthe ‘Green Revolution’ which, in the late 1960s,allowed farmers to increase their agricultural

output of mainly cereal grains such as rice,maize, and wheat. However, research by DrHowarth Bouis, an economist at IFPRI andfounder of HarvestPlus, found that vitamin andmineral intake in non-staple foods and animalproducts is more highly correlated with healthoutcomes. Making staple foods – on whichpoorer, rural communities were so dependent– more nutrient-rich could therefore contributeto addressing so-called ‘hidden’ hunger. This in-tersection between nutrition and agricultureled to biofortification, a movement that hasbrought ministries of health and agricultureunder one roof (although it took two decadesto achieve this). In many HarvestPlus targetcountries, these two ministries are coordinatingclosely to enable biofortification.

Biofortification in practiceConventional plant breeding is not new. Earlyfarmers chose the best-looking plants and seedsand saved them for next year’s planting. As thescience of genetics became better understood,plant breeders were able to select certain desir-

HarvestPlus began as a research (‘challenge’)programme of the global research partnershipCGIAR (www.cgiar.org). It is coordinated by twomembers of the consortium, the InternationalFood Policy Research Institute (IFPRI) and theInternational Centre for Tropical Agriculture(CIAT). In addition to IFPRI and CIAT, HarvestPlusworks with more than 200 scientists, researchersand other experts around the world, workingclosely with scientists from International Maizeand Wheat Improvement Centre (CIMMYT),International Institute of Tropical Agriculture(IITA), International Crops Research Institute forthe Semi-Arid Tropics (ICRISAT), and theInternational Potato Centre (CIP) to select andbreed biofortified crops. HarvestPlus nutritiongenerates the research required to consolidatethe case for single-nutrient crops and extend itsproof-of-concept approach to traditionalcombinations of biofortified crops.

Box 1 About Harvest Plus

Eliab Simpungwe, Harvest Plus, 2012

Vitamin A fortified maize

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News

able traits in a plant to create improved varieties.All the nutritious crops released or in the nearpipeline through the efforts of HarvestPlus andits partners were or are being developed usingconventional plant breeding.

Farmers do not have to make changes togrow biofortified crops. After the initial outlayof funds for development of the biofortifiedcrops, the recurrent costs are minimal. Advan-tages are many: biofortification is built on whatpoor households, who likely have no access toor cannot afford commercially marketed forti-fied foods grow and eat (staple); there is a one-time-only investment to develop seeds thatfortify themselves (which keeps recurrent costslow); the germplasm (the living tissue fromwhich plants can be grown) can be shared glob-ally; and biofortification produces higher yieldsin an environmentally friendly way.

In most cases, farmers will be able to savetheir seed and replant it, or grow new plants

from stem and root cuttings. Many crops, suchas sweet potato, cassava, pearl millet and beans,can be replanted every year from plant cuttingsor seed that the farmer has saved. In the case ofhybrids, farmers usually purchase fresh seed foreach planting season in order to maintain highproductivity. Biofortified nutritious crops arebeing made available as public goods to na-tional governments. Wherever these seeds aretypically sold in markets, they are competitivelypriced so that subsistence and smallholderfarmers can afford them. In the long run, thecost difference between these seeds and non-biofortified varieties should be negligible.

HarvestPlus approachHarvestPlus focuses on three crucial micronu-trients that are most limited in the diets of thepoor: vitamin A, zinc and iron, and breed theseinto key staple crops. Thousands of differenttypes of crop seeds stored in seed banks thathave naturally higher amounts of iron, zinc andvitamin A are screened. Nutritional genomicistsuse tools such as marker-assisted selection tohelp speed up the breeding process. Harvest-Plus uses these more nutritious seeds to breednew crop varieties with higher micronutrientcontent that are also high-yielding and haveother traits farmers want.

These new varieties are tested in the targetregion, partnering with farmers to ensure buy-

in from the farming communities. Studies areconducted to ensure that these new crops havesufficient amounts of the nutrient needed to im-prove nutrition. The national government thenofficially releases the best-performing varietiesof micronutrient-rich crops for farming commu-nities to grow, eat and sell in local markets.

Experiences from IndiaThe future of biofortification in India lookspromising (see Box 2). The 2013-2014 budget inIndia allocated funds equivalent to 40 million USdollars to develop farms growing micronutrient-rich crops, reflecting India’s plan to develop‘nutri-farms’ where iron-rich pearl millet, zinc-rich rice and wheat, and protein-rich maize willbe grown. India’s strong scientific infrastructureis an asset in developing biofortified crops, whilethere are sophisticated marketing networks ofseed companies that are essential to dissemi-nate these crops. Policy-makers and other stake-holders are key targets of evidence generatedon the nutritional benefits of biofortified cropsand how this food-based approach can be effec-tive in improving nutrition on a large scale.There are also ongoing efforts to leverage pri-vate and public sector partners and work outways to mainstream biofortified crops in India.

Evidence of nutrition impactWith more people and countries adopting bio-fortified crops globally, evidence is emerging onthe nutritional and health impact of these crops.Over the last few years, leading scientific journalshave published studies that demonstrate the ef-ficacy of biofortified crops (see Box 3). Nutritiondata demonstrates that biofortified foods can re-verse iron deficiency and reduce the incidenceand duration of diarrhoea, one of the leadingcauses of preventable death in children underfive years old. A small daily ration of orangesweet potato is enough to provide a young childwith his/her daily vitamin A requirement.

CostThe 2008 Copenhagen Consensus, comprisingthe world’s leading economists, estimated thehealth benefit-to-cost ratio of biofortified nutri-tious crops as US$17 of benefits for every dollar

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In India, HarvestPlus and its partners aredeveloping new varieties of rice and wheat withincreased amounts of zinc (and iron) and pearlmillet with increased iron (and zinc) usingconventional breeding. While there is a one-timecost fixed to developing these nutrient-richvarieties, which are also high-yielding, they can begrown by farmers and consumed year after yearalongside other traditional foods.

Pearl millet is eaten daily by more than 50 millionpeople in the semi-arid regions of India. The iron-rich pearl millet variety was developed inpartnership with the ICRISAT in India. Throughpartners Nirmal Seeds and Shakti Vardhak, some140,000 farming households were reached with

Box 2 Developments in India

A 2015 study found that vitamin A-rich orangesweet potato (OSP) reduced both the prevalenceand duration of diarrhea in young children inMozambique (Hotz et al, 2012).

In India, pearl millet bred to be richer in iron wasable to reverse iron deficiency in school-agedIndian children (Finkelstein et al, 2015).Previously, the same iron-rich pearl millet hadbeen shown to provide iron-deficient Indianchildren under the age of three with enough ironto meet their daily needs, and to provide adultwomen in Benin with more than 70 per cent oftheir daily needs (Kodkany et al, 2013).

A study from Rwanda found that dailyconsumption of meals with beans bred to bericher in iron helped prevent and reverse irondeficiency in women in just four and a halfmonths (Haass et al, 2016).

In Zambia, switching to orange maize, which isrich in beta-carotene, provided maize-dependentpopulations with up to half their daily vitamin Aneeds. In a controlled efficacy study, children whoate vitamin A maize showed significant increasesin their total body stores of vitamin A (Gannon etal, 2014). There is also evidence that maize thathas been bred to have higher zinc content canprovide enough zinc for a growing child in theirformative years (Chomba et al, 2015).

Box 3 Selection of published evidenceof nutrition impact

iron pearl millet seed in 2015. That included over340 metric tons of the open-pollinated varietyDhanashakti and 13 metric tons of the hybridvariety Shakti-1201. Cumulatively, more than onemillion people across four states (Maharashtra,Rajasthan, Uttar Pradesh and Haryana) haveaccessed iron pearl millet in the three years sincethe first variety was released. For wheat-producingstates, four zinc-rich varieties have beendistributed to 35,000 farming households, thanksto partnerships with various seed companies.Farmers in the states of Uttar Pradesh and Biharreceived and planted 350 metric tons of zinc wheatseed produced through Astha Beej Co, Sood Foods,Said Seeds and Shakti Vardhak.

Vitamin A cassavacompared with a less

nutritious white version

Harvest Plus, N

igeria, 2012

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Newsinvested. Once a particular micronutrient isbred into a crop line, the trait remains. Thismakes the process of biofortification, over time,sustainable and cost-effective.

A very simple cost comparison betweensupplementation, fortification and biofortifica-tion was done by HarvestPlus researchers. Theyfound that one year of vitamin A supplementa-tion for 37.5 million pre-school children inBangladesh, India and Pakistan can be boughtfor US$75 million. The same amount can buyenough iron fortification for one year for thesame populations. It is also the cost of developingand disseminating iron and zinc-rich rice and

wheat varieties for South Asia, which will be avail-able year after year without much investment.

ConclusionsBiofortification is an approach to preventingmicronutrient deficiency that is sustainable andscalable: it now reaches more than 15 millionpeople in initial focus countries in Africa andAsia. Cumulatively, more than 100 biofortifiedvarieties across ten crops have been released in30 countries, where second and third waves ofeven higher nutrient lines are being tested forfuture release. Candidate biofortified varietiesacross 12 crops are being evaluated for releasein an additional 25 countries. The goal is to

reach 100 million people with biofortified nu-tritious foods by 2020 and one billion peoplewith biofortified foods by 2030.

It is a nutrition-smart agricultural interven-tion supported by robust scientific evidencedemonstrating that regular consumption of tra-ditionally cooked biofortified food crops im-proves the nutritional status of the mostvulnerable groups: rural and marginal-urban,poor women of child bearing age (pregnant ornot) and children aged 0 to 24 months.

For more information, visit: www.harvestplus.org/

ReferencesChomba, Westcott CM, Westcott JE, Mpabalwani EM,Krebs NF, Patinkin ZW, Palacios N and Hambidge KM. ZincAbsorption from Biofortified Maize Meets the Requirementsof Young Rural Zambian Children. J. Nutr. January 21, 2015,doi: 10.3945/jn.114.204933.jn.nutrition.org/content/early/2015/01/21/jn.114.204933.full.pdf+html.

Finkelstein JL, Mehta S, Udipi SA, Ghugre PS, Luna SV,Wenger MJ, Murray-Kolb LE, Przybyszewski EM, Haas JD. ARandomized Trial of Iron-Biofortified Pearl Millet in SchoolChildren in India. J Nutr. 2015 Jul;145(7):1576-81. doi:10.3945/jn.114.208009. jn.nutrition.org/content/145/7/1576.long

Gannon B, Kaliwile C, Arscott SA, Schmaelzle S, Chileshe J,Kalungwana N, Mosonda M, Pixley K, Masi C,Tanumihardjo SA. Biofortified orange maize is as efficaciousas a vitamin A supplement in Zambian children even in thepresence of high liver reserves of vitamin A: a community-based, randomized placebo-controlled trial. Am J Clin Nutr.2014 Dec;100(6):1541-50. doi: 10.3945/ajcn.114.087379.ajcn.nutrition.org/content/100/6/1541.long

Haas JD, Luna SV, Lung’aho MG, Wenger MJ, Murray-KolbLE, Beebe S, Gahutu J-B and Egli, IM. Consuming IronBiofortified Beans Increases Iron Status in Rwandan Womenafter 128 Days in a Randomized Controlled Feeding Trial. J.Nutr. June 29, 2016, doi: 10.3945/jn.115.224741.jn.nutrition.org/content/early/2016/06/28/jn.115.224741.full.pdf+html

Hotz C, Loechl C, Lubowa A, Tumwine JK, Ndeezi G,Nandutu Masawi A, Baingana R, Carriquiry A, de Brauw A,Meenakshi JV, Gilligan DO Introduction of β-carotene-richorange sweet potato in rural Uganda resulted in increasedvitamin A intakes among children and women and improvedvitamin A status among children. J Nutr. 2012Oct;142(10):1871-80 jn.nutrition.org/content/142/10/1871

Kodkany BS, Bellad RM, Mahantshetti NS, Westcott JE,Krebs NF, Kemp JF and Hambidge KM. Biofortification ofpearl millet with iron and zinc in a randomised controlledtrial increased absorption of these minerals aboutphysiologic requirements in young children. J. Nutr. July 10,2013, doi: 10.3945/jn.113.176677jn.nutrition.org/content/early/2013/07/10/jn.113.176677

Minimum Standardsfor Age and DisabilityInclusion inHumanitarian Action

The Minimum Standards for Age andDisability Inclusion in HumanitarianAction have been developed for useby all practitioners involved in hu-

manitarian response, including staff and volun-teers of local, national and internationalhumanitarian agencies. The Standards are in-tended to inform the design, implementation,monitoring and evaluation of humanitarianprogrammes; to strengthen accountability topeople with disabilities and older people; andto support advocacy, capacity-building andpreparedness measures on age and disabilityacross the humanitarian system.

The Sector Standards on Food Security andNutrition have a set of Sector Specific Standardsand Action Points which can be selected to ad-dress the specific context of the humanitarianresponse, based on the initial assessments.The following is an example of how the Mini-mum Standards can guide your response to in-clude older people and older people withdisability in a comprehensive response:

Nutrition Standard 1 • The nutritional status of older people and

people with disabilities is systematically assessed and monitored;

• Nutritional assessments are used to trigger and inform emergency nutrition responses that include or target older people and people with disabilities.

Actions to Meet the Standard – a sample of pointsthat are included in the Minimum Standards:• Use sex-, age- and disability-disaggregated

data to assess the nutritional status of adults and children with disabilities and older people;

• Use outreach programmes to identify and include those who cannot reach registrationpoints;

• Ensure nutrition assessments are informed by food security assessments in order to identify and address factors affecting the nutritional status of people with disabilitiesand older people. Include these groups in strategies for the prevention of micronutri-ent deficiency.

This is a pilot document and feedback is wel-come, contact Diana Hiscock, email: diana.his-cock@helpage.org or adcap@helpage.org

The Minimum Standards have been devel-oped as part of the Age and Disability Capacityprogramme (ADCAP), which is funded by theUK Department for International Development(DFID) and the United States Agency for Inter-national Development (USAID).www.helpage.org/what-we-do/emergen-cies/adcap-age-and-disability-capacity-building-programme/

To learn more, download the Minimum Stan-dards for Age and Disability Inclusion in Hu-manitarian Action fromwww.helpage.org/download/56421daeb4eff

To access the webinar on Health and Nutritionin Humanitarian settings, please go to the Dis-aster Ready website disasterready.csod.com.Register for free to access the webinar andother content.

75-year-old Elema during the East-Africadrought crisis in 2011

Erna Mentesnot H

intz/HelpAge International, Ethiopia, 2011

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Despite impressive growth and insti-tutionalisation, the humanitariansystem is facing a crisis. According toa recent report on humanitarian

challenges in the Sahel region, the humanitar-ian system risks being outpaced by new threatsand vulnerabilities linked to conflict, technol-ogy and natural disasters. The authors assertthat the system is struggling to adapt to the so-cial and political changes spawned by globali-sation, constrained by the way thehumanitarian system is organised with a frame-work for decision-making that risks becomingobsolete.

Recent crises in Afghanistan, Somalia, Haiti, SriLanka and Pakistan as well as current emergen-cies – Syria, South Sudan, Central African Re-public, among other less visible crises – raisequestions about the very foundations of hu-manitarianism. The authors argue that unlessurgent steps are taken, humanitarian action willlose its relevance as a global system for savingand protecting the lives of at-risk populations.The report identifies areas where, given the po-litical will, immediate improvements could beintroduced in order to make the humanitariansystem more effective in responding to currentcrises and disasters.

As part of its analysis of the current human-itarian system and its strengths and weak-nesses, the Feinstein International Center (FIC)at Tufts University has produced a series of casestudies that analyse blockages and game

changers affecting humanitarian action in re-cent crises. This study focuses on the Sahel andis one of four case studies developed for thePlanning from the Future study, conducted incollaboration with Kings College, London andthe Humanitarian Policy Group at the OverseasDevelopment Institute (ODI).

The SahelUntil the early 2000s, the Sahel was on the mar-gins of geopolitical interest and humanitarianaction and debate. The African region stretchesin a 4,000km band from Senegal on the westcoast to Chad in the east, encompassing Sene-gal, the Gambia, Mauritania, Mali, Burkina Faso,Niger, Chad and Cameroon. The Sahel countriesshare a French colonial heritage (apart from theGambia) and features of a common currencyand lingua franca.

Today, the Sahel is centre stage because of acomplex crisis that has potential ramificationsfar beyond the region. The situation is due to aset of interconnected factors, including:• The emergence of conflicts, strong non-

state armed and non-armed actors, transnational criminal networks, and a counter-terrorism agenda;

• The tense relationship between humanitar-ian action and development, which has fostered a competitive rather than collabo-rative environment among organisations operating in the region;

• The impact of climate change on livelihoods; and

• The weakness of governance across the region.

This report, based on field visits to Mali, Nigerand Senegal, describes how these issues areplaying out across the Sahel and discusses theimplications for humanitarian action. It raisesimportant questions for the future of humani-tarian action in the Sahel and beyond. The au-thors introduce the history of the region andnature of the current crisis, with details onmajor stakeholders – an array of the state andnon-state actors, including conflict actors andtransnational criminal networks. The largestmultilateral donors to the Sahel are the UnitedStates and the European Union, with the 2012drought marking a sudden increase in human-itarian funding for the region.

Major findings, themes andlessons learnedFindings are organised around the concept of“game changers” (factors that emerged fromthe crisis or were relatively new, and for whichthe humanitarian community is ill-prepared todeal with), and “blockages” (either things thatare blocking humanitarian action in a givencontext, including long-standing problems);some findings contain elements of both.

The main findings focus on the Sahel (andmore generally, West Africa) as a relatively neg-lected and peripheral region of intervention foraid, compared to other global crises. This is re-flected in smaller budgets and observed differ-ences in professionalisation of humanitarianstaff (the region is considered a “less presti-gious” posting with limited circulation of staffoutside the Francophone “pocket”).

Problems have tended to be viewed in de-velopmental rather than humanitarian terms,with the chronic crisis perceived as a “failure” indevelopment, thus lacking humanitarian own-ership and innovation as seen in other regions.This fuels the uncomfortable coexistence be-tween development and humanitarian action,whereby the Sahel’s main problems (food secu-

Regionalhumanitarianchallenges inthe Sahel

Summary of report1A family in their tent in Mali, displacedfrom their homes due to conflict

WFP/Jane H

oward, M

ali, 2012

Location: The Sahel

What we know: The Sahel is currently in complex crisis fuelled by conflict, climatechange and weak governance.

What this article adds: A recent case study of regional humanitarian challengesin the Sahel, informed by visits to Mali, Niger and Senegal, identifies majorshortcomings in the humanitarian system as currently organised. Competition ratherthan collaboration characterises the humanitarian/development relationship.Humanitarian architecture is complex, duplicative and bogged down in coordination.Conflict is the dominant view of the region by donors; increased security measurespose challenges to operations. Large aid agencies are increasingly not operational,with energies diverted to reporting and accountability to donors, rather thanbeneficiaries. National agencies are operationally significant but lack power withinthe aid dynamic. Solutions are available, but political will is currently lacking.

1 Donini, Antonio and Scalettaris, Giulia. 2016. Case Study: Regional Humanitarian Challenges in the Sahel. Planning fromthe Future, Component 2. The Contemporary Humanitarian

Landscape: Malaise, Blockages and Game Changers. Feinstein International Center. Medford: Tufts University. fic.tufts.edu/assets/Sahel-case-study-Final-09-05-16.pdf

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rity, malnutrition and epidemics) can be framedin both terms.

The chronic nature of the situation makes ita complex humanitarian environment. The hu-manitarian situation is understood to be in con-stant expansion and polarisation, with localactors only playing a minimal role. Local non-governmental organisations (NGOs) are used toaccess insecure areas but not treated as “equals”.While international players raise issues of ac-countability and capability of local agencies, na-tional NGOs voice frustrations regardingbureaucracy and challenges in accessing inter-national humanitarian funds.

Large aid agencies are losing their “fieldcraft” as they are increasingly not operational,with energies diverted to reporting and ac-countability to donors, rather than beneficiar-ies. Coordination and transaction costs are high,

since inter-agency dynamics absorb largeamounts of human and financial resources. Of-ficial coordination mechanisms involve the UNOffice for the Coordination of Humanitarian Af-fairs (OCHA), Inter-Agency Standing Committee(IASC)-mediated clusters, UNHCR (refugees)and a parallel ECHO (European Civil Protectionand Humanitarian Aid Operations) coordinationsystem; sub-groups/fora/working groups areproliferating partly in response to inadequaciesin existing systems.

Key lessons include:• The Sahel is rapidly changing, with conflict

becoming a key lens through which the region is viewed by donors. The escalation in security measures will pose increasing challenges to humanitarian agencies;

• There are implications for humanitarian principles and staff security in the perceived

alignment with external political/military agendas;

• The humanitarian aid system has still not found its footing and is struggling to deal with the complexity and tensions sur-rounding the Sahel crisis;

• The appointment of a regional humanitariancoordinator has been an innovation but it is unclear if it has made the system any more effective; and

• The humanitarian architecture is complex, duplicative and bogged down in coordination.

The report concludes that solutions are availableto make the system more effective, but politicalwill is lacking. The humanitarian system in theSahel, as elsewhere, is becoming more remoteand functional to the needs of the main players,rather than the populations it purports to serve.

By GESNOMA, Winds of Hope, Sentinelles, and Médecins sans Frontières

NOMA (cancrum oris and fusospiro-chetal gangrene or Necrotising Ulcer-ative Stomatitis), disfigures childrenrapidly, if they survive. It is one of the

most devastating and disfiguring human dis-eases worldwide and was designated a healthpriority by the WHO in 1994 (1). NOMA is still aneglected disease, and there is not much knownabout its causes, prevention and optimal treat-ment. Fortunately, with simple interventions,NOMA can be addressed and contained and peo-ple with NOMA can be cared for. Thus, this dis-ease deserves more attention from healthcareworkers, nutritionists, researchers and policy-makers. In this article, we explain NOMA, explorethe relationship between NOMA and nutritionand suggest how health workers in nutrition pro-grammes can be involved in its identification and

The incidence of NOMA among children isestimated at 140,000 per year and the preva-lence at 770,000 cases worldwide (2, 3). Lowerestimates are 100,000 children per year who areaffected by NOMA, of whom 20,000 survive(www.nonoma.org). However these figures arelikely gross underestimates; NOMA is underre-ported since it occurs in remote areas, peopleare not eager to let the world know there is adisfigured member of the family, and the dis-ease progresses rapidly to death. Most cases ofNOMA (80%) occur in countries in the SAHELbelt, such as Chad, Nigeria, Niger, but also inAsia and South America. In the past, NOMA oc-curred in Europe too, where it was associatedwith poverty and the presence of other infec-tious diseases such as measles or tuberculosis.

The precise causes of NOMA are unknown, butthe disease is thought to be related to immunedysfunction. Reduced immune function is inturn associated with poverty, the presence ofother diseases (measles, malaria, pneumoniaand HIV/AIDS (4)), malnutrition (5), poor hygieneand sanitation (no clean water, contact with an-imal waste), as well as lack of primary health careand health promoting activities like vaccination.Lack of oral hygiene is also a risk factor forNOMA; one of the early stages of NOMA is gin-givitis and other infections in the mouth.

Screening for gingivitis:

• Gums: redness, pain, bleeding• Hyper salivation, drooling• Bad breath • Anorexia• Gingival ulceration• Facial swelling / oedema.• Dry necrosis, loss of tissue, possible bone sequestrum

management. Two posters are included with theprint edition of Field Exchange, one for an out-pa-tient and one for an inpatient consulting roomsetting, in both English and French.

What is NOMA?NOMA is a gangrene in the orofacial area. Thecourse of the disease is very aggressive and fast.It starts as a gingivitis that develops into a gin-gival ulcer and/or necrotising gingivitis, spread-ing rapidly throughout the tissues of the mouthand face. The infection can result in necrosis oftissue and bone in the face which, combinedwith sepsis, is fatal in most patients. NOMA notonly disfigures the patient but also causes dys-function in eating and speaking, resulting inmalnutrition and social isolation (2). If NOMA isuntreated, 70-90% of patients will die.

A boy having undergone rehabilitative surgery during the surgical camp, organisedin collaboration between HUG (Hôpitaux Universitaires Genevois) and Sentinelles,in Ouagadougou, Burkina Faso, 2013.

Mylène Zizzo, 2013

NOMA:

A neglected disease!

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Treatment of NOMAThe early stages, such as simple gingivitis,should be treated with mouth washes of saltedwater and general oral hygiene. A complicatedgingivitis (with necrosis, spontaneous gingivalbleeding and pain) requires professional dentalhygiene and follow up (if available). If dental hy-giene and follow up cannot be achieved, antibi-otics are needed. When there is a necrotisinggingivitis/stomatitis with oedema of the corre-sponding facial region, antibiotics are manda-tory. The later stages should be managed by anintense antibiotic regime in order to stop thespread of the infection and to avoid the deadlycomplications (such as septicaemia). Once theinfection is over, and depending on the localisa-tion of the NOMA, physiotherapy aimed to avoidcomplete trismus (jaws constriction) must bestarted for those patients developing this com-plication. In many cases, specialist reconstruc-tive surgery is needed and can only be planned

once the scarring process is over and no earlierthan one year after the acute NOMA. Treatmentto improve function, counselling and actions tomaintain dignity of the patient must always bepresent from the beginning of the lesion.

Simple gingivitis can be treated in an ambu-latory therapeutic feeding centre (ATFC), theclinic and at home by rinsing with salted waterfor 14 days. In inpatient settings, such as an in-patient therapeutic feeding centre (ITFC) orhospital, mouth washes with 0.5% Betadine 4times per day for 5 days (maximum) can also beused. Then, application of a solution consistingof 2 parts 1.4% bicarbonates at to 1 part nysta-tine 4 times per day for at least 10 days, or pos-sibly over the total duration of thehospitalisation, can be applied with the aid of acompress rolled up on a tongue compressor(the caregiver can be taught to do this). In thecase of necrotising gingivitis, the above localtreatment should be completed with antibi-otics (amoxicillin-clavulanate combination oramoxicillin plus metronidazole).

The treatment should be complemented byactive nutrition support (e.g. supplementationwith lipid nutrition supplements (LNS) or ther-apeutic foods where severely malnourished),treatment of any other existing infections, andupdating of vaccination status. Prompt recog-nition of the early stage of NOMA (gingivitis)and treatment at this stage can prevent subse-quent tissue destruction and disfigurement.This implies early recognition and active screen-ing for NOMA.

Malnutrition and NOMAMalnutrition (moderate and severe) is the mostimportant risk factor for NOMA (5). Thereforeprevention of malnutrition (along with treatingunderlying diseases, improving vaccinationcoverage and HIV testing) is an important stepin the prevention of NOMA. This means that allmoderately or severely malnourished individu-als should be screened for signs of gingivitis. Inaddition, every patient in inpatient and outpa-tient nutrition treatment centres should bescreened for gingivitis (simple and severe) andother mouth abnormalities. Once the NOMA in-fection is treated, many patients still have se-vere lesions in the mouth and face that canhamper eating, chewing, swallowing, talking,and sometimes even vision or breathing. Goodnutritional support and guidance, with possiblephysiotherapy, can help to return to an accept-able nutritional status. Prior to any surgery, thelesion must no longer be active and the patientshould be well nourished; close monitoring oftheir nutrient status and supplementary feed-ing is often necessary before surgery can beperformed.

Active screening in feedingprogramme Feeding programmes treating moderate andsevere malnutrition have a concentration ofchildren at risk for NOMA and are thereforeexcellent places to target these children; theycan play an important role in controlling

NOMA in an area. Activities to include in afeeding centre are: • Systematic screening of patients on

admission for gingivitis• Nutritional rehabilitation• Vaccination• Systematic HIV counselling and testing• Screening of siblings and mothers, • Improvement of water quality, sanitation

and hygiene• Education of patients and caretakers on

mouth hygiene and NOMA • Reporting of cases of NOMA in the village

by caretakers • Referral of NOMA patients to specialised

institutes (where available)

Accessing guidance andsupportSentinelles, Winds of Hope, GESNOMA (allmembers of the International NoNoma Federa-tion) and Médecins Sans Frontières (MSF) havecreated a working group to collaboratively de-velop several kinds of support:• Posters for the consultation room in French

and English for inpatient (hospital, ITFC) and outpatient facilities (outpatientmedical clinic and outpatient/ambulatory therapeutic feeding centres (ATFC)) (included in this edition of Field Exchange)

• Guidelines on treatment of NOMA • Support to specialised centers for surgery • Background information • Guidelines on management of moderate

and severe acute malnutrition • Research

Nonoma (FR): www.nonoma.orgWinds of hope (EN, FR, GE): www.windsofhope.orgSentinelles (FR, EN): www.sentinelles.org

Study of the Human Rights Council AdvisoryCommittee on severe malnutrition and child-hood diseases with children affected by nomaas an example. UN General Assembly. 24th Feb-ruary 2012. Human Rights Council Nineteenthsession Agenda item 5. www.righttofood.org/wp-content/uploads/2012/09/A-HRC-19-73.pdfwww.righttofood.org/work-of-jean-ziegler-at-the-un/noma/

References1. Bourgeois DM, Leclercq MH. The World Health

Organization initiative on noma. Oral Dis. 1999; 5:172-74

2. Ashok N, Tarakji B, Darwish S, Rodrigues JC, Altamimi MA; A Review on Noma: A Recent Update. Global Journal of Health Science. 2016;4 (53-59)

3. Baratti-Mayer D, Pittet B, Montandon D, Bolivar I, Bornand JE, Hugonnet S, Jaquinet A, Schrenzel J, Pittet D; Noma: an “infectious” disease of unknown aetiology. Lancet infect Dis. 2003; 3: 419–31

4. Masipa JN, Baloyi AM, Khammissa RAG, Altini M, Lemmer J, Feller L; Noma (Cancrum Oris): A Report of a Case in a Young AIDS Patient with a Review of the Pathogenesis; Head and Neck Pathol. 2013;7:188–192

5. Baratti-Mayer D, Gayet-Ageron A, Hugonnet S, François P, Pittet-Cuénod B, Huyghe A, Bornand J, Gervaix A, Montandon D, Schrenzel J, Mombelli A, Pittet D. Risk factors for NOMA disease: a 6-year, prospective, matched case-control study in Niger. Lancet Global Health 2013; 1: e87-96

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Treating non-communicablediseases in Jordan

MSF, Jordan

By Emily Mates, ENN Technical Director (meeting attendee)

eLearning module on improving nutritionthrough agriculture and food systems

There is an increasing burden of non-communicable diseases (NCDs)among people displaced and other-wise affected by humanitarian crises.

Humanitarian organisations are facing newchallenges when confronting them as there aremany uncertainties regarding the best strate-gies to implement NCD care in these crisis-af-fected settings.

A recent (2nd September 2016) one-daysymposium on the topic was hosted by the Lon-don School of Hygiene and Tropical Medicine(LSHTM) Centre for NCDs and Centre for Healthand Social Change (ECOHOST) and MédecinsSans Frontières (MSF). It brought togetherspeakers from academic, development and hu-manitarian organisations to address some keyissues faced when working to improve the careof patients with NCDs. Presenting agencies in-cluded MSF, International Medical Corps,LSHTM, NCD Alliance, United Nations HighCommissioner for Refugees (UNHCR), UnitedNations Relief and Works Agency for Palestine(UNRWA), International Rescue Committee, In-ternational Committee of the Red Cross and theUniversity of Geneva.

The burden of NCDs in the Middle East re-gion is increasing, particularly cardiovasculardisease (CVD), respiratory disease, diabetes andcancers, with an estimated 1.7 million deathsper year; diabetes rates are amongst the high-est in the world. It is very difficult to get peopleto change behaviour even in the developedworld; in crisis situations, this becomes evermore difficult. Mental health issues are often anacute problem amongst refugees. Particular

problems associated with NCDs in humanitar-ian settings include:• Varying burdens, depending on the context• Impact on health care infrastructure of host

nations; there are additional problems when host nations have largely private health care systems

• There are currently multiple protocols and guidelines in existence, depending on the context

• Insufficient mental health services• As in non-crisis situations, people generally

prefer medication to lifestyle change.

Some lessons can be drawn from the global re-sponse to the HIV pandemic, although with HIVthere is a single cause with high burden, whichmakes it easier for researchers and practitionersto activate around it. The situation with NCDs ismore complex, as it involves a heterogenousgroup of diseases with no single cause and vari-able burden, depending on context. A key con-siderations is the mortality risk when treatmentis interrupted. For example with CVD and statintreatment, if treatment is interrupted the resultsare not too serious; with type 1 diabetes, mor-tality risk is extremely high with treatment in-terruptions.

Regarding nutrition, obesity was raised as acausal factor but further nutrition considerationsregarding NCDs (prevention or management) inhumanitarian settings were not discussed.

Main summary points included: • We must improve our understanding of the

needs, which will vary by context, to respondto the challenges effectively – traditional

humanitarian systems do not currently cater well for assessment of NCD needs.

• Lessons can be applied from other chronic disease programmes such as HIV/AIDS.

• Standardised guidelines, tools and training are needed on how to deal with NCDs in emergency settings.

• Cohort monitoring is required to identify gaps in service provision and evaluate services.

• Service must be patient centred, with trained and incentivised health workers.

• Institutional structures and resources sup-portive of integration for chronic disease management alongside traditional human-itarian response are required.

• Recognising the mortality consequences oftreatment interruptions, it was suggested that a matrix is needed for use at organisa-tional level regarding what problems exist and how acute they are, to ensure contin-ued treatment.

• More research is needed: two systematic reviews on effectiveness of NCD interven-tions and integration of HIV/NCDs presented at the meeting were inconclusive due to lack of evidence.

Video recordings of all presentations are avail-able at: www.msf.org.uk/event/symposium-im-proving-care-of-people-with-non-communicable-diseases-in-humanitarian-settings

This symposium is linked to a thematic serieson NCDs in humanitarian crises being pub-lished in the journal ‘Conflict and Health’. See:www.conflictandhealth.biomedcentral.com

The new eLearning module ‘ImprovingNutrition through Agriculture andFood Systems’ is now online. It is de-signed to assist professionals from any

fields related to food security, agriculture andfood systems that are involved in designing andimplementing nutrition-sensitive programmes,investments and policies. The module uses ascenario-based and experiential learning ap-proach to illustrate the linkages between agri-culture, food systems and nutrition. It providesa series of examples of nutrition-sensitive poli-cies and interventions and gives an overview of

global and regional initiatives and commit-ments related to nutrition on which learners canbuild to integrate nutrition in their work.

This module was developed by FAO’s Nutri-tion and Food Systems Division and Partner-ships, Advocacy and Capacity DevelopmentDivision, in collaboration with the World Bankand European Union, and with technical inputsfrom many partners.

It is available in the FAO e-learning page:www.fao.org/elearning/#/elc/en/course/NFS

Other related e-learning modules are:Nutrition, Food Security and Livelihoods: Basicconcepts. A short course on the basics of nutri-tion. www.fao.org/elearning/#/elc/en/course/NFSLBC

Agreeing on causes of malnutrition for joint ac-tion. A key resource to improve the under-standing of the multi-sectoral causes ofmalnutrition and support integrated nutritionplanning. www.fao.org/elearning/#/elc/en/course/ACMJA

Improving care ofpeople with NCDs inhumanitarian settings

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FANTA’s Body Mass Index (BMI) Wheel

Determining BMI is a way for health workers to identify malnutri-tion in children over 5 years of age, adolescents, and non-preg-nant, non-lactating adults. BMI is calculated as body massdivided by the square of the body height(kg/m2). In 2014, FANTA

and the Boston Children’s Hospital created the BMI Wheel for health careworkers in developing countries to quickly calculate BMI and BMI-for-age,as well as determine a client’s nutritional status using a single time-savingtool. The FANTA Project is pleased to announce that the BMI Wheel is nowavailable.

The design files for the BMI wheel are available in English, Spanish, andPortuguese for organisations interested in printing the wheel for their ownuse. For details on how to print and use the tool, including an informationalvideo, visit: www.fantaproject.org/tools/body-mass-index-bmi-wheel

Any questions or experiences on using the tool should be sent to: fantamail@fhi360.org

Launch of BabyWASHCoalition

The newly launched BabyWASH Coali-tion is a five-year initiative comprisingorganisations across civil society,United Nations (UN) organisations,

funders, academics and the private sector. It isfocused on increasing essential integration be-tween programming, policy-making and fund-ing in the areas of water, sanitation and hygiene(WASH); early childhood development (ECD);nutrition; and maternal newborn and childhealth MNCH), to improve child well-being inthe first 1000 days.

It is built on the premise that half a millionchildren and 30,000 mothers annually couldsurvive and thrive through better and more in-tegrated approaches to maternal and youngchild health. WASH is often missing from nutri-tion, ECD, and MNCH programming, despite agrowing evidence base on the need for link-ages. There are many policy, attitudinal, andfunding barriers to integration. The coalitionaims to leverage its collective strengths to breakdown these barriers. The coalition is a direct re-sponse to the Sustainable Development Goals(SDGs) call for increased partnerships and inter-sectoral collaborations, and is in support of theEvery Woman Every Children Global Strategy,which has a newly enhanced focus on multi-sector actions.

Main coalition objectives 1) Develop and disseminate lessons and

guidance for programme integrationBesides being a source of information and case studies of successful integration, the

Coalition will create a toolkit for programmeimplementers on how to successfully inte-grate BabyWASH interventions into their programming and work collabo ratively with other sectors and organisations.

2) Define integration metricsThe Coalition will use current research and success stories to define the key compo-nents and metrics of beneficial integration. Where appropriate, the Coalition will assist in planning pilot programmes to validate metrics.

3) Advocate for stronger focus on integrated care in the first 1,000 days of lifeThe Coalition will use case studies and evidence to advocate for more integration between sectors. Funders and policy-makers will be targeted to minimise current barriers to integration.

Who can be involved? The Coalition is open to all organisations inter-ested in promoting improved maternal, new-born and young child health outcomes throughincreased sector integration. The Coalition is es-pecially interested in finding national champi-ons who can advocate for or implementBabyWASH interventions at a local level.

Interested organisations can join the Coali-tion as a Community of Practice (CoP) memberor as a dedicated member of one of the work-streams. CoP members commit to providing in-formation and case studies for the monthlyresource newsletter, staying up to date on

BabyWASH news, and being an advocate for in-tegration in their circles of influence. They willalso be asked to review materials created byeach of the workstreams. Organisations in-volved in one of the workstreams will meetmonthly to move Coalition deliverables forwardand work in a dedicated team on advocacy, pro-gramme guidance, and metrics for integration.

For more information, or to join the Coali-tion, visit www.babywashcoalition.org or con-tact Peter Hynes, BabyWASH CoalitionCoordinator, email: admin@babywashcoali-tion.org or follow: #BabyWASH

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Over the past four months (1st July to31st October), 88 questions havebeen posted on en-net, generating228 responses. Forty-two vacancy

announcements have been posted, which haveaccumulated almost 12,000 views on the web-site; and eight upcoming trainings.

en-net has increasingly seen posts alertingreaders to new research and guidance in areasthat have received much attention on the site,such as coverage assessment www.en-net.org/forum/16.aspx and WHO updates on HIV andinfant feeding www.en-net.org/question/2579.aspx which is a welcome development,assisting people to access research and evi-dence-based information. In addition, therehave been several posts recently to encouragereaders to engage in online consultations andexperience-sharing by researchers and thosedeveloping guidelines. These include SphereHandbook consultation, updated guidance onInfant feeding, and contributions to research on“Understanding the contextual factors enablingevidence-based decision making in disasters:Organisational contexts and other disaster re-lated contexts”. The latter is still open for inputshere, www.en-net.org/question/2697.aspx

In the Scaling Up Nutrition (SUN) forum areathere has been a call for experiences on engag-ing nutrition champions for a new guide to bepublished by the Institute of DevelopmentStudies (IDS) and the SUN Movement Secre-tariat. Contributions have been shared by indi-vidual practitioners, SUN Focal Points,government ministers and civil society allianceconveners. Findings so far include: The Prime Minister galvanised Namibia into ac-tion after a review illustrated that the countrywas facing a major challenge in reducing ma-ternal deaths and infant mortality and makingslow progress towards its Millennium Develop-ment Goals (MDGs). A survey was then con-ducted which clearly showed the links betweenthe high rates of anaemia in pregnant womenand stunting in children and these poor out-comes. It was against this background that theNamibia Alliance for Improved Nutrition(NAFIN) was born. NAFIN is multi-sectoral andmulti-stakeholder. Its mission is to provide evi-dence-based information to policymakers onthe state of nutrition in Namibia; promote socialmobilisation in favour of balanced diets; pro-mote breastfeeding; build awareness amongpregnant mothers about the need to visit ante-natal clinics; promote public hygiene such asgood sanitation and hand washing.

The SUN Civil Society Alliance Pakistan(SUNCSA, Pak) organised sensitisation sessions

of Parliamentarians in all provinces and at Fed-eral level to engage them to play an importantrole in implementation of Inter-sectoral Nutri-tion Strategies and enactment/ enforcement ofrelevant legislation, such as Protection and Pro-motion of Breastfeeding laws, mandatory foodfortification laws, etc. Parliamentarians can alsohelp increase budgetary allocations for nutri-tion specific and nutrition sensitive interven-tions. They found key messages that work wellare:(1) The current malnutrition crisis in Pakistan

has been estimated to cost the economy 2-3% of Gross Domestic Product (GDP) per year; Pakistan cannot afford to sustain this drain on the economy.

(2) If prioritised, malnutrition can be ended in a generation in Pakistan! Addressing mal-nutrition is one of the best investments Pakistan can make in its future.

(3) Improving nutrition is transformational - families become healthier, wealthier and better educated, because• Children who are malnourished learn less

at school, and earn less when they grow up.

• Iron and iodine deficiency in childhood reduces IQ by up to 25 and 13 points respectively.

• Malnutrition makes children more likely to acquire communicable diseases like measles and also develop complications. Malnutrition also reduces the effectivenessof certain vaccinations.

The SUN CSA, Pak is now developing policybriefs and provincial scorecards to equip themwith ready to reference information required forpolicy making and planning.

The Sierra Leone Alliance Against Hungerand Malnutrition is a civil society advocacy non-governmental organisation and an alliance ofover 150 networks. They came together as analliance after persistent reports identifying mal-nutrition as one of the major causes for the highmaternal and infant mortality in the country,one of the key issues responsible for SierraLeone’s low position in the Human Develop-ment Index.

To enhance government commitment tonutrition, the alliance is currently leading the ef-forts to include nutrition and food security is-sues in the National Constitution in the currentconstitutional review process. The effort has al-ready yielded fruit: under Protection of Socio-economic Rights, to be free from hunger and tohave food of acceptable quality, has been in-cluded. The alliance is currently hosting, on be-half of Sierra Leone, the Ecosystem Based

Adaptation for Food Security Assembly whichis a Pan African institution, and thereby encour-aging other nutrition activists to include cli-mate change issues in their nutrition activities.

Follow the discussion and add your contribu-tion at www.en-net.org/question/2700.aspx

Finally, there have been several calls on en-net for access to more nutrition materials inFrench, Spanish, Russian and Portuguese. Thisranges from translated guidelines to SMARTsurvey reports. The dearth of available literaturein languages other than English is a significantissue. If you have links or materials to share,please do so, here www.en-net.org/question/2583.aspx or www.en-net.org/question/2705.aspx or contact post@en-net.org. en-net has amirror French site, launched earlier this year,www.fr.en-net.org. We very much welcomefeedback on the quality of translations on thissite and suggestions to make it increasingly ac-cessible and useful to French speakers. All feed-back is welcome to post@en-net.org.

To join any discussion on en-net, share your ex-perience or post a question, visit www.en-net.org.uk

ContributionsNahas Angula, Muhammad Irshad Danish, Has-sane, Edward Jusu, Dr. Bonnix Kayabu, RegineKopplow, Scaling Up Nutrition/Transform Nutri-tion Moderator.

By Tamsin Walters, en-net moderator

En-net update

News

A child awaits her check-up at a community clinicin Nyankpala in the Northern Region of Ghana

WFP

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By Daniel Muhinja, Sisay Sinamo, LydiaNdungu and Cynthia Nyakwama

Daniel Muhinja is NationalNutrition Specialist withWorld Vision (WV) Kenya,providing technicalleadership to nutritionprogramming. He has overten years’ experience in the

design, management, monitoring anddocumentation of nutrition programmes.

Dr Sisay Sinamo MPH, MD iscurrently Nutrition Advisorfor WV International EastAfrica Region, supportingnine countries. He hasworked in developmentaland emergency nutrition

programming for the past 16 years.

Lydia Ndungu is NutritionProgramme Officer with WVKenya and provides nutritiontechnical capacity-building,mentoring, resourcemobilisation, nutritionadvocacy, research,

documentation, programme design, monitoringand evaluation.

Cynthia Nyakwama is HealthProgramme Officer with WVKenya. She has over 10 years’experience in developingand managing nationalprogrammes and projects forhealth on malaria and

HIV/AIDS with international non-governmentalorganisations.

The authors acknowledge the Ministry of Health,International Rescue Committee, Save the Childrenand Islamic Relief. The project was funded by theDepartment for International Development(UKaid), World Vision UK and World Vision Canada.Thanks also to Colleen Emary, Senior EmergencyNutrition Advisor, World Vision International, forassistance in the development of this article.

Fieldexperiencesfrom NorthernKenya

Open Data KitSoftware toconductnutritionsurveys:

BackgroundNutrition programmes require high qualityand timely data for appropriate decision-making. In the past, nutrition programmesused time-consuming manual processes fordata collection and analysis. Open Data Kit(ODK) is a free and open-source set of toolswhich helps organisations author, field andmanage mobile data collection solutions

(see Box 1). Its core developers are researchersat the University of Washington’s (UW) De-partment of Computer Science and Engi-neering and active members of Change, amulti-disciplinary group at UW exploringhow technology can improve the lives ofunder-served populations around the world.WV is using ODK extensively for nutritionand health surveys across Asia and Africa;

Open Data Kit is an open-source set of tools that enables online generation offorms/questionnaires, data collection on mobile phones and submission to a centralserver which is downloaded during analysis. ODK is made of up of three platforms:

ODK Build: Enables users to create questionnaires using a drag-and-drop form designeror an Excel spreadsheet;

ODK Collect: Phone-based replacement for paper forms for data collection;

ODK Aggregate: Provides a ready to deploy online repository to store, view and exportcollected data.

Data collected using ODK may be stored by Google servers or organisational servers. Theserver is a safe repository for data collected (cloud), and can be used for future analysis byother internal parties, such as WV-support offices.

Box 1 About ODK

Location: KenyaWhat we know: Manual survey data collection and analysis is resource-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 toconduct a SMART survey. Compared to manual data collection, it provedcheaper (less staff), quicker (instant data upload ready for analysis), lessprone to error (immediate data checks possible) and abuse (GPS checks onrandom sampling) and more environmentally friendly (printedquestionnaires not needed). Data aggregation (hosted on cloud server orinternal servers) allows for further future analysis. Electricity/power packs(for charging), mobile internet (for data upload) and smartphones are neededbut were not a barrier. Minor suggestions are made to the developers toimprove usability.

Field Article

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to date, 19 countries have been trained on ODK.World Vision Kenya introduced the concept ofODK for nutrition surveys conducted in Kenya;this article shares their experiences around this.

MethodologyWorld Vision conducted a three-day LQAS (LotQuality Assurance Sampling) survey trainingusing ODK for 12 staff from a consortium offour non-governmental organisations (NGOs)and equipped them with skills to create a surveytool, upload data and download it for analysis.is training led to the development of a Stan-dardised Monitoring Assessment for Relief andTransition (SMART) survey generic tool by thenutrition sector in Kenya. Sixty enumeratorsand 20 team leaders in Turkana County and 30enumerators and ten team leaders in Wajir weretrained for four days to conduct SMART surveys.During the fourth day, the survey teams com-pleted a pilot exercise using smartphones. iswas followed by six days of data collection inthe field.

Table 1 compares manual survey requirementsagainst using ODK. Use of ODK saves on printingor photocopying bulky questionnaires and trans-porting them during data collection to centraldata entry centre. It reduces the number of staffneeded to collect data, as no data entry staff arerequired (data is collected using the smartphonesin the field), and it saves on time needed toaccess data that has been collected. ODK improves

data quality by using a Geographic InformationSystem to verify randomness of the data collectedin the clusters (Figure 1) and by using skiplogic, which ensures all questions are answered.Data collected is easily accessed and is stored ina server, hence it cannot be manipulated; WVKenya used Google servers to store data anddid not encounter any challenges. Use of smart-phones in two surveys saved approximatelyUS$8,352 compared to paper-based surveys.One survey of 25-35 clusters requires one set ofsix smartphones, which cost about US$3,180,and which are used for subsequent surveys.

Lessons learned Developing the survey tool using MicrosoExcel is more user-friendly, easier and fasterthan using online ODK build function. SinceExcel is offline, it is easier to work with; e.g.changes can be made that are then uploaded.

Power conservation, internet connectivityand mobile network coverage influence the timeto upload survey data. To enable the smartphonesto keep power longer, ‘app lock’ is used to locksome applications, which reduces power wastage.Back-up power banks of about 5,200mAH werepurchased by World Vision to address the chal-lenge of some smartphones being drained ofpower during data collection. ese power banksare able to charge a smartphone twice in a day.It is also essential to map out availability ofmobile network or internet so that the surveyteams can upload data daily. Survey teams wereprovided with data bundles to allow data uploadwhile in the field; bulk 300MB costs aboutUS$10 and is shared among teams.

Use of smartphones is not a substitute forsurvey team supervision, which is key duringdata collection to provide support and ensuresurvey protocols are followed.

Making survey supervisors accountable forsmartphones and consistent use of one smart-phone per team reduces loss and mismanagementof smartphones. To ensure responsibility andcare for the equipment, supervisors signed a

form accepting that the smartphone was in theircustody, that they would take care of it and beresponsible in case of loss.

Plausibility checks were done on a daily basisand data analysis for anthropometry was doneeasily on downloading the data. e field surveyteams uploaded survey data daily. e surveymanager would download the data and conductplausibility checks, relaying any data qualityissues to the team supervisors to ensure subse-quent data was of better quality.

Global Positioning System (GPS) improvesthe quality of data by locating the sampledhousehold. Collection of GPS information enablesmapping of data during the data collectionprocess to show randomness of the data. isprotects against the risk that a data collectionteam could falsely complete the questionnaires.

Recommendations to the developers are toincrease the cloud size to accommodate moredata sets, especially for organisations conductingmany surveys, without charging fees for cloudstorage. In addition, it is difficult set up questionsnormally in tabular format where each columnrequires different types of ODK responses. Forexample, for questions on utilise “add group”,the ODK output is normally a link that requiresadditional publication; hence more time isneeded to organise the data before it is transferredto another soware program for analysis.

ConclusionODK has proved to be a good platform forfaster, cost-saving collection and aggregation ofnutrition survey data. World Vision’s experiencewith ODK has been shared with other partners;the Nutrition Information Working Group inKenya has embraced the platform and supportsits use. e positive Kenya experience reflectsWorld Vision’s positive experiences in othercountries.

For more information, contact Daniel Muhinja.Email: daniel_muhinja@wvi.org

Access ODK at: opendatakit.org

Figure 1Geographic information system mapping of datapoints for a survey in Turkana county Table 1 Comparison of traditional vs ODK surveys

Survey aspect Manual With ODK

Data clerks Required Not required

Printing andphotocopyingquestionnaires

Required Not required

Questionnairetransportation

Required Not required since data is uploaded onservers

Time taken tocompletequestionnaire

40-60 minutes (dependingon size of questionnaire)

15-25 minutes

Data access Up to several days tocomplete entry

Immediately uploaded

Data quality Compromised at times Improved – GPS tracking, no omissionsand use of skip mode. Pictures taken inreal time (for example, oedema checks)

Environment Excessive paper waste Environmentally friendly

Data Can be manipulated Secure and cannot be manipulated

Number ofpeople per team

Minimum of four Two is sufficient

Mobileconnection

Does not require mobile orinternet

Requires mobile or internet to senddata to central servers

Electricity Not required (questionnaireis photocopied in advance)

Requires electricity to chargesmartphones as survey progresses

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Survey SMART phone charging

Field Article

Source: World Vision Kenya

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ContextCurrent crisisSouth Sudan, the world’s newest nation,has chronic vulnerabilities and is facedwith multiple crises alongside historicalmarginalisation, acute insecurity, economicdecline, disease and lack of access to services,infrastructure and food. e armed conflictin South Sudan has caused a major publichealth crisis since December 2013, disruptingessential primary and secondary healthcareservices and infrastructure. Since then, de-spite diminishing intensity of the armedviolence and increased humanitarian accessin the most-affected areas, the conflict hasspread to new areas that were previouslystable, causing further displacement anddamage to livelihoods. In July 2016, thecountry was already facing rising food in-security (due to deepening economic crisis,unresolved tensions and depleted foodstocks from limited household production)and critical malnutrition levels, when re-newed and severe conflict broke out. ishas sparked a new wave of mass displace-ment and has been devastating for civilians;health and nutrition facilities have beenattacked, damaged and looted.

Prior to the July 2016 crisis, 4.42 millionpeople were estimated to be in need ofemergency healthcare; an estimated 4.7million people are now in need of healthassistance. e conflict has compoundedan already dire health situation, documentedby appalling health indicators, includingthe following mortality rates: maternal(2,054/100,000 live births); neonatal(43/1,000); infant (83/1,000); and under-fives (106/1,000).

e current prevalence of acute malnu-trition in South Sudan is unprecedented.Global acute malnutrition (GAM) ratesnow exceed emergency thresholds of 15%in all states except Central Equatorial andLakes. An estimated 5.1 million people areclassified as severely food and nutritionallyinsecure. e GAM level in Northern Bahr

el Ghazal, one of the 10 former states ofSouth Sudan before reorganisation in 2015,has hit the catastrophic level of 33.3%, in-dicating that one in every three childrenaged 6 to 59 months is acutely malnourished.In Western Bahr el Ghazal, GAM prevalenceis now 20.6%, a nearly two and a half-foldincrease in malnutrition in the last sixmonths (8.5%, Dec 2015). Food insecurityis at critical levels in Northern Bahr elGhazal, Warrap, Western Bahr el Ghazal,Upper Nile, and Lakes Region1.

WHO role in South SudanLess than 40 per cent of the population hasaccess to basic health and humanitarianservices, and more than one third is inurgent need of food, agriculture and nutri-tion assistance. e WHO Country Office(WCO) in South Sudan provides basichealthcare in line with the WHO/AFROtransformation agenda2 and Universal HealthCoverage principles. Adequate and timelyhealth humanitarian response and surveil-lance are effected through coordinationwith partners, addressing inequality in thedelivery of priority health services acrossthe country by targeting the most under-served populations. As Health Cluster leadagency, WHO works to ensure a functioninghealth sector coordinating mechanism in-volving UN agencies, partners, health au-thorities, donors and community members,and provides up-to-date information oncountry health situation and needs, includingregular situation reports and bulletins3.

Under the Health Security and Emer-gencies operations, emergency nutrition isa strategic sector for WHO in South Sudan.Since the onset of the crisis in early 2014,WHO has provided technical and strategicguidance to the nutrition humanitarian

Location: South SudanWhat we know: Management of SAM children with medicalcomplications is critical; communicable disease burden can rise inemergencies, increasing caseload and adding strain to existing healthservices, including key medicines supply and management.

What this article adds: Throughout the heightened emergency phase inSouth Sudan from 2014 to 2016, WHO intensified support to nutritionprogrammes with increasing focus on inpatient management of medicallycomplicated severe acute malnutrition (SAM). A SAM-specific medicineskit was devised and introduced in June 2016, along with a comprehensivecapacity-building package and consistent M&E tools, in line with existingWHO Global Guidelines and national information systems of the healthand nutrition sectors. Kits were distributed to one third of functioningstabilisation centres before the latest escalation in violence disruptedservices and monitoring. This initiative reflects WHO’s operational role innutrition programming in emergencies.

1 IPC analysis 2016.2 www.afro.who.int/en/rdo/transformation-agenda.

html3 The work of WHO in South Sudan, 2015. Working

towards better health outcomes for the people of South Sudan.

Field Article

By Marina Adrianopoli and Allan Mpairwe

Marina Adrianopoli has beensupporting WHO in South Sudanas Emergency Nutrition FocalPoint since 2014. She has over 10years’ experience in advising onand implementing nutritionemergency response, policy-

making processes and country-level programmesfocusing on public health nutrition and food andnutrition security in different emergency anddevelopment contexts in East Africa, Central Asia andEastern Europe.

Dr Allan Mpairwe is theProgramme Manager for HealthSecurity and Emergencies for theWHO Country Office in SouthSudan. He has over 15 years’experience in implementingemergency health services in

resource-limited settings and has supportedemergency response operations in South Sudan forthe last seven years. He was instrumental in theinitiation and introduction of the new kit formanagement of children with SAM with medicalcomplications in South Sudan.

The authors gratefully acknowledge Dr UsmanAbdulmumini, WHO Representative in South Sudan,and colleagues from the Country Office in Juba,Magda Armah, Health Cluster coordinator, and SylvainDenaire, Operation Officer, for playing a crucial role insupporting the implementation process at thenational level. Thanks also to HavaskhonAbdulatipova, Henry Lagu and the staff of the WHOJuba Logistics Unit, who provided logistics support.Deep appreciation is expressed to Dr AdelheidOnyango, WHO AFRO Regional Advisor for Nutrition,Sophie Laroche, WHO HQ Essential Medicines, andcolleagues at WHO Headquarters Department ofNutrition for Health and Development for theirtechnical guidance, advice and continued support.

A poster sharing these experiences was presented atthe World Nutrition Congress, Cape Town, SouthAfrica, in September 2016. Improving strategies forinpatient management of severe acute malnutrition andmedical complications in children: A new WHO medicalmodule distributed in South Sudan as innovative WHOEmergency Response on Nutrition. Marina Adrianopoli,Allan Mpairwe and Sophie Laroche.

WHO emergencynutritionresponse inSouth Sudan

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community and Ministry of Health (MoH) duringthe level 3 emergency. It has effectively supportedreview of strategic plans, policies, guidelines andcriteria, and provided operational guidance onnutrition, through close collaboration with theMoH and partners. WHO is also actively engagedin intensifying timely sharing of nutrition infor-mation to better plan the response, as well asstrengthening linkages and integration betweenhealth and nutrition.

is article documents WHO-led developmentsand progress around the treatment of complicatedSAM in South Sudan.

Identified gap: Challenges inmanagement of complicatedSAMAccording to Nutrition Cluster (NC) projections,in 2016 nearly 690,000 children under five yearsof age are expected to be acutely malnourished,of whom more than 230,000 will be severelymalnourished. e burden of SAM children withmedical complications is significant and estimatedat up to 10% of the total SAM caseload (approx-imately 6% in 2015)4. Figure 1 reflects the ad-missions trend of malnourished children withmedical complications at a stabilisation centre(SC) through 2015. Medical complications ofSAM include: severe oedema; poor appetite in-cluding inability to suckle breastmilk effectively;and one or more Integrated Management ofChildhood Illness (IMCI) danger signs5. Childrenpresenting these conditions should be treated asinpatients in SCs, where clinical and nutritioncare is provided. However, the lack of basicmedical supplies drastically reduces the capacityto deliver effective and immediate response.

e most common morbidities amongst in-ternally displaced persons (IDPs) in South Sudanare acute respiratory infection (ARI), acute bloodydiarrhoea, and malaria (see Table 1); the most

common causes of death are malaria, followedby ARIs, and acute watery diarrhoea. Commu-nicable diseases remain a concern throughoutthe country due to poor sanitation, shortage ofsafe drinking water, crowded living conditions,malnutrition, and poor immunity. ere hasbeen a notable upsurge in the scale and frequencyof outbreaks of epidemic-prone diseases, especiallyin displacement sites where malnutrition andpoor immunity render young children and preg-nant women particularly vulnerable. A majorcholera outbreak was reported in the secondquarter of 2016 and is ongoing.

As of September 2015, some 55% of the healthfacilities in Unity State, Upper Nile State andJonglei were no longer functioning. Stock-outs ofessential medicines exacerbate the critical situation7.e conflict hampers access to and delivery ofhumanitarian assistance and has already increasedthe operational costs of implementing the hu-manitarian response. is is exacerbated by thevery fragile health systems (lack of skilled staff,supplies and equipment, leadership, functioningfacilities, etc.) at all levels. Most of the healthfacilities in Juba and affected states are almostnon-functional, as health personnel fail to reportfor duty due to the prevailing insecurity8.

SCs are usually set up in hospitals or in PrimaryHealth Care Centres (PHCCs), which are normallysituated at Payam headquarters. ey provide re-ferral services as well as laboratory services fordiagnosis, maternity and inpatient care. EachPHCC is expected to serve a catchment area ofaround 50,000 people. Drugs used in the SC arepart of the hospital or PHCC package; thereforeSCs rely on hospital and PHCC stock and usemedicines that are also administered to sick non-SAM children who present. As a result of serviceintegration, procurement and budgeting exclusivelyfor SCs’ stock of medicines is not common practice.Since they are embedded in static health facilities,SCs are also more exposed to closure in times ofinsecurity and displacement compared to outreachand outpatient mobile nutrition services.

WHO responseAn improved inpatient care component of CMAMin South Sudan called for measures to addresscritical drugs shortage through timely procurementof essential medicines, ensuring coverage coun-trywide including conflict-affected areas and interms of protection of civilians (PoC). Additionalactions such as training were required to develop

and reinforce the capacity of medical teams man-aging patients with SAM with medical conditions.In this challenging context, WHO South Sudanhas identified the provision of a medical kit forSCs and the related capacity-building packageand guidelines as a comprehensive strategy tosupport SCs managing SAM children with medicalcomplications (MSAM/MC).

e innovative procurement strategy shapedby WHO in South Sudan entails:• Design and technical development of an inov-

ative kit (see Box 1), which has been distrib-uted in South Sudan and has been available in the online WHO catalogue since April 2016.South Sudan was the first country in the worldto introduce the medical kit in June 2016;

• Standardisation of the set of medicines neededin SCs, aligned to South Sudan national med-icine usage and taking into considerationquality, safety and efficacy of medicines supplied;

• Fast track procurement, involving supply ofstandard, pre-packed kits ready to meet priori-ty health needs in an emergency, agile supply chain management and strategic sourcing of SC drugs to support positioning of supplies;

• e inpatient care component of the IntegratedManagement of Acute Malnutrition (IMAM) national guidelines will be updated, aligned with the Hospital Care of Children Pocket Book 2013 (reference guidelines in SCs);

• Quality assurance, as all drugs are obtained from reliable sources; and

• Integrated feedback mechanism (report), so that the service can be continuously im-proved in response to feedback on delivery.

is strategy enables MoH and partners operatingSCs to be autonomous in providing timely treat-ment. It also provides a stopgap measure, offeringrelief for hospital stocks of medicines, whichcurrently are not procured and managed specifi-cally for children with SAM/MC.

TrainingTo provide guidance on medicine usage and sup-port partners in delivering refresher training tostaff working in SCs, WCO South Sudan has de-veloped a context-specific, capacity-building pack-age on inpatient management of SAM focusedon medical conditions. Building on the WHOGuidelines and training for the inpatient treatmentof severely malnourished children9, the packagehas been developed by WHO Emergency NutritionSouth Sudan, with the support of implementingpartners and WHO AFRO Regional Office, andcleared by MoH, Republic of South Sudan.

4 South Sudan Humanitarian Response Plan 2016.5 www.who.int/maternal_child_adolescent/documents/IMCI

_ chartbooklet/en/6 WHO South Sudan (EWARN) Early warning and disease

surveillance bulletin. www.who.int/hac/crises/ssd/epi/en/7 WHO/MOH Situation Reports on Cholera in South Sudan,

August 2016.8 Humanitarian Needs Overview, 2016.9 Based on WHO Guidelines for the inpatient treatment of

severely malnourished children, available at www.who.int/ nutrition/publications/severemalnutrition/9241546093/en/, and WHO Paediatric emergency triage, assessment and treatment: care of critically-ill children Updated guideline 2016 www.who.int/maternal_child_adolescent/documents/paediatric-emergency-triage-update/en/

10 WHO Pocket book of hospital care for children: Second edition www.who.int/maternal_child_adolescent/documents/child_hospital_care/en/

Field Article

Admissions trend of malnourished children with medical complications at astabilisation centre (SC) in Bentiu Protection of Civilians site, 2015 Figure 1

60

50

40

30

20

10

01 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 No

. of Sam

cases w

ith medica

l com

plica

tions ad

mitted

Weeks

05 5 5

17

11 7

161711 9 7 8

1513

7 813

61112

1519

242419

28

18

34

46

37

2927

34

42

4850

3237

38

293028

35

2924

42

96

Table 1 Top causes of morbidityamong IDPs6

No Disease Cumulativecases 2015

Cases as % of totalconsultations

1 Malaria 276,913 28%

2 Acute respiratoryinfection (ARI)

187,673 19%

3 Watery diarrhoea 82,747 9%4 Acute bloody

diarrhoea10,386 1%

5 Measles 598 0.002%

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e package consists of four tools: 1) A comprehensive refresher training of 70

slides covering key steps of the ManagementSAM/MC, addressing both clinical and sup-portive care for conditions to be treated with the medicines provided. Most slides can be used as stand-alone handouts or posters. It is not a substitute for full training on appropriatemanagement of SAM with medical complica-tions, designed for health-care providers.

2) A pictorial manual illustrating medical conditions associated with SAM in children, accompanied by detailed explanations.

3) Pocket book of hospital care for children: Second Edition – Guidelines for the man-agement of common childhood illnesses. is includes a full chapter on the inpatient management of SAM, web link to the Pocketbook10 and links to free applications for android phones and iphones.

4) WHO video – Emergency Treatment, which illustrates urgent actions required and stan-dard emergency procedures on giving oxygen,glucose, fluid and antibiotics to help improv-ing the quality of inpatient care for the man-agement of SAM/MC in children.

e capacity-building package was illustrated tothe nutrition and health community in SouthSudan during the ‘kick off’ meeting and distributedto all nutrition and health cluster partners runninginpatient care programmes. Technical orientationon the package has been provided by WHOduring ad hoc orientation sessions conductedcollectively and on a one-to-one basis with allinterested partners and the MoH.

Monitoring Five monitoring components have been developedby WHO South Sudan aimed at collecting, man-aging, analysing and reporting on key indicatorsto track progress, plan response and prioritiseactions to improve service delivery (see Box 2).

Preparatory workA consultative process began in November 2015led by WCO Emergency Unit/Nutrition, involvingthe MoH, NC, Health Cluster and implementingpartners, and technically supported by WHOHQ. Key steps of the process have included tech-nical consultations with MoH PharmaceuticalDepartment, Nutrition Unit and Primary DirectorGeneral; verification and review of the list ofmedicines to ensure consistency with the List ofEssential Medicines of South Sudan; and meetingswith partners at different levels to corroboratethe effectiveness of drugs utilisation. is infor-

mation, together with several field-mission find-ings, was instrumental in better identifyingcapacity needs, information gaps, stock capacityand skills in management of supplies. is laidthe foundations for developing the capacity-building and monitoring packages.

ImplementationProcurement of the first 20 kits by WHO SouthSudan began in November 2015. e process ofprocurement for these initial kits was long (sixmonths) as it involved medicine procurementfrom different suppliers, MoH clearance and as-sembly of the kits in Juba. (Now that the kitfeatures in the WHO online catalogue, the shipmenttakes approximately one month from the purchaseorder). e first recipient, MoH, and partners’facilities were selected based on average monthlycaseload, prevalence of GAM (and associatedSAM) in the catchment area, population figuresincluding number of children under five as perthe official statistics, documented gaps in stockof medicines, and confirmed presence of medicalofficers operating in the SC (given the nature ofthe kit and skillset required). e selection processwas coordinated by WHO Emergency Nutrition,supported by the Health and Nutrition Clustercoordination team and guided by the MoH.

e strategy was launched in June 2016 inconjunction with the distribution of kits. edistribution covered nearly one-third of the totalfunctioning SCs across all ten (former) states

(16 facilities out of a total 5811), ranging fromhospitals to PHCCs in host communities, IDPand PoC sites. Supplies are calculated to treat1,000 children over three months. e distributionstrategy took into account the different levels ofvulnerability across the country and aimed at re-sponding to the high needs in urban contextsand PoC sites, where the SCs integrated in themain hospitals of the capital Juba and clinics inPoC sites required increased support.

Sadly, as soon as the distribution was completed,a renewed and terrible wave of violence eruptedagain, drastically reducing the capacity of partnersto respond to the emergency. Most of the staffwere relocated (WHO and other nutrition/healthcluster implementing partners’ personnel workedremotely from the region in July, August andSeptember) and the monitoring system has beeninterrupted.

ConclusionsThe overall response reflects an active imple-menting role of WHO in an emergency, specificallyin the context of the CMAM approach. WHO’srole has been to strengthen complicated casemanagement, which tends not to attract the sameattention as the prevention, outreach and outpatientservices for MAM and SAM children. e expe-rience in South Sudan reflects efforts to strengthencoordination and synergies between clusters andother key actors at national and field levels in thecontext of CMAM. e development of a stan-dardised module of medicines for SAM/MCbrought a unique opportunity for WHO SouthSudan to increase effectiveness and sustainabilityof life-saving nutrition interventions and to boostWHO strategy shaped around improved inpatientmanagement of SAM/MC, which encompassesprovision of medical supplies, capacity-buildingand review of national guidelines.

For more information, contact: Marina Adrianopoli, email: Marina.adrianopo-li@gmail.com, tel: +393497507123 or Dr AllanMpairwe, email: mpairwea@who.int ; ampair-we@gmail.com, tel: +256772510026

Field Article

11 Nutrition Cluster, March 2016.

The objective of the new WHO kit Second line drugs for the medical management of Severe AcuteMalnutrition with medical complications is to provide essential drugs for the inpatient management ofsevere acute malnutrition with medical complications in children (MSAM/MC).

The content is organised into four modules which constitute one kit, sufficient to treat 50 children withSAM/MC. The kit contains 33 medicines and 11 health commodities. The modules are:

Routine drugs module Contains routine drugs also used in outpatient nutrition programmes(anthelminthic, antibiotics, retinol and resomal).Basic module (analgesic, antifungal, antibiotics, solutions for treatment of hypoglycaemia,dermatological preparations, ophthalmological preparations, health commodities and renewable).Supplementary module (medicines used in heart failure, antibiotics, ophthalmological preparations). Malaria module (Coartem tablets, artesunate, malaria rapid diagnostic tests and lancets), incorporatedin the kit to address one of the top priority diseases reported in the context under consideration.

The kit does not contain nutritional commodities as it has been designed to complement existing kits,equipment and supplies already provided by UNICEF and WFP. The provision of kits complements thecollective NC response in South Sudan, largely focused on outpatient and preventive care of SAM.

The kit was established in line with the recommendations of the 1999 WHO ‘Management of severemalnutrition: a manual for physicians and other senior health workers’ and the ‘Course Director Guide ofthe related WHO Training Course, 2002’. The list of drugs, initially developed in 2011, was reviewed bySAM management experts, the WHO Expert Committee on Essential Medicines, and with advice fromcolleagues from relevant WHO departments (HAC, CAH), and revised accordingly.

Box 1 Content of WHO SAM kit

Tool 1: Stock inventory form, to track the quantity of medicines dispensed and the balance in eachfacility. Tool 2: The Inpatient Therapeutic Programme (ITP) SC data collection form, employed by the currentNutrition Information System (NIS) of the NC in South Sudan, is integrated as the second tool. Partnersare 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. Tool 3: Additional information on the medical conditions diagnosed and treated, including eyeproblems, severe anaemia, SAM with oedema, malaria, suspected/confirmed HIV infection and ARI(including TB and pneumonia).Tool 4: Final feedback form, to assess the appropriateness of medicines and material provided(quantity, suitability) and suggestions for improvements. Tool 5: Challenges and strengths, for submission at least once and any time during implementation.

Box 2 Monitoring tool

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Agency profile......................................................

Name: WaterAid

Address: WaterAid, 47-49 Durham

Street, London, SE11 5JD, UK

Email: healthystart@wateraid.org

Website: www.wateraid.org/uk

Year founded: 1981

Chief executive: Barbara Frost

No. of HQ staff: 289

No of staff worldwide: 1151

ENN interviewed Dan Jones and MeganWilson-Jones from WaterAid for theField Exchange agency profile slot. Meganis the Policy Analyst for health and hy-

giene in the global policy team, while Dan (norelation) is Advocacy Coordinator for HealthyStart, WaterAid’s current global advocacy priorityto improve child health and nutrition by integratingwater, sanitation and hygiene into health policiesand programmes worldwide. Both used to workfor RESULTS UK (which advocates for buildingthe public and political will to end poverty) and,since they are relatively new to the organisation,checked in with some longer-serving colleaguesto answer some of our questions. e answerswere very interesting.

WaterAid was set up in 1981 by the UK waterindustry following a irsty ird World con-ference, which was prompted by the industry’sdesire to respond to the UN Decade on Water.e UK water industry raised £25,000 and Wat-erAid was born, starting with projects in Zambiaand Sri Lanka. Fast forward to 2016 and WaterAidhas just celebrated its 35th anniversary. Its growthhas been truly phenomenal: in the six years from2009 to 2015, it provided 9.6 million people withclean water and a further 13 million with sanitationfacilities. It also expanded its country programmesin that time from 22 to 37, including countriesin Asia, Africa and the Americas. is year, Wa-terAid India became the first country programmeto become a member of the WaterAid InternationalFederation. e secretariat for the Federation isbased in the UK and all members (Australia,Canada, India, Japan, Sweden, United Kingdomand United States of America) are involved inadvocacy and fund-raising in respective countries.

Dan explained that WaterAid’s general oper-ational model is to work with local partners totarget the most marginalised communities. It isbest known for its ‘taps and toilets’ programmes;a reflection of its founding by a group of waterengineers. Over the years, the organisation hasevolved into using a ‘transformation and sus-tainability advocacy-based model’, working closelywith national governments, who are encouragedto take ownership of scaling up and delivering

sustainable water, sanitation and hygiene (WASH)services for the whole population. is newstrategy is much more about advocacy and exer-cising influence; WaterAid still supports on-the-ground programmes, but increasingly uses themto demonstrate what can be done to local, districtand national decision-makers in order to provideevidence and support the government in scalingup and ‘owning’ the provision of national services.WaterAid also invests in work to enable citizensto claim their rights. As it looks to influencegovernments on how much and how they spendon WASH, it supports them in budget planningand tracking. It also looks at international insti-tutions and donor agencies and how WASH needsto be integrated into health, nutrition and edu-cation, because WASH underpins many of theSustainable Development Goals – as Megan putsit simply: “ey all need WASH for success”. eultimate aim is national-led plans that donorscoordinate and harmonise funding streams behind;an ambition that explains WaterAid’s engagementwith mechanisms such as the Sanitation andWater for All global partnership (SWA)1; similarto the SUN Movement in the WASH world.

Megan explained that nutrition is a relativelynew area of interest for WaterAid, as part of its ex-panding work on health. e growing evidence oflinks between WASH and nutrition, as well ascritical work on environmental enteric dysfunction(EED), has helped promote greater focus on nutritionwithin the organisation. e World Health Organ-isation (WHO) estimates that half of all undernu-trition is linked to infections caused by unsafewater, lack of sanitation and poor hygiene. Mostmember countries now have health advisors thatcover nutrition, and country programmes are in-creasingly employing health and nutrition staff.Megan mentioned two recent WaterAid nutrition-sensitive WASH programmes. One is in Bangladesh,where the WASH programme has an elementspecifically to improve access to water for foodproduction. e second, in Nepal, is collaborationwith the Ministry of Health and builds hygiene andnutrition behaviour-change into the routine im-munisation of rotavirus. WaterAid has just developedinternal guidance material on how to improve thenutrition-sensitivity of WASH programmes.

Dan explained that the organisation still seesitself very much as a development agency with afocus on long-term sustainable programming,although emergencies do occur where they operatein fragile contexts. For example, in Nepal recently,WaterAid found itself working as part of theWASH cluster, contributing hygiene expertise toprogramming. e organisation has also beeninvolved in the Ebola crisis in West Africa, aswell as engaging in policy dialogues on anti-mi-crobial resistance. Megan described how theseexperiences reinforced the vital importance andmajor gaps in provision of clean water, sanitationand good hygiene in hospitals and health clinics.(WHO estimates that, for example, 38% of health-care facilities in low and middle-income countrieslack access to clean water, making preventingand controlling infections impossible).

WaterAid is increasingly collaborating withthe SUN Movement at global and national levels.e SUN Movement Secretariat has contributedgreatly to WASH policy development at nationallevel, with country staff becoming members ofthe national Civil Society Alliance. WaterAid hasalso recently become part of the new BabyWASHcoalition, working closely with World Vision(lead) and others. is coalition is bringing to-gether actors from Early Childhood Development,Nutrition, Health and WASH, and was launchedat this year’s UN General Assembly.

WaterAid believes that multi-sector program-ming is essential to ending malnutrition. However,its recent Missing Ingredients report (summarisedin this edition of Field Exchange), which analysednational nutrition action plans, found that apartfrom Timor Leste and Nepal, very few countriesare comprehensively embedding and integratingWASH into these plans. Furthermore, very fewWASH plans make reference to nutrition. Meganreflected that designing WASH programmesthrough a nutrition or health lens can lead tobetter quality programmes; for example by targetingprogrammes based on nutrition vulnerability.With regard to behaviour change, there is a realopportunity to come together and combine efforts

1 sanitationandwaterforall.org/

WaterAid/ Ernest Randriarimalala, Madagascar, 2016

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– taking breastfeeding and food hygiene as ex-amples, both involve changing behaviours, whichis challenging. However, through utilising multipledelivery channels and delivering joint messaging,especially if one reinforces the other, this couldlead to more effective and sustained behaviourchange.

WaterAid is not a research-organisation anddoes not engage in randomised controlled trials,however it is well placed to contribute to thelearning and evidence around delivering coordi-nated and integrated programmes, oen describedas operational research. Although the nutritionfocus of its work has so far been on stunting(where there is the strongest evidence of a link

between WASH and nutrition), it is likely that,given the increasing evidence of overlappingpathways for wasting and stunting, the attentionof WASH actors like WaterAid may start toinclude a focus on wasting.

Our last question concerned the major chal-lenges for scaling up nutrition-sensitive WASHprogramming. Dan reflected that, in order forWASH services to lead to nutrition outcomes,the services must be utilised, and changing be-haviours is very challenging. It requires under-standing the specific context (knowing what mo-tivates behaviours and what the barriers are),which is informed through rigorous, formativeresearch. e typical time-frame of WASH pro-

grammes can also be problematic, as they areoen too short to report nutrition impact unlessfollowed for a number of years. Finally, stake-holders need to stop thinking in silos. Dan sug-gested that this occurs on multiple levels – pro-gramme silos, sector silos, divided ministerialresponsibility in governments, and even siloswithin donors (humanitarian and development).is, he argues, needs to change.

WaterAid is a large and highly respectedWASH agency that is starting to look at howpolicy and programming can best support nutri-tion. ENN greatly looks forward to includingWaterAid learning in this relatively new area infuture issues of Field Exchange.

Views .........................................................................

Q: How would you summarise South Sudan’scurrent nutrition situation? A: Overall, the nutrition situation in South Sudanis worrying, with global acute malnutrition(GAM) persistently above the emergency thresholdin the Greater Upper Nile, Northern Bahr elGhazal, Warrap states and Eastern Equatoriastates (FSNMS, Dec 20161). According to themost recent national data, nearly one third ofchildren under five years old are stunted, 23 percent wasted, and 28 per cent underweight (SSHHS2010)2. e prevalence of GAM varies seasonallyand substantially across states, with peaks of upto 30 per cent in some locations.

From April to August 2016, a total of 26county-level assessments were conducted; 81%of these assessments showed GAM rates abovethe 15% WHO emergency threshold. Based onthe analysis, the GAM/Proxy GAM3 was ‘ExtremeCritical’ (>=30% prevalence) in Aweil North andAweil West, which were the only two counties

with recent assessments4, and ‘Critical’ (15% to29.9% prevalence) in Akobo, Twic East, Uror,Abiemnhom, Guit, Mayom, Mayendit, Panyinjar,Rubkona, Bentiu POC, Pariang, Longetchuk,Nasir, Maiwut, Ulang, Wau, Gogrial West andGogrial East. Counties classified as ‘Serious’ (10%to 14.9% prevalence) were Kapoeta North, Melut,Maban and Tonj North, while Kapoeta South isin ‘Alert’ (5% to 9.9% prevalence).

e deterioration in the nutrition situation isprimarily due to physical insecurity (which partlyhinders the humanitarian response), the effectsof the economic crisis, and depleted stocks fromthe last harvest. In the Greater Upper Nile, whileconflict subsided in most areas, it persists in somepocket areas. Furthermore, the economic crisis(partly due to devaluation of the South Sudanesepound and exponential increase in food prices in2016), coupled with persistent violence, notablyin Wau and some parts of the Greater Equatoria,aggravate the malnutrition situation5. Major ad-

ditional contributing factors to malnutrition inthe worse-off counties are sub-optimal Infant andYoung Children Feeding (IYCF) practices andpoor water, sanitation and hygiene (WASH) facilitiesand practices. Child-feeding practices, such asuntimely introduction of complementary foodsor poor quality and inadequate quantity of thesefoods, contribute substantially to the high levelsof malnutrition. Additionally, low exclusive breast-feeding practices are a key contributing factor.

In the upcoming season (September to De-cember 2016), the nutrition situation is expectedto improve slightly in most counties due to theexpected harvest, pasture and availability of milk.Admission trends to nutrition centres are alsoexpected to decrease in most counties in thecountry during this season. However, taking intoconsideration the current existing burden ofacute malnutrition, market price trends and theexisting high level of conflict, the nutritionsituation in Northern Bahr el Ghazal and Unitystates are not likely to see significant changesand will likely remain in ‘Critical’ phase (GAMprevalence currently 15% and 29.9% respectively).

Q: Since joining the Scaling Up Nutrition(SUN) Movement in June 2013, whatimportant steps have been taken andmilestones achieved in South Sudan as a resultof joining the Movement?A: e Republic of South Sudan officially joinedthe global SUN Movement in 2013 aer a letter

Overcoming the challenges ofnutrition information systems

South Sudan nutrition:

e health sector in South Sudan, the youngest nation in Africa, has been growingfrom strength to strength amid insecurity and emergencies that have affected thegeneral nutrition situation. e Ministry of Health and partners are implementingvarious nutrition programmes and coordinating efforts to put in place a sustainablenutrition information system. In an interview with Titus Mung'ou, ENN RegionalKnowledge Management Coordinator (SUN), Rebecca Alum William, the Director ofNutrition in South Sudan, and Shishay Tsadik, the Nutrition Technical Advisorseconded to the Ministry of Health by Save the Children International, discuss progressmade.

1 World Food Programme South Sudan, Food Security and Nutrition Monitoring Report (FSNMS) bulletin 18 July 2016.

2 South Sudan Household Health Survey 2010 Final Report, published August 2013.

3 Proxy GAM is a term used to denote findings from rapid nutrition assessments where conditions often involving insecurity have prevented standard ENA SMART methodolo-gies being used.

4 August 2016 Aweil North and Aweil West exhaustive MUCA screening result.

5 World Food Programme South Sudan, Food Security and Nutrition Monitoring Report (FSNMS) bulletin 18 July 2016.

Agency Profile

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of commitment was signed by H.E the Vice Pres-ident. e letter expressed the political commit-ment from the Government of the Republic ofSouth Sudan to scaling up nutrition in the country.

e SUN Movement was launched in thecountry with commitment to include nutritionin the Food Security Council so that it became‘the Food and Nutrition Security Council (FSNC)’in in 2013, the same year of the launch of SUNMovement. e FNSC is a high-level, multi-sector policy coordination platform chaired byH.E the President. SUN Movement activitieshave been slow since the launch, with limitedprogress in establishing the country’s SUN Sec-retariat and SUN networks, developing the Na-tional SUN Work Plan and other activities. ispartly reflects the crisis which erupted in 2013,resulting in a refocus on humanitarian activities.However, revitalisation of the SUN Movementstarted again in April 2016. A six-month detailedwork plan for revitalisation of the country’s SUNMovement was developed with a focus on con-ducting social mobilisation and advocacy, estab-lishment of different SUN Networks, developmentof work plans for the networks, and developmentof a national SUN work plan. Factors that con-tributed to this revitalisation included nutritionbeing prioritised in Ministry of Agriculture andHealth policies, strengthening of the NutritionDirectorate by the Ministry of Health (MoH),and United Nations (UN) agencies supporting a‘rebooting’ of the SUN Movement in the country.

e South Sudan SUN Movement Steeringcommittee was established in late 2015 with aresponsibility to provide technical support toSUN networks and advise the SUN Focal Point,the Under-secretary in the MoH. is position istemporarily located in the MoH with its permanentlocation still under discussion. e steering com-mittee is composed of UN agencies (UNICEF,WFP, WHO and FAO) and government line min-istries chaired by the MOH Nutrition Director.e Steering committee conducts weekly meetings.

Media advocacy has been identified as one ofthe key strategies for advancing the SUN Move-ment in South Sudan. rough advocacy, it ishoped to reach out to the many stakeholdersthat can have an impact on nutrition in SouthSudan, as well as inform them about SUN activities.

e establishment of multi-stakeholder net-works including UN agencies, Donor, Civil Society,Academia/Research, and Business/Private Sectorhas begun.

Government SUN Focal Point and SUN rep-resentatives from MoH and Ministries of Agri-culture and Finance have attended global andregional meetings and workshops for experi-ence-sharing and learning exchange.

Q: In 2013, South Sudan nutrition actors notedchallenges of nutrition information during emer-gencies and the need for a coordinated, validatedNutrition Information System (NIS). Significantand important changes were then made to vali-dation of SMART surveys, OTP/SFP (Outpatienterapeutic Programme/Supplementary FeedingProgramme) reporting harmonisation, IPC (In-tegrated Phase Classification) and FSMNS (Food

Security and Nutrition Monitoring System). Havethese improvements been maintained and whatsteps are being taken or are needed to strengthenNIS in South Sudan?A: Yes, improvements have been made and main-tained. ere are efforts to integrate the NIS intothe District Health Information System (DHIS)and Health Management information system(HMIS). Currently, nutrition information reportingformats, registration books and other tools arebeing developed and finalised in consultationwith the Nutrition Information Working Group(NIWG). Nutrition information is then sharedwith the M&E Department of the MoH.

Together with the nutrition coverage network, the MoH and Nutrition Cluster facilitated a les-son-learning workshop on how to maintain thecapacity of partners and government actors toconduct coverage assessments for the treatmentof SAM and MAM and maximise the use of cov-erage assessment results.

Beyond the traditional SMART assessments,there are initiatives to consider other monitoringmechanisms like the Integrated Food Securityand Nutrition Causal Analysis (IFANCA),strengthening the FSNMS and IPC system forSouth Sudan which helps MoH to make informeddecisions.

Q: How is the MoH undertaking its functions asthe Secretariat of NIWG? What key lessons andchallenges have MoH noted in coordinating ac-tivities with NIWG members? A: In April 2015, the MoH assigned two nationaltechnical staff, together with the Nutrition Advisorseconded from Save the Children (SCI) workingwith the NIWG, to lead the overall coordinationof the group. Moreover, there is an initiative tointegrate NIWG’s Technical Working Group(TWG) into the MoH’s M&E Department, whereall health and nutrition information activitiesare coordinated, to ensure sustainability of thefunction of NIWG. However, due to competingpriorities, this may take time.

Q: In South Sudan, the NIWG officially reportsto the Nutrition Cluster. How has this arrangementimproved coordination of nutrition information?A: e NIWG is still reporting to NutritionCluster, which is one of the limitations, since theMoH is unable to access, utilise and review theworking group’s performance. However, the moveto integrate within the MoH’s M&E Departmentwill address this and provide a comprehensivedatabase of assessment proposals and results.

Q: What is the role of the Government and keyactors in sustaining the NIWG? How have SUNMovement actors/networks connected with NIS?Have SUN actors’ activities been influenced byNIS?A: e Government and partners sustain theNIWG. Once the SUN networks are established,it is hoped that the NIS will help inform theirplanning and activities.

Q: How has the NIS helped shape policies andprogrammes in relation to country and globalnutrition targets?A: e available information from SMART surveys,IPC, FSNMS and programme reports significantly

helps nutrition stakeholders in resource mobili-sation, planning and decision-making. However,most nutrition assessments focus on emergenciesand the results don’t influence stakeholders inaddressing longer-term nutrition resilience andprotection responses.

Q: e need for advocacy by Nutrition Clusterpartners to build MoH understanding of the im-portance of information systems in relation topreparedness and response planning was identifiedin 2013. Has it been addressed? How? A: e MoH has started emphasising the criticalimportance of NIS. ere are moves to integratesystems, as outlined earlier; NIS tools and indi-cators have been identified; and the MoH islooking for resources to train and build thecapacity of health and nutrition service providersand personnel involved in data collection, reportingand analysis on how to use these nutrition infor-mation tools (mainly the reporting formats, reg-istration books, monitoring and supervisionchecklists). e integration/harmonisation willcritically allow for a central database within gov-ernment that can be used for planning, deci-sion-making and further research.

Q: How has MoH addressed the challenge of itscapacity to lead and implement NIS and engagetechnically in NIWG? What progress has theMoH made in enhancing its capacity in infor-mation management?A: e developments outlined so far reflect actionsand progress made in this regard, such as movesto harmonise NIS within DHIS and HMIS, inte-grate the NIWG within the MoH’s M&E Depart-ment, and transition the Nutrition Cluster NISto DHIS and HMIS. In terms of enhanced capacity,SCI seconded a Nutrition Technical Advisor tobuild capacity of the NIWG and NIS and theMoH has assigned two technical staff responsibleto the NIWG who are receiving training supportedby partners. e MoH has taken a leadershiprole as chair and co-chair of the NIWG and theMoH Nutrition department is working closelywith the Nutrition Cluster team and partners.

Q: Overall, to what extent has strengthening ofthe NIS (helped by the Nutrition Cluster andlargely driven by emergency programming needs)contributed to the aims and objectives of theSUN Movement and how could the existing NISin South Sudan be strengthened to further enableSUN Movement aims and objectives?A: e current NIS provides a means to understandthe levels of malnutrition in South Sudan, theinvestments on nutrition, the gaps, priorities andthe need for national and local government lead-ership to tackle the situation. However, in orderto strengthen the contribution of NIS to the ob-jectives of the SUN Movement, NIS should movebeyond SMART, FSNMS and IPC to include as-sessments which involve a causal analysis of mal-nutrition. ere is also a need for harmonisedand standardised national SMART and coveragesurvey guidelines, in line with the internationalguidelines. Furthermore, the most recent nationalhousehold survey (Demographic Health Survey)was conducted in 2010. is urgently needs up-dating, as there has been substantial change inthe nutrition landscape over the past six years.

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Field Article

Fieldexperiencesfrom coverageassessmentsin Afghanistan

Sampling ininsecureenvironments:

By Marina Adrianopoli and Allan Mpairwe

Ben Allen has been GlobalCoverage Advisor for ActionAgainst Hunger UK for the pasttwo years. He has now left topursue further study in publichealth. From 2010 Ben workedwith ACF-UK in evaluation,

learning and, more recently, on methodologies toassess the coverage of CMAM programmes. He hasdirectly supported two SQUEAC assessments inAfghanistan and provided remote support to manyothers.

Mark Myatt is a consultantepidemiologist and seniorfellow at University CollegeLondon. His areas of expertiseinclude infectious diseases,nutrition and survey design.

Nikki Williamson is SeniorProject Officer at ActionAgainst Hunger UK,specialising in the coverageassessment of CMAMprogrammes. Previously shewas SLEAC Programme

Manager in Afghanistan, managing theimplementation of the five SLEACs addressed in thisarticle. Nikki has also conducted a regional SLEACand district SQUEAC in Uganda.

Danka Pantchova is NutritionSurveillance and PreventionAdvisor with Action Contre laFaim France. Previously shetechnically supported all ACFnutrition programmes inAfghanistan, including

coverage assessments.

Hassan Ali Ahmed is theNutrition Surveillance Head ofDepartment with ActionContre la Faim Afghanistan. Hehas worked on nutritionsurveillance projects in Kenya,Somalia and Afghanistan for

the last seven years and has wide experience ofconducting nutrition assessments, includingSQUEACs, SLEACs, SMART and Rapid SMART surveys.

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Location: AfghanistanWhat we know: Afghanistan is a challenging place to implementcommunity-based management of acute malnutrition (CMAM) andcoverage assessments, due to persistent insecurity.

What this article adds: Coverage assessments are important but not life-saving interventions; exposure to risk should be managed and minimisedfor staff. Insecurity typically affects spatial representation of villages andachieving minimum samples. Including only safe and accessible villages islikely to inflate coverage estimates; bias introduced due to adaptationsshould be clearly reported. Qualitative information from identified casesand additional qualitative studies can also valuably inform programmereform and, to some extent, compensate for the limitations to the surveysample. A number of steps can help achieve the basic principles of datacollection while ensuring the safety of staff and informants. These includebalancing risks, triangulation and monitoring of security information, useof local staff, additional context-specific staff training, strongcommunication protocols and documentation of challenges for widerlesson learning.

When evaluating access andcoverage of CMAM serv-ices in insecure environ-ments, restrictions on data

collection limit assessments. is articledescribes the challenges faced in samplingduring coverage assessments of severeacute malnutrition (SAM) treatment serv-ices across Afghanistan and provides somemethodological guidance for obtainingthe most reliable information while main-taining staff safety. e article draws onexperiences from five different SLEAC1

assessments (in Laghman, Badakshan,Jawzjan, Bamyan and Badghis) and threeSQUEAC2 assessments (in Samangan,Paktya and Kunar) supported by ActionAgainst Hunger (ACF) and the CoverageMonitoring Network3 (CMN) in Afghan-istan4. Details on these coverage methodsare available at: www.coverage-monitor-ing.org/training-centre/

e assessments faced two broad cate-gories of conflict related to insecurity. First,hostile environments largely caused by conflictbetween government forces and armed op-position groups (AOGs) or inter-ethnic andtribal conflict. Specifically, this entails un-predictable fighting with a risk of crossfireincidents, checkpoints and kidnap. Second,direct hostility towards staff and users byarmed groups known to be hostile towardsgovernment, United Nations (UN) agencies,and staff of national and international non-governmental organisations (NGOs) wasalso experienced. Health workers may beperceived to be part of government anddata collection activities are viewed with

1 Simplified LQAS (lot quality assurance sampling) evaluation of access and coverage.

2 Semi-quantitative evaluation of access and coverage.3 See www.coverage-monitoring.org/4 See www.coverage-monitoring.org/country/

afghanistan/to access the reports.

MUAC screening inHazrat-e-Sultan District

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further suspicion (considered as intelligencegathering). e possibility that family planningactivities are being implemented attracts evenwider suspicion (i.e. not just from armed groups)of local and/or international NGO activity.

In Afghanistan, war and insecurity are a bar-rier to accessing healthcare services (MSF, 2014)in terms of both demand (users seeking care)and supply (partners providing care). For example,one in two people are said to be concernedabout making dangerous journeys to receivehealthcare (MSF, 2014), and implementing part-ners are under great strain to provide reliablesupplies of commodities (ACF, 2016; see thisreport for more details on the nature of insecurityand how it impacts CMAM service delivery).Awareness of insecurity patterns can help withplanning and implementing assessments (seeBox 1 for examples).

A key guiding principle is that, whilst coverageassessment is key to improving programme per-formance, assessment should not expose surveyteams or informants to unacceptable risk:

Handling insecurity in SLEACand SQUEAC assessmentsIn order to achieve a reliable classification orestimation of coverage in a given area, a minimumsample size of SAM children is required, from aspatially representative selection of villages. Toachieve this, both SLEAC and SQUEAC stage 3(wide-area surveys) use a two-stage process,sampling and case finding. e impact of inse-curity in Afghanistan on both processes is shownbelow.

Stage 1: Sampling villagesTwo sampling methods are commonly used toselect villages: the ‘list method’ and CSAS(grid/quadrat) method. For both, engagementwith security advisors and informants familiarwith the area (e.g. programme and survey staff)was essential to assess the level of insecurity ineach village. Some subjective interpretation (in-cluding understanding of unacceptable risk andassessment of the reliability of information re-quired) was required, but triangulation by source(e.g. use survey staff, programme staff, health

centre staff and locals) strengthened this appraisal.During each assessment, at least three informantswere openly asked to identify villages that theyknew to be unsafe, to give the reasons why, andto identify other potentially unsafe/inaccessiblevillages. Unsafe villages were monitored.

Villages identified as unsafe and inaccessiblefrom all sources were considered dangerous;where lists did not concur, further data/informantdiscussion clarified the situation. e end resultwas a full list of villages with security status andreasons for insecure classification. Insecure vil-lages were not visited and the security situationfor selected villages was monitored for change.If there was any doubt, case finding in thatvillage was postponed until the security situationhad improved (if within the survey period) orwas abandoned. Table 1 shows the number ofvillages that were removed (during the initialsecurity review) and then abandoned (due to achange in the situation) for each SLEAC assess-ment undertaken in Afghanistan. A rigorous,open and participatory process in the securityreview and on-going monitoring was importantto ensure staff trust in the final security decisions,whilst benefiting from the team’s local knowledgeand experience.

Stage 2: Case finding at villagelevelOnce villages had been selected, it was necessaryfirst to identify an appropriate survey team togo to each village, and second to identify saferoutes into and out of villages. To increase ac-ceptance, local survey staff were employed whoknew local customs (e.g. dress codes, the needfor chaperones for female staff), were aware ofwhether communities accepted non-local women,and were familiar with local perceptions of datacollection activities. Survey team members foreach village were then carefully considered toensure familiarity. If at least one member of asurvey team was already known to local au-thorities (e.g. governors, police commanders,paramilitary commanders) and local leaders,then activities at village level were facilitated.Teams and individuals unfamiliar with an areaor different ethnicity could be at higher risk ofbeing threatened, told to leave or kidnapped. In

A number of the assessments took place inmountainous areas where security challengestended to be found in more remote areas,away from larger towns and roads. This map ofLaghman province shows secure (blue) andinsecure (red) villages. The secure villages aregenerally along the main roads at the bottomsof the valleys and the insecure villages in themore remote mountain areas.

Box 1a Patterns of insecurity:Topography

In Jawzjan, villages along the internationalborder and along roads accessing areas in thenorth were more insecure. In the areasremaining, along roads and around the twomain towns, the security status of villages wasmixed, with secure and insecure villages beingin close proximity to each other.

Box 1b Patterns of insecurity:Localisation

In most provinces, an initial indication of thesecurity conditions was useful but likely tochange over the duration of the assessment. Inthe case of Badghis, the initial reports a fewmonths before the assessment indicated that,despite a generally challenging securityenvironment, three whole districts could besampled. By the time of assessment, thesampling frame was reduced to around halfthe villages in just two of seven districts.

Box 1c Patterns of insecurity:Volatility

Table 1 Villages considered insecure initially and subsequently abandoned dueto insecurity

Province Total #Villages

Proportionremainingafter initialsecurityreview

# Villagessampled

# Villagesvisited

% ofsampledvillagesabandoned

Reasons for abandoning villages

Badakhshan 1,692 53% 91 85 7% Clashes broke out in some villages andelsewhere, the team were advised on arrival toturn back. One small town selected became astrategic checkpoint for AOG and wastherefore considered too dangerous to visit.

Badghis 985 13% 28 25 11% Recent escalation in conflict from nearbyvillages.

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 twocommunities.

Laghman 621 60% 45 33 27% Half of these were in Alingar district whereIMAM activities were ceased. Others were inmountainous areas where conflicts escalatedand teams were told to turn back bycommunity elders.

Field Article

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order to identify safe routes into and out of vil-lages, a risk assessment was undertaken, againtriangulating various sources of information.Security on roads is oen subject to rapid change(e.g. due to the use of roadside bombs or check-points) and required close monitoring.

On the day of visiting the village, a securityassessment was conducted using available sources(programme staff, drivers and friends) and,when possible, village leaders were called in ad-vance to confirm safe access. If no village-levelcontact was available but all available informationindicated safety, then teams proceeded and con-tacted village leaders upon arrival. When infor-mation at base was not available, survey teamsassessed the security situation while travellingto the village and upon arrival. In Afghanistan,village leaders would advise survey teams toleave if hostile forces were present in the villageor nearby. Teams should and would abort fieldactivities if there is anything above a low levelof risk.

Once the team and routes had been identified,the following considerations were made to ensureongoing monitoring of the security situation:• Work with survey teams and teams from

other programmes to monitor the on-goingsecurity situation;

• Liaise with local security services and para-military 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 inthe field.

Depending on the existing staff capacity, addi-tional resources (for example, a specialist inradio and security) may be needed to ensurethis level of communication is maintained.

In each village, active and adaptive casefinding (which involves local knowledge and

local informants to find suspected cases and as-sumes a level of social cohesion) and door-to-door case finding (going to every house) wereused to identify SAM children. Once a suspectedcase was found, the child was screened usingmid-upper arm circumference (MUAC) and forbilateral pitting oedema. e caregiver was askedwhether the child was in treatment and all caseswere interviewed in order to identify boostersand barriers to access.

Due to the security risk, assessment leaders,who were oen international staff, were notpermitted to travel to villages to supervise datacollection, and field training was not possible.To compensate, training included extra practicalclassroom-based exercises, including role-play.A tailored form ensured that teams recorded

numbers of children screened, houses visited,cases found, and households refusing entry ineach village.

During fieldwork, communication was alsoenhanced. Mobile telephone or radio contactwas sustained during village visits for assistanceand remote supervision. In the earlier stages,teams oen called the survey leader on arrivaland on concluding case finding to crosscheckthe course of action decided. When possible,end-of-day debriefings, in person or by phone,were conducted and information gathered (in-cluding challenges faced and solutions to over-come them) was shared amongst the entire teamfor collective learning.

Consequences of adapted samplinge insecure environment in Afghanistan

challenges spatial representation of villages andachieving a minimum sample of children – twokey aims of SLEAC surveys and stage 3 (wide-area survey) of SQUEAC surveys.

e sample of villages that are both accessibleand safe is unlikely to be spatially representativeof the entire intended programme catchmentarea; identified insecure villages will tend to beisolated. If spatial representivity is likely to bebadly affected, alternative villages (or contingencyclusters) could be selected as close to the originalvillage as possible. In the Afghanistan assessments,alternative villages were not used due to timerestraints, resulting in a smaller sample sizethan planned and therefore less accurate andprecise coverage classification or estimates. eremoved villages are typically places whereservice delivery and access are more affected,and where coverage is likely to be lower. Includingonly safe and accessible villages is likely to inflatecoverage estimates. e sampling method andany potential bias should be clearly noted whenreporting the assessment.

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MUAC screening in Hazrat-e-Sultan District

MUAC measurement at an OTP site

Nicki W

illiamson, A

fghanistan

Moham

eed Yousaf Shoor, Afghanistan

Field Article

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IntroductionDuring the SLEAC assessment in Jawzjan, largeareas of the province and entire districts weredeemed to be inaccessible for the survey team.In order to understand more about coverageand access of SAM treatment in these areas, asmall study was designed.

MethodologyQualitative data was collected throughstructured interviews with programmemanagement staff, health facility staff andpatients. Three health facilities wheresurrounding villages were deemed insecurewere visited. In each health facility, interviewswere conducted with at least two staffmembers (engaged with CMAM) and two tofour patients (visiting for CMAM treatment).

The following considerations were made tomaintain the safety of the surveyor:• Locally known survey team members were

sent and local community members and health staff should be informed in advance.

• Advise that the study is about the CMAM programme – do not say it is a study on security since this may raise unnecessary concerns.

• When meeting people, do not ask for interviews (which are often seen as interrogatory), just explain that you are there to talk about the CMAM programme.

• Ensure the conversation is conducted in a secure and relaxed environment where the informant can speak openly and in a free manner.

Themes investigatedInterview guides were developed to supportsurveyors in collecting useful information onchallenges to access and service delivery. Differentguides were developed for caregivers and for staffto collect the following information:

Caregivers at the health facility:• Information about their journey: means of

transport, duration, cost, whether there were obstacles, whether insecurity affects the journey and how the decision is made to visit the facility.

• Information about available alternatives when the decision is made not to visit the health facility, such as use of CHW (community health worker) or traditional medicine.

Staff at the health facility:• Information about the running of the

programme: details of any past closures due to insecurity, and whether insecurity affects the logistical running of the programme, for example in ready-to-use therapeutic food (RUTF) supply.

• Information about activities away from the health facility such as alternative strategies to reach SAM cases, e.g. use of CHWs, outreach activities and training and supervision visits.

FindingsThese investigations provided information abouttypes of insecurity, as well as the impact ofinsecurity on community access and on theprovision of services.

Impact on community access:• People are not able to take the road because of

checkpoints and threats on the way.• Women were not able to travel alone, and

therefore without a male chaperone (who was not always available) were not able to access services.

• More than half of the informants (five out of nine) spoke of clashes between AOG and government security forces (Afghan NationalSecurity Forces (ANSF)) as a factorpreventing them from making the journey to the health facility.

• Instead of making a journey, they either use alternative treatments (such as buying medicine from shops or using fortified milk) or simply must wait until security is better before travelling to the health facility.

Impact on provision of services:• Insecurity inhibits activities required for

operating the SAM sites, specifically those involving movement within the district, such as monitoring, training, supervision and supply of RUTF.

• Delivery of RUTF was managed through relationships with local shura, who had strong links with armed groups, which enabled the continuation of treatment services.

• Many areas in the province are too insecure for any monitoring or supervision to be conducted safely. For example, in Qush Tepaand Darzab, which are long-term insecure, the last support visit to the health facilities was possible in 2010.

• In Darzab, the health facility (a sub-centre) has now closed because the staff did not feel safe to work there.

In order to compensate for loss in surveycoverage and to access information in inaccessibleareas, additional quantitative and qualitativestudies can be conducted. Quantitative analysiscan compare numbers of admissions or defaultingrates from insecure areas with those from secureareas to look for differences and provide someindication of coverage levels.

Interviews can be conducted in nearby healthcentres with residents that have travelled frominaccessible areas, and with health staff thatcover those areas. Alternatively, specific surveystaff members for whom the risk is deemed ac-ceptable may be able to visit an otherwise inac-cessible area. In these circumstances, the staffmember should be carefully prepared and con-sulted, together with security advisors. Box 2outlines details of a qualitative study on insecurityconducted in Jawzjan.

Guidance for practitionersIt is possible to undertake SQUEAC and SLEACassessments in insecure environments, but thismay affect the quality and reliability of the in-formation. e bias introduced by the removalof villages from the sampling frame must berecognised and clearly reported. However, thequalitative information (on barriers and boosters)

collected from the cases found during the surveyremains useful and can provide evidence forprogramme reform.

A number of steps can ensure the mostreliable and comprehensive information regardingcoverage and access, achieving the basic principlesof data collection while ensuring the safety ofstaff and informants. e following ten pointsshould be considered by practitioners undertakingcoverage surveys in insecure environments:1. Adhere to the basic principle that CMAM

programmes are child-survival pro-grammes, therefore performance must be assessed and coverage assessments them-selves are not life-saving activities throughout the assessment;

2. Ensure triangulation of security informa-tion with survey team members and other local sources related to the accessibility of villages;

3. Use a rigorous and participatory processto review the security status of villages;

4. Ensure constant assessment of the securitysituation, especially in sampled villages andaccess routes;

5. Use local survey staff who both know the area and are known in the area;

6. Where possible make contact with the

village leader prior to travelling to the village;

7. Allow for extra time training and super-vising survey teams and include role play activities;

8. Ensure regular communication with surveyteams to monitor their safety and provide close supervision, including daily debriefings;

9. Develop context-specific qualitative and quantitative studies to investigate factors affecting access in the inaccessible areas; and

10.Document all limitations, challenges and adaptations to the methodology in the finalreport.

For more information, contact: Nikki Williamson,email: n.williamson@actionagainsthunger.org.uk

ReferencesMSF, 2014 Afghanistan: Between rhetoric and reality – theongoing struggle to access healthcare. Médecins SansFrontières. www.msf.org.uk/article/afghanistan-between-rhetoric-and-reality-%E2%80%93-ongoing-struggle-access-healthcare.

ACF, 2016 A review of SAM management in Afghanistan:Lessons from 2013-2016. ACF International.www.cmamforum.org/Pool/Resources/Afghanistan-Review-of-SAM-management-2016.pdf

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

Field Article

By Samson Desie

Samson Desie is a nutritionspecialist who has worked in thesector for more than a decade andcurrently works as Nutrition ClusterCoordinator with UNICEF Somalia.

Intergenerational cycleof acute malnutritionamong IDPs in Somalia

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Location: SomaliaWhat we know: High levels of acute malnutrition persist among internally displacedchildren in Somalia; socio-cultural practices that impact women, including teenagepregnancy, are a major underlying cause.

What this article adds: A Nutrition Cluster (NC) visit to an outpatient therapeuticprogramme in Garowe, Somalia, found only one third of children were accompaniedby their mother; over half of mothers were less than 18 years of age. The remainingadmissions presented with a sibling, usually less than ten years of age; mothers wereabsent in search of work. The NC considers school nutrition a key strategy to breakthe intergenerational cycle of malnutrition in the Somalia context; it invests innutrition development and fosters humanitarian-development connections. Toaddress the circumstances witnessed in Garowe, the NC has developed a pilotcomprehensive school-nutrition programme in collaboration with the EducationCluster to build evidence with a view to scale-up.

BackgroundChildren in internally displaced persons (IDP)sites in Somalia remain at increased risk ofacute malnutrition. e validated and endorsedDeyr (short rainy season) 2015 nutrition surveyconducted by Somalia Food Security and Nu-trition Analysis Unit (FSNAU) indicates a dete-rioration in the nutrition situation in five IDPsites (Dhobley, Baidoa, Dolow, Garowe andGalkayo) among the 13 sites surveyed in Sep-tember 2015; these are areas of critical concern(see Figure 1). Furthermore, the latest Gu (mainrainy season) 2015 findings show little improve-ment in the median global acute malnutrition(GAM) rate, with IDPs in Dolow having theworst rates of malnutrition (sustained criticalGAM rates of 25% and severe acute malnutrition(SAM) prevalence of 6.1%). Further deteriorationwas also observed, moving from Serious to Crit-ical in Garowe and Galkayo (sustained hot spots

for the last five seasons), as well as amongBossaso IDPs (12.5 % to 16.8 %). e resultscall for urgent action in this protracted crisis,and the critical need to scale up multi-sectorprogrammes in an integrated manner, includingat IDP site level.

“When a 13-year-old girl gets married andhas a baby, there is oen stress between her andher husband, which can lead to divorce… Aer adivorce, the girl is le to provide for the children,but most oen they are not able to due to lack ofresources” (Mothers focus group discussion).

The underlying causes ofsustained malnutritionSustained levels of acute malnutrition in IDPsites have always been a challenge in Somalia;studies and surveys have been conducted tounderstand the underlying causes of its persis-tance despite ongoing interventions. A recent

nutrition causality study outlines socio-culturalpractices as one of the major underlying causesand highlights certain socio-cultural beliefs andpractices in particular that have a major impact,including female genital mutilation (FGM), earlymarriage and premature, repeated child bearingby girls (13+ years) (SNS Consortium, 2015).Infant and young child feeding (IYCF) practicesare weak and adversely affected by heavy women’sworkloads, increased shis to cash economiesand absent fathers (due to divorce and khatuse).

e Nutrition Cluster (NC) visited a GaroweIDP site on 24 February 2016. At the time, 37children were admitted in the outpatient thera-peutic programme (OTP). During the visit, only14 (36%) children arrived with their mothers;eight (57%) of the mothers were aged 18 yearsor under. e remaining children came to thecentre with their siblings, who are mostly childrenunder the age of ten themselves. On furtherdiscussion with these children, it was understoodthat most mothers were away in town, lookingfor casual labour (e.g. cleaning, cooking, carryingand domestic service). Leaving children to beattended by older siblings is a significant factorlimiting the care children require, especiallythose suffering from malnutrition. e fact thatmany mothers are under 18 years old is also anunderlying cause of the sustained level of acutemalnutrition.

e story of Sabri and her daughter (see Box1) is typical of the phenomenon of the inter-generational cycle of malnutrition which seesteenage mothers give birth to an intrauterinegrowth-restricted infant and/or a low-birth-weight (LBW) baby (a baby born weighing lessthan 2.5 kg). e intergenerational cycle of

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Field Article

A young caregiver withan infant in her charge

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growth failure, first described in 1992 in theSecond Report on the World Nutrition Situ-ation (UNSCN,1992) and illustrated in Figure2, explains how growth failure is transmittedacross generations through the mother. etheory is that small adult women are morelikely to have LBW babies, and LBW childrenare more likely to have growth failure duringchildhood. us, in turn, girls born with aLBW are more likely to become small adultwomen. e cycle is accentuated by highrates of teenage pregnancy. is situation,coupled with early marriage and early divorcein Somalia, is becoming a major problembut is not fully appreciated by all stakeholders.

Actions to take in Somaliae authors of the UNSCN Nutrition PolicyPaper No 18 on LBW (Pojda & Kelley, 2000)found that many questions about reducingLBW rates remain unanswered. e paperhighlights the urgent need to find sustainablepractices that will improve women’s nutritionalstatus prior to pregnancy and weight gainduring pregnancy. Many actions can be takenin the Somalia IDP context. Efforts to improveadolescent nutrition are needed, especially

to control micronutrient deficiencies in ado-lescent girls. e nutrition programme inSomalia has never carried out such activitiesand should be piloted in selected IDP siteswith a view to scale-up. Districts with highburdens of sustained acute malnutrition couldalso be targeted with similar actions; lessonsfrom the experiences would help to scale upsuch approaches. e strategy should alsoattempt to link with livelihoods and othersocial protection and safety-net programmes.

Teenage pregnancy is a probable significantcause of malnutrition in most parts of Ethiopia,including IDP sites. It is well recognised thatthe size and body composition of the motherat the start of pregnancy is one of the strongestinfluences on foetal growth (Kramer, 1987).Studies in the USA have shown that there ismaternal and foetal competition for nutrientsin adolescent mothers, and birth weight ofinfants of adolescent mothers are around200g lower compared to non-adolescentmothers (Scholl et al, 1997). Given this,efforts should be directed towards developingcommunity-based adolescent girls’ clubs inorder to help with the early detection of

Figure 1 Prevalence of GAM among IDPs in Somalia (Post-Gu, 2016)

Very Critical (>30%)

Critical (15-30%)

Serious (10-<14.9%)

Alert (5-<9.9%)

Acceptable (0-<5%)

30

20

10

0

Burao IDP

s

Dhusam

reeb ID

Ps

Hargeisa ID

Ps

Qardho ID

Ps

Kism

ayo IDP

s

Mogadish

u IDP

s

Galkayo IDP

s

Dhobley IDP

s

Baidoa ID

Ps

Bossaso IDP

s

Garowe

IDPs

Dolow IDPs

Child growthfailure

Low-birth-weight

baby

Early

pregnancy

Small adultwomen

Low weightand height

in teens

Figure 2 Intergenerational cycle of growth failure

Field Article

An adolescent motherwith her baby

Sabri Abdiaziz Aliwith her daughter,Palestine Mohamed

Box 1: Sabri’s storyIn Garowe IDP site, Sabri Abdiaziz Ali is the 16-year-old mother of an 11-month-old girl,Palestine Mohamed. Sabri has lived almost herentire life as an IDP, living here since 2001, whenshe was treated for malnutrition at the age ofone. She was married at 14 and divorced by thetime her daughter was just two months old.Since then she has been living with her mother,who is also an IDP. She often goes to the townseeking work to help provide for her daughter.

Sabri hopes to be able to educate her daughterand not remain in the IDP camp for the rest ofher life. She breastfed her daughter for twomonths only, until the time of her divorce, andhas not breastfed since as she is busy earningsurvival income. Her daughter often suffersfrom diarrhoea and cough and was recentlydiagnosed, at ten months old, as severelymalnourished. Her daughter’s condition hassignificantly improved since she was admittedto the UNICEF-supported OTP four weeks ago.Now at 11 months, she is improving andgaining weight with regular treatment andtherapeutic feeding. During the visit, she had agood appetite and was active. The OTP serviceis implemented by Save the ChildrenInternational (SCI) and fully funded andsupported by UNICEF and USAID.

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and the risk of delivering a LBW baby seems tobe determined very early in pregnancy (Smithet al, 2002). In addition, evidence from Asia(Mason et al, 2002), rural India (Rao et al,2001), Indonesia (Semba et al, 2008) and refugeecamps in Nepal (Shrimpton et al, 2009) suggeststhat consumption of micronutrient-rich foods(milk, green leafy vegetables, fruit and parboiledrice) and iodized salt during early pregnancy isassociated with increased birth weight andweight-for-age in young children. e followinginterventions are therefore recommended forinclusion in existing services, in particular forpregnant and lactating women (PLWs): 1. Establish a system to provide comprehen-

sive and routine nutrition assessment, counselling and support services, includingpregnancy weight-gain monitoring; promo-tion of maternal nutrition (including ade-quate food intake); provision of supplementary food to malnourished PLWs; and ensure early identification and treatment of acute malnutrition among PLWs;

2. Ensure PLW access to micronutrient services,including provision of routine iron folic acid or multiple micronutrient supplemen-tation; promotion of the use of iodised salt; and deworming during the second and third trimesters of pregnancy;

3. Develop key action-oriented nutrition mes-sages to increase the involvement of fathers,grandparents and faith-based/traditional community organisations in supporting PLWs, including ensuring access and utili-

sation of WASH practices; and4. Support the involvement of women groups

in nutrition-sensitive agriculture and liveli-hood programmes and ensure access to time and labour-saving technologies.

Nutrition and EducationClusters join forceseir experience of the horrifying reality promptedaction by the NC to come up with a concreteoption to reach adolescent girls. e NC considersschool nutrition a key strategy to break the in-tergenerational cycle of malnutrition in Somalia.A school-nutrition initiative also offers strategicengagement for a long-term resilience perspective,is in the interests of developmental nutrition andhelps bridge the humanitarian-development nexus.In collaboration with the Education Cluster, acomprehensive school-nutrition programme hasbeen developed which will be implemented in afew selected schools to generate further evidencewith a view to possible scale-up. e project willfollow a continuous learning and adoptive ap-proach and will start with an adaptation of theWorld Bank FRESH (Focusing Resources onEffective School Health, Hygiene, and NutritionProgrammes) framework. Funded by the SomaliaHumanitarian Funding (SHF) as a pilot, it willbe implemented by SCI in Baidou. We lookforward to sharing learning from our ongoingimplementation of comprehensive school nutritionamong IDPs as well as host communities.

For more information, contact: Samson Desie,email: sdesie@unicef.org

teenage pregnancies in communities and educategirls on improved life skills for teenage pregnancyprevention.

Actions to take: Adolescentinterventions1. Establish a system to provide comprehensive

and routine nutrition assessment and coun-selling services for adolescents at commu-nity, school (Ministry of Education, 2012) and health-facility level;

2. Develop key action-oriented, nutrition behavior-change communication messages for adolescents, especially for girls, and promote and demonstrate these messages through different communication channels,community and facility contact points;

3. Ensure adolescents have access to micronu-trient services;

4. Ensure access to reproductive health servicesfor boys and girls (delaying early marriage and early pregnancy, family planning, pre-vention of harmful traditional practices);

5. Ensure access to and utilisation of water, sanitation and hygiene (WASH) practices inhouseholds, communities and schools;

6. Conduct regular monitoring of nutritional status of school-age children/students; and

7. Promote girls’ education and economic empowerment of out-of-school adolescents.

Actions to take: Nutritional status of womene influence of maternal nutritional status onpregnancy outcomes seems equally importantin early and late pregnancy (Neufeld et al, 2004)

ReferencesKramer, 1987 – Kramer, MS. Determinants of low birthweight: methodological assessment and meta-analysis.Bulletin of the World Health Organization. 1987; 65(5):663–737.

www.ncbi.nlm.nih.gov/pmc/articles/PMC2491072/Mason et al, 2002 ¬– Mason JB, Deitchler M, Gilman A,Gillenwater K, Shuaib M, Hotchkiss D, Mason K, Mock N,Sethuraman K. 2002 Iodine fortification is related toincreased weight-for-age and birthweight in children in Asia.Food Nutr Bull. 23:292-308

Ministry of Education, 2012 – National School Health andNutrition Strategy. Government of Ethiopia October 2012.

Neufeld et al, 2004 – Neufeld LM, Haas JD, Grajeda R,Martorell R. Changes in maternal weight from the first tosecond trimester of pregnancy are associated with fetalgrowth and infant length at birth. Am J ClinNutr. 200479(4):646-52

Pojda & Kelley, 2000 – Pojda J and Kelley L, Low Birthweight− Nutrition policy discussion paper No. 18. United NationsAdministrative Committee on Coordination Sub-Committeeon Nutrition. 18 September 2000. www.unscn.org/layout/modules/resources/files/Policy_paper_No_18.pdf

Rao et al, 2001 – Rao S, Yajnik CS, Kanade A, Fall CH,Margetts BM, Jackson AA, Shier R, Joshi S, Rege S, LubreeH, Desai B. Intake of micronutrient-rich foods in rural Indianmothers is associated with the size of their babies at birth:Pune Maternal Nutrition Study. J Nutr 2001;131:1217-24.

Scholl et al 1997 – Scholl TO, Hediger ML, Bendich A,Schall JI, Smith WK, Krueger PM. Use of multivitamin/mineral prenatal supplements: Influence on the outcome ofpregnancy. Am J Epidemiol 1997;146:134–41.

Semba et al, 2008 – Semba R, de Pee S, Hess SY, Sun K,Sari M and Bloem M. Child malnutrition and mortalityamong families not utilizing adequately iodized salt in

Indonesia. Am J ClinNutr. 2008 87(2):438-44.

Shrimpton et al, 2009 – Shrimpton R, Thorne-Lyman A,Tripp K, and Tomkins A 2009.Trends in low birthweightamong the Bhutanese refugee population in Nepal. Foodand Nutrition Bulletin 30 (2) S197-206.

Smith et al 2002 ¬– Smith GCS, Stenhouse EJ, Crossley JA,Aitken DA, Cameron AD, Connort JM. Early-pregnancyorigins of low birth weight. Nature 2002;417:916.

SNS Consortium 2015 – Nutrition Causal Analysis Study –South and Central Somalia November 2015.reliefweb.int/report/somalia/nutritional-causal-analysis-study-south-and-central-somalia-november-2015

UNSCN, 1992 – United Nations System StandingCommittee on Nutrition 2nd Report on the World NutritionSituation − Volume I: Global and regional results. ACC/SCN,October 1992. www.unscn.org/layout/modules/resources/ files/rwns2_1.pdf

Young mothers andcaregivers attendingthe OTP

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People in aid

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

e research team investigating men and householdfood security in an internally displaced personscamp in Kenya (see research in this edition)

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Participants in the Evidence Aid priority setting meeting, 2013(see research in this edition)

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Editorial teamJeremy Shoham,Marie McGrath, Judith Hodge,Chloe Angood, Nick Mickshick.

Carmel Dolan andEmily Mates areTechnical Directors.

Jeremy Shoham andMarie McGrath are FieldExchange Co-Editors andTechnical Directors.

Orna O’ Reilly designsand produces all ofENN’s publications.

Phil Wilks (www.fruitysolutions.com) manages ENN’s website.

Chloe Angood is anutritionist workingpart-time with ENN ona number of projects.

Claire Reynolds isENNs Senior Operations Manager,based in Oxford

Clara Ramsay is theENN’s Finance Assistant,based in Oxford.

Viktorija Nesterovaite isENN's Project Assistantbased in Oxford.

Peter Tevret is ENN’sSenior Finance Manager, based in Oxford.

About ENNENN is a UK registered charity, international in reach, focused on supporting populations at high risk ofmalnutrition. ENN aims to enhance the effectiveness of nutrition policy and programming by improvingknowledge, stimulating learning, building evidence, and providing support and encouragement topractitioners and decision-makers involved in nutrition and related interventions.

ENN is both a core team of experienced and academically able nutritionists and a wider network of nutritionpractitioners, academics and decision-makers who share their knowledge and experience and use ENN’sproducts to inform policies, guidance and programmes in the contexts where they work.

ENN implements activities according to three major workstreams:Workstream 1: Experience sharing, knowledge management and learning. This includes ENN’s coreproducts: Field Exchange, Nutrition Exchange and en-net, as well as embedded knowledge managementwithin two key global nutrition fora (the Scaling Up Nutrition Movement (SUN) and the Global NutritionCluster (GNC)).

Workstream 2: Information and evidence on under-researched nutrition issues. This comprises ENN’sresearch and review work on filling gaps in the evidence base for improved nutrition policy and programming.

Workstream 3: Discussion, cooperation and agreement. This includes a range of activities for discussing andbuilding agreement and consensus on key nutrition issues. It includes ENN’s participation in and hosting ofmeetings, its activities as facilitator of the IFE Core Group and its participation in the development of trainingmaterials and guidance, including normative guidance.

ENNs activities are governed by a five year strategy (2016-2020), visit www.ennonline.net

Contributors for this issue:

Front coverPupils from the Catholic school inAmpahadimy Fokontany running infront of their sanitation block. Ankazobedistrict, Madagascar; WaterAid/ ErnestRandriarimalala, Madagascar, 2016

Judith Fitzgerald, is the Operations and Mailing Assistant at the ENN.

Tui Swinnen is ENN’sGlobal KnowledgeManagement Coordinator (SUNMovement)

The Team

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Mercy LakerJoy TooseLeni Martinez Del CampoEmily SylviaConcern Burundi TeamJeanette BaileyRachel ChaseMarko KeracAndré BriendMark ManaryCharles OpondoMaureen GallagherAnna KimMustafa GhulamMohammed H Alshama’aDaniel MuhinjaSisay SinamoLydia NdunguCynthia NyakwamaMarina AdrianopoliAllan MpairweSamson DesieAlexandra Rutishauser-PereraErin HomiakMike ClarkeJeroen JansenClaire AllenClaudia RodriguezIris Emanuelly SeguraAna Paula Cantarino Frasão de CarmoDaniela BicalhoVanessa Manfre Garcia SouzaFlavia SchwartzmanBetzabeth SlaterRebecca Alum WilliamShishay TsadikTitus Mung'ouJennifer ChapinGESNOMAWinds of HopeSentinellesMédecins sans Frontières Saul GuerreroErin BoydClaire HarbronDiane HollandAbi PerrySophie WhitneyErick Boy Dan JonesMegan Wilson-Jones

Charulatha BanerjeeEmily MatesPeter Hynes

Field Exchange supported by:

Office SupportClaire Reynolds, Clara Ramsay, Peter Tevret,Judith Fitzgerald, Viktorija Nesterovaite.

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Thanks to all who contributed or helpedsource pictures for this issue.

DesignOrna O’Reilly/Big Cheese Design.com

WebsitePhil Wilks

The Emergency Nutrition Network (ENN) is a registered charity in the UK (charity registration no: 1115156) and acompany limited by guarantee and not having a share capital in the UK (company registration no: 4889844).Registered address: 32, Leopold Street, Oxford, OX4 1TW, UK. ENN Directors/ Trustees: Marie McGrath, JeremyShoham, Bruce Laurence, Nigel Milway, Victoria Lack and Anna Taylor.

ENN32, Leopold Street, Oxford, OX4 1TW, UK

Tel: +44 (0)1 865 324996Fax: +44 (0)1 865 597669Email: office@ennonline.net

www.ennonline.net