The management ofacute malnutritionat scale:

A review of donorand government financing arrangements

Summary Report

March 2013

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This review responds to concerns identified by countries scalingup nutrition

1 Wasting or oedematous malnutrition

This review was undertaken by Jeremy Shoham andCarmel Dolan, ENN Technical Directors, and Lola Gostelow,an independent consultant engaged by the ENN.

This review was made possible by funding from CIDAand Irish Aid; the ENN gratefully acknowledge the supportof both agencies in this regard. The views expressed hereinare those of the ENN and can in no way be taken to reflectthe official opinion of Irish Aid or CIDA.

Numerous people (and too many to mention here) havegiven freely of their time and insights into the successesand challenges of CMAM scale up and we warmly thankthem all for their contributions. These includegovernment nutrition staff, key donors, UN and NGOagencies, academia and individuals.

The section on Official Development Assistance wassupported by Lydia Poole and Mariella Di Ciommo fromDevelopment Initiatives and we thank them for theirvaluable contributions.

In particular, we thank the Governments of Kenya andEthiopia and their supporting partners (UNICEF, WFP, andinternational NGOs) for hosting the visits for the casestudies. We also thank Theresa Banda (seconded to ENNby Valid International) for allocating some of her timewhilst working in Malawi and Nigeria to understandingthe financing situation for CMAM in these countries.

This review focuses on the financing arrangementsfor programmes that manage acute malnutrition1 atscale through the community based management ofacute malnutrition (CMAM) approach. It follows up onan international conference on CMAM co-hosted bythe Government of Ethiopia and the ENN in AddisAbaba in 2011. At this four day event, governmentrepresentatives from 24 African and Asian countriesshared their experiences of CMAM scale up andhighlighted the challenges they face with currentfinancing arrangements in terms of resourcepredictability and sustainability.

Acknowledgements

We thank Marie McGrath for carefully reviewing thedocument and adding substantial material andinsights on UN agency roles and responsibilitiesaround the treatment of acute malnutrition.

Contacts: Jeremy Shoham, ENN Director,shoham@btinternet.com and Carmel Dolan, ENNDirector, carmel@ennonline.net

Electronic versions of this summary report, as well asthe main report, are available at www.ennonline.net

Citation: Shoham J, Dolan C, Gostelow L, ENN (2013).The Management of Acute Malnutrition at Scale: AReview of Donor and Government FinancingArrangements. Summary Report. March 2013.

Cover picture credit:L Matunga/UNICEF, Somalia, 2011

This review considers the enabling and constrainingaspects of humanitarian, transition and developmentfinancing, the contexts and rationale in which severeacute malnutrition (SAM) and moderate acutemalnutrition (MAM) are jointly addressed in CMAMprogramming; the role of key United Nations (UN)agencies in enabling programme integration andcoordination; individual donor policies and strategiesfor supporting CMAM in emergency, transition anddevelopment contexts; and opportunities forachieving greater impact of efforts to manage acutemalnutrition. The review involved country case

The ENN is a UK registered charity whose activities include lesson capture on nutrition and food security programming inemergencies and high burden contexts to inform practice andresearch. See full profile of activities at www.ennonline.net

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2 Specifically: undernutrition, which encapsulates acute malnutrition, stunting and micronutrient malnutrition.

Undernutrition is receiving unparalleled attention internationally

Though expensive, CMAM is a cost-effective, scalable intervention

studies from Kenya, Ethiopia, Malawi and Nigeria(developed based on interviews with governmentand other stakeholders, plus review of essentialdocuments); in-person and telephone interviews withdonors, UN agencies and foundations involved inCMAM financing, programming and research1, greyliterature review; and donor feedback (CIDA and IrishAid) on findings.

Acute malnutrition is a life-threatening conditionaffecting approximately 60 million children globally atany point in time. This caseload comprisesapproximately 20 million children aged below 5 yearswith SAM and 40 million under-five children withMAM. Children with SAM have a nine times greaterrisk of dying than well-nourished children and childrenwith MAM have a three times higher risk of dying.

This is a problem of global public health significanceand one set to escalate. Climate change and theeconomic downturn are expected to lead to anincrease in the acute malnutrition caseload overcoming years. Thus, the treatment of acute

The conclusions and recommendations contained inthis review are based on a process of synthesising theexperiences and perspectives of the manystakeholders highlighted above but are aligned inparticular with the views of governments faced withthe challenges of scaling up CMAM programming.Where recommendations are made by the ENNspecifically, these are indicated.

malnutrition will unfortunately remain necessary untilother interventions are implemented at sufficientscale to prevent undernutrition and to reduce theprevalence of acute malnutrition.

Globally, political interest in food security, globalhunger and nutrition2 is greater than it has been fordecades. The development of the Scaling UpNutrition (SUN) movement, the Hunger Summit inLondon on the margins of the 2012 Olympic gamesand various high-level SUN events and actions atcountry level are testament to an unparalleledmomentum in the nutrition sector.

Until the late 1990s, treatment of SAM was throughtherapeutic feeding centres in hospitals and healthcare centres. Performance was poor, coverage wasextremely limited (<5%), mortality was often in excessof 30% and recovery rates were poor. The advent ofready to use therapeutic foods (RUTFs) in the late1990s made it feasible to manage SAM in thecommunity instead of in centres, and led to thedevelopment of the CMAM approach. Thecommunity mobilisation and ownership of theprogramme is the cornerstone of the approach.CMAM allows early detection and referral of‘uncomplicated’ SAM cases to out-patient centres(whilst cases of ‘complicated’ SAM continue to bemanaged as in-patients by health sector staff ), andtheir progression to targeted supplementary feedingprogrammes (SFP) so as to maximise full recovery.

Over the past 12 years, CMAM programmes havebeen implemented to varying degrees of scale inover 65 countries. The latest UNICEF mapping reportestimates that 2 million out of an estimated 20 millionSAM cases are now being treated. While this is asignificant increase in SAM treatment, it representsjust 10% of the global SAM burden. MAM treatment,however, has often not kept pace with the scaling upof SAM treatment. The pace of increasing coveragefor in-patient treatment of complicated SAM is notmonitored and therefore, is also unknown. It isimportant to note that many countries with very highcaseloads of acutely malnourished children – such asIndia, Nigeria and Indonesia – have extremely lowCMAM coverage. Should CMAM be scaled up in suchcountries, global coverage of treatment willsubstantially increase.

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Children being treated for acute malnutrition can takeup to 100 days to recover (or even longer when theyrelapse). Untreated children with MAM who do notdeteriorate to SAM will take far longer to recover.During this period of recovery, the linear growth of achild will be curtailed. There is strong evidencedemonstrating that the first 1000 days of life (700+days ex-utero) are a critical window of opportunity foraddressing stunting. Yet, since prolonged or recurrentperiods of acute malnutrition most commonly affectchildren within these first 1000 days (especially thoseaged 12 to 24 months), it is likely that this will block asignificant proportion of the period for optimal childgrowth. Furthermore, the results of recent researchshow that there may be an additive or cumulative riskof mortality when a child has acute malnutrition and isalso stunted. It therefore makes sense to consideracute malnutrition and stunting together and this isincreasingly being emphasised by the SUN movement.

In addition to these biological reasons, there are alsosound geographical and contextual reasons to makethe link. Over half of the world’s acutelymalnourished children live in a small number ofcountries (e.g. India, Bangladesh, Pakistan, Nigeria andIndonesia) and these countries also suffer from veryhigh levels of stunting. Furthermore, a number of

The World Bank estimated3 the cost of scale up toaddress 80% of the acute malnutrition burden in 36high burden countries to be US$6.2 billion. Thisrepresented over half the total cost for scaling up the13 direct nutrition interventions demonstrated to beeffective by the Lancet Series of 2008. The way inwhich these costs were estimated assumed no costsavings through integration with government healthsystems and other child health and nutritionprogrammes, such as the integrated management ofacute malnutrition (IMCI) and infant and young childfeeding (IYCF).

other sub-Saharan African and Asian countriesaffected by conflict, chronic or acute crises have beenunable to reduce prevalence of undernutrition; theytherefore bear significant burdens of acutemalnutrition as well as stunting.

There is a pervasive misconception that acutemalnutrition is a short-term problem of concern tohumanitarians whereas chronic malnutrition(stunting) is a long-term development problem. Thisis undoubtedly fuelled by current terminology whichdemarcates the two. However, stunting and acutemalnutrition are linked biologically and thereforeneed to be linked programmatically. Children withacute malnutrition or with declining nutritional statusare at a higher risk of linear growth retardation orstunting. Therefore, an untreated chronic or repeatedstate of acute malnutrition will very likely reduceefforts to prevent or reverse stunting. In addition,programmes which address the causes of one ofthese conditions will in all probability have a positiveimpact on the other condition, as both share common(though not all) elements of the malnutrition causalpathway. The emerging understanding of linkagesbetween acute malnutrition and stunting, however,are at a very early stage in relation to programmes andagency roles and responsibilities.

Undernutrition – acute malnutrition and stunting – demands acoherent response

CMAM tends to be funded as a 'humanitarian response'

There has been little concrete discussion around thedegree to which different governments can afford tofinance programmes to treat and prevent acutemalnutrition. As a result, there are no current estimatesfor the external (donor and private) resourcesrequired for scale up globally, though this is likely tobe substantially lower than the US$6.2 billion figure.

There are varying country based estimates of percapita costs for treatment of SAM and MAM rangingfrom US$70 for the treatment of SAM in Nigeria, toUS$150 for the combined treatment of SAM andMAM in Kenya to US$110-200 for the treatment of

3 Scaling Up Nutrition. What will it Cost? Susan Horton et al. World Bank 2010.

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SAM and MAM in Ethiopia. An important determinantof cost is whether it is for starting up a programme asin an emergency or for expansion of a programme tomeet a chronic need.

At least half of the cost of SAM treatment is for RUTF.Dried skimmed milk (DSM) powder represents aroundone-third of the RUTF cost, largely because it is a highcost imported commodity. The remaining CMAMprogramme costs are (in no particular order of costmagnitude) for antibiotics, measuring equipment,training, outreach, community mobilisation andreferrals, monitoring and evaluation, and reporting.

Governments and supporting partners are still at anearly stage of reliably estimating the costs of CMAMscale up. A number of countries, including many thatare partners in the SUN movement, have recently orare in the process of costing CMAM in tandem withother high impact direct nutrition interventions, aswell as a range of nutrition sensitive strategies aimedat preventing undernutrition. The new joint UN ‘onehealth tool’ could also help governments to ascertainmore reliable and standardised estimates of costs aspart of a package of nutrition and health interventions.

In most cases, the costs for treating SAM and MAM faroutstrip the current domestic government budgetsallocated to nutrition. Country-led efforts to reducethe cost of CMAM through establishing RUTF localproduction have largely been unsuccessful. In thesmall number of countries where significant localproduction has been achieved (e.g. Ethiopia), costshave decreased by around 20%, but in other countries,like Malawi, locally produced RUTF has been moreexpensive than RUTF produced by the main globalmanufacturer in Europe. Predictions for the future costof RUTF (as currently formulated) suggest it couldincrease further, due to the increasing price of DSM onthe global market. However, local production bringsother advantages besides costs, including speed ofdelivery which reduces likelihood of stock-outs. Localproduction of RUTF at higher than current levels ofCMAM coverage may allow for greater economies ofscale and cost reduction. Furthermore, research intothe development of alternative RUTF formulationsusing local foods in India may bring down costs evenmore dramatically. It may also be the case that whereRUTF is put on government medical supplies lists, priceswill decrease as this will obviate importation taxes.

The limitations of current financial tracking means it isnot possible to state how much of the externalfinancing for scale up to address acute malnutrition is

coming through development or humanitarianbudgets of donor agencies. In many cases, however,scale up has occurred following the onset of anemergency. Furthermore, close to 70% of allhumanitarian funding is going to the same group ofcountries, year in, year out. By definition this fundingis short-term (6-9 months) and has to be renegotiatedeach year. This has created a number of problems forgovernments and partners attempting to scale upprogrammes: for example, stop-start programming,managing different funding cycles, difficultiesintegrating CMAM with other preventive nutritionactions and negotiating the different administrativeand contractual requirements of donors. This hasbeen the case in Ethiopia and Kenya, where virtuallyall costs for CMAM, since it was first implemented,have been covered through humanitarian funding.

Encouragingly, some donors are beginning toapprove multi-year funding in chronic emergencieswhere both acute malnutrition and stunting levels arehigh. However, very few donors are managing tocombine humanitarian and development funding toallow not only longer term planning but also moreintegrated and sustainable programming, linkingprevention with treatment within a nutritionresilience framework. This is largely due to thecompartmentalisation of humanitarian anddevelopment departments within the same donororganisations.

Longer-term financing arrangements for nutritionprogrammes are multi-faceted, complex and poorlytracked. Only in a very few instances are donorsfinancing nutrition through health or dedicatednutrition SWAps (sector-wide approaches). There canalso be several funding sources within thedevelopment sections of individual donors providingfunds for different elements of the CMAM approachor different actors implementing CMAM. In short, themechanisms are complex and opaque.

Very little financing to treat acute malnutrition isbeing channelled through government. Whether it ishumanitarian financing or longer-term financing, it ismainly channelled through the multilateral agencies(notably UNICEF and WFP) and non-governmentalorganisations (NGOs). Whilst there are numerousfinancing mechanisms that donors deploy for othersectors (e.g. pooled funds/SWAps and more generalbudget support), this is not the case for nutrition inthose countries where CMAM is being scaled up.Further, there are very few examples of the mainCMAM commodities being integrated into

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Lessons from this review

government medical supply systems. It is questionablewhether this approach to financing fosters increasednutrition governance in these countries.

While the humanitarian imperative has driven CMAMonto the agenda of many countries, the remit of

development actors has generally not included thetreatment of acute malnutrition. This is despite theevidence that for many countries, acute malnutritionis a long-term and widespread problem requiringconcerted prevention and treatment efforts if childmortality is to be reduced.

Three UN agencies – UNICEF, WFP and WHO – havesignificant responsibilities for acute malnutritiontreatment in non-refugee contexts. UNICEF isresponsible for the treatment of uncomplicated SAMand WFP has recently assumed responsibility for theprevention and treatment of MAM (and prevention ofstunting). In principle (yet to be reflected in a globalagreement), WHO has responsibility for complicatedSAM treatment, as well as providing normativeguidance on treatment protocols and programmedesign for governments and implementing partners.In refugee settings, UNHCR has responsibility for SAMtreatment and WFP/UNHCR Memoranda ofUnderstanding (MOUs) govern co-operativearrangements regarding programming.

This review finds that the division of roles andresponsibilities between the UN agencies supportingefforts to address acute malnutrition (in non-refugeesettings) makes it difficult to ensure coherent andwell coordinated programmes – particularly withregard to children suffering from MAM. There aremany examples where WFP are not present in acountry where UNICEF is implementing the SAMcomponent of CMAM and there are countries whereWFP is present and UNICEF is not. Whilst the mostrecently agreed division of labour between both

Management of acute malnutrition faces ongoing challenges dueto the division of UN agencies’ roles and responsibilities

agencies (2011) allows for UNICEF to implement SFPsin WFP’s absence, arrangements for this are provinghighly context specific, and in many cases limited.Even where all UN agencies are present, programmesmay not converge geographically or institutionally.

Governments and their partners report considerableconfusion with stop gap measures being employedby partner agencies on the ground to treat MAM,such as discharging children at higher cut off pointsor relying on IYCF counselling for MAM childrenwhere SFPs are absent. Unfortunately, there is noglobal mapping of the extent to which outpatienttherapeutic programmes (OTP) and SFP programmesconverge within CMAM programming and thereforeno global overview of the coherence of SAM andMAM programming. What is clear is that theseparation of UN agency roles needs to be re-appraised in light of multiple negative countryprogrammatic experiences. The 'One UN' approach,being piloted in various countries in Africa and Asia,provides an opportunity for WFP, UNICEF and WHO tocoordinate their efforts around the treatment andprevention of acute malnutrition, and deliverprogramming addressing MAM and SAM through“one leader, one programme and one budget atcountry level.”

Misconceptions around acute malnutrition need tobe challenged. There is need to prioritise preventionand treatment programmes as part of integrated andlong-term high impact direct nutrition interventionpackages (for example with IMCI, IYCF) alongsidenutrition sensitive strategies.

In order to encourage a broader conceptualisation ofthe problems amongst governments and otherstakeholders, advocacy needs to emphasise howacute malnutrition reduces the window ofopportunity for addressing stunting. Furthermore,when the two conditions exist in the same individual

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4 McDonald. C et al (2013). The effect of multiple anthropometric deficits on child mortality: meta-analysis of individual data in 10 prospective studies from developing countries. American Journal of Clinical Nutrition. Feb 20th 2013, doi 10.3945/ajcn.112.047639

there is a significant cumulative risk of mortality4. Inaddition, advocacy to promote the development ofcosted plans for scale up of CMAM need toemphasise that these are not fixed costs, since otherpreventive activities should lead to a reduction in theacute malnutrition caseload; thus costs shoulddiminish over time as treatment programmes arescaled down. Countries prone to emergencies,however, should be aware of the need to retaincapacity and resources to scale up if the prevalenceof acute malnutrition increases, in order to addressthe consequences of both immediate and longerterm malnutrition.

Current financing arrangements from multiplesources and through multiple supporting andimplementing partners inevitably pose challenges forgovernment in coordination, in making resourceallocation decisions and in ensuring alignment ofprogrammes with national policies. Exceptionally, theWorld Bank is increasingly providing significant loansdirectly to governments for CMAM programming,including RUTF purchase (e.g. in Nepal and Kenya).

The current donor agency financing arrangements forCMAM (and nutrition more generally) largely flowthrough the multilateral agencies and non-governmental organisations (NGOs), which is likely toinhibit the leveraging of domestic budgets bynutrition departments in ministries. Treasuriestherefore tend to view CMAM programmes asexternal to their financial considerations.

Governments may need support to develop wellcosted national nutrition plans. Once these have beendeveloped, many countries will need considerableexternal financial support to implement them. At thesame time, there are a number of countries who canand should be able to allocate significant domesticresources to cover scale up costs. Clarity andagreements are needed on the realistic split betweendomestic and external resource requirements andhow this should change over time on a countryspecific basis. Cost sharing by donors andgovernments should, where possible, offer a route toleveraging greater domestic budget allocations tofinance nutrition scale up, including CMAM.

The remit of development actors has generally notincluded the treatment of acute malnutrition. However, the persistence of chronically high levels of

acute malnutrition should be recognised as both adevelopment and humanitarian issue, and needs totherefore become a key concern of developmentactors (implementing partners and donors alike).

The onset of emergencies in a context wheregovernments allocate regular domestic resources fortreatment could dictate that humanitarian financingbe deployed to deal with surges in cases of acutemalnutrition and in this way, guarantee alignment ofthese resources with existing governmentarrangements.

A significant impediment to scaling up CMAM is thecost of RUTF. Although local production is increasingglobally, it is unlikely to significantly lower costs. Localproduction will however confer other advantages, e.g.improved supply chain and economic benefits forlocal farmers. Exploration of options to bring downthe cost through research into different RUTFformulations and RUTF alternatives is on-going butneeds much greater emphasis and rapiddissemination of findings. There is the potential to putRUTF on the essential medical supplies list therebyobviating import taxation and further reducing prices.

It is likely that the transaction costs of multiple UNagencies and implementing partners (NGO) involvementin the treatment and prevention of acute malnutrition isconsiderable and that costs can be reduced bystreamlining responsibilities. Furthermore, the overviewand process for setting roles and responsibilities needs tobe reviewed and clarified with respect to how a conditionlike acute malnutrition is ‘carved up’ and then allocated tomultiple agencies, without full consideration as to howtheir respective programmes are to be coordinated.

Over the longer term, it is highly unlikely thatgovernments and supporting donors and partnerscan afford the cost of treatment of MAM alongsideSAM as envisaged in the original CMAM model, i.e.using ready to use foods. There is limitedunderstanding of whether current approaches to thetreatment of MAM are effective, affordable andfeasible. Research into the prevention and treatmentof MAM needs to become a funding priority formultiple stakeholders with a focus on non-food (forexample IYCF counselling, cash and vouchers) as wellas food based approaches.

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As an agency with the mandate to provide normativeguidance on nutrition issues, WHO is well placed tocompile a briefing note on the relationship betweenacute malnutrition and stunting based on thepublished literature. This note should becontextualised by providing an overview of theevidence for persistent high levels of acutemalnutrition in many countries and the high burdenof stunting in others. Based on this, the note shouldseek to clarify that ‘acute malnutrition’ is not simply aresult of emergency events and should challengeinterpretation or assumptions associated with theterminology to clarify misconceptions about its‘emergency’ nature. Furthermore, the note shouldunderscore the need for coherent approaches to thetreatment and prevention of acute malnutrition overthe long-term. Key areas for research could usefully be

funding and/or combing humanitarian anddevelopment funding to achieve greater CMAM scaleand thus nutrition resilience. Each donor will havedifferent sets of institutional and political challengesin achieving this, so good practice examples mightbe shared between donors to fuel ideas. If thisambition is underpinned by clearly articulated donornutrition policies, which explicitly acknowledge thatthe persistently high prevalence or high burden ofacute malnutrition in many countries is adevelopment concern rather than a problem to beaddressed through emergency response, thenadvocates of this type of financing arrangement willhave greater leverage within their organisations toeffect change.

Taking action to strengthen the management ofundernutrition

1 Clarify the links between acute malnutrition and stunting

2 Clarify and streamline donor policies and financing arrangements

highlighted, such as prospective studies using existingtreatment programmes showing the impact of acutemalnutrition on stunting and cognitive development.

The SUN Secretariat, along with others such asREACH, are encouraged to continue to clarify togovernments the programmatic advantages oflinking acute malnutrition and stunting and thetheoretical underpinning of this. Key messages torelay are that acute malnutrition is a developmentconcern in the interests of child survival and that itreduces the window of opportunity for addressingstunting and therefore future human capital anddevelopment. This necessitates prioritisingprevention and treatment programmes as part ofintegrated and long-term high impact direct nutritionintervention alongside nutrition sensitive strategies.

There is an opportunity for donor agencies todevelop clearer policy statements and operationalstrategies around the relationship between acutemalnutrition and stunting and the implications fortheir investments in prevention and treatment ofacute malnutrition. These policies could clarify thatprogrammes for the prevention and treatment ofacute malnutrition can be financed out ofdevelopment funding windows where there is noemergency. Furthermore, where an emergencyoccurs, it is imperative not to displace developmentfinancing. In some contexts it may be appropriate tocombine humanitarian and development funding.

In recurrent or chronic emergency contexts and infragile states, where humanitarian funding dominates,donors can explore ways of instigating multi-year

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programmes for acute malnutrition. Existingmechanisms could help make donors moreaccountable, such as the annual report submitted bythe SUN movement to the UN Secretary General; theannual reports to the G8 and African Union on theNew Alliance on Food Security and Nutrition5; reportssubmitted to the World Health Assembly as part ofthe monitoring of the agreed global 2012 target toreduce stunting by 40% by 2025; as well as specificanalyses of these trends undertaken by specialistagencies such as Development Initiatives.

Looking forward, there may also be scope toincorporate such donor accountability in the post-Millennium Development Goal (MDG) framework6,either in association with a specific nutrition target oras part of a wider priority around child mortality, aideffectiveness or good governance. Donoraccountability could also be strengthened under theauspices of the EC; following the same process that isbeing prepared currently within the SUN movement,the EC could track and report on nutrition spendingby all EU member states (many of whom are notmembers of the SUN movement), therebybroadening the reach of such accountability systems.

The importance of nutrition governance also playsout at country level. In Ethiopia, for example, thegovernment’s strategic leadership on nutrition isbeginning to address the historical schism betweenhow undernutrition is understood, monitored andmanaged. Options are currently being explored as tohow best to bring all aspects of undernutritiontogether coherently.

3 Strengthen nutrition governance

In the interests of strengthening nutritiongovernance, donors could increasingly exploreopportunities to fund CMAM (and nutritionprogramming in general) through direct support togovernments in certain contexts (e.g. pooled orearmarked funds or direct budget support), ratherthan through UN and international NGOimplementing partners. However, for this to occur,national CMAM plans/strategies need to beembedded in the pooled fund agreement so thatnutrition managers have explicit access to theseresources.

Where donors continue to fund through multilateralor international NGO partners, it would be advisableto consider the increased transaction costs of thisapproach and a clear exit strategy. Where theimpediments to funding government are directlyconcerned with accountability, transparency and‘corruptability’ efforts could be made over a realistictime-frame to address these, i.e. institution of aneffective audit system.

In order to make progress on these issues, the ENNwould advise that advocacy efforts are undertakenthrough high-level donor forums to develop jointstatements of intent by donors. This process could besupported by ensuring the development of moresophisticated finance tracking mechanisms thancurrently exist so that donor financing arrangementscan be monitored more closely. Again, the SUNmovement offers a practicable avenue for this, wheredonors have already embarked on a process todevelop a shared approach to tracking resourcesaimed at nutrition.

In addition, good practice examples of where donorshave entered into a more equitable arrangementwith governments for financing CMAM throughformally agreed cost sharing should be activelyshared between donor organisations.

In general, it is in the interests of all stakeholders thatthere is greater transparency around donor financingof nutrition, including prevention and treatment

5 There are five objectives agreed to by the New Alliance, including one on nutrition and one on accountability. http://www.whitehouse.gov/the-press-office/2012/05/18/fact-sheet-g-8-action-food-security-and-nutrition.

6 The current Millennium Development Goals expire at the end of 2015. Although much will have been achieved over their 15-year life span, many of the targets set for each of the eight goals will not have been reached. A process is underway to consider whether new global goals should be set for 2016 onwards and what these should cover.

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Treatment of MAM is not always considered orincluded as a core component of CMAM. WFP, whichhas assumed responsibility for addressing MAM, isabsent from many of the countries with highprevalence rates or high burdens of MAM. WhereWFP is not present in a country, clarity is needed as towhether and how UNICEF needs to be resourced tofulfil the role of supporting children with MAM havinggraduated from SAM treatment, a responsibilityimplicated in the WFP/UNICEF matrix of collaboration(2011). Equally, in areas where UNICEF is not presentbut WFP is, clarity is needed as to how uncomplicatedSAM cases should be treated.

Given that CMAM scale up relies on integration intoexisting health systems and good inpatient supportfor the complicated caseload, the role of WHO inenabling this, in terms of global overview as well ascountry level support to government, needsstrengthening. The current situation whereby WHO

4 Clarify UN roles and responsibilities

5 Inform country level strategies for funding CMAM scale up

has to seek funding for this role from other UNagencies will need to be addressed

In addition, and as a minimum, there is an urgentneed for the global mapping of OTPs, which iscurrently carried out by UNICEF annually, to becomplemented by mapping of SFPs and stabilisationcentres within CMAM programmes. This could beinformed by a country based analysis showing eachagency’s presence and the burdens of MAM and SAMand would assist donors in determining whether toinvite or support new proposals. This type ofmapping could be supported by WFP and WHOrespectively, or where these agencies are absent orlack capacity, with the support of UNICEF. Withoutthis information, it is impossible to know the extent towhich the current UN tripartite arrangement isproviding the level of support needed to scale-up ona country by country basis or where critical gaps existwhich need to be filled.

Given the recent surge in costing exercises for scalingup national nutrition programming, including CMAM,it is very important that such calculations are basedon integration of CMAM programmes into existinghealth services, and take account of the decline inacute malnutrition as prevention efforts achieveimpact. Good examples of this type of costing shouldbe captured and disseminated for replication in othercountries, with donors supporting governments inundertaking these exercises. The World Bank is wellplaced to offer such support, having led theinternational costing efforts to date and beeninstrumental in supporting the development ofnational costed plans in specific countries. The SUNmovement is another critical actor in this area,having catalysed a great deal of the country costingwork undertaken in the last two years. Members ofthe SUN Donor Network will play a key role infurthering such efforts.

Based on these costing exercises, donors willincreasingly have an opportunity to work together ona country by country basis to agree a strategy and

vision for financing of CMAM within efforts to scaleup nutrition generally. Donor coordination forums atcountry level could provide the impetus for this in‘signed up’ countries. At the global level, donors mayexplore different strategies for how to supportgovernments scaling up programmes for theprevention and treatment of acute malnutrition.These strategies will need to account for differentelements of and contexts for programming, such assupplies versus human resources, relative grossdomestic products (GDP) of countries and increasingdomestic expenditure by governments over arealistically set time frame. These strategies can thenbe clearly articulated in donor policy documents.

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6 Enable better technical coordination between donors

7 Priorities for donor research and study

The ENN, in the course of this review have observedthat there may be added value in greater technicalcoordination between donor organisations at globallevel and recommend that a regular technical forumfor donor organisations working in the nutrition sectorbe convened. While the SUN Donor Network meetsvia teleconference on a regular basis, it is not clearwhether this mechanism sufficiently allows donors toreview nutrition policies and financing arrangementsas a group. A global forum for technical discussion

Funding for research into different RUTF formulationsand alternatives is a priority. The findings from on-goingresearch in India need to be rapidly disseminatedonce available. It will also be important to moreactively engage the support of the private sector indeveloping cost saving value chain models for localproduction of RUTF. Furthermore, product standardsfor treatment of SAM (SPHERE and World HealthOrganisation) may need to be revised if cheaper andmore sustainably funded formulations are to be used.

Another priority area for research is cost-effectivenessof different approaches for preventing and treatingMAM. The EC could lead on this research, building onECHO’s recent consultation on the prevention andtreatment of MAM, but securing broader involvementacross the humanitarian and development communities.

There needs to be a review of lessons learnt from theroll out and scale up of anti-retroviral therapy (ART)and malaria programmes globally, which have beenunderpinned by innovative financing arrangements.Lessons may well help inform efforts to scale upCMAM programming. One lesson had been identifiedalready: “In the past decade, the great majority ofadditional funding for health has been through newvertical funds focused principally on specific diseasesor interventions, such as vaccination. Important asthese are, the record shows that their unintendedconsequences have included a neglect of broaderhealth objectives and systems. In addition, because

would also allow donors to collectively prioritise keyresearch areas and institutional arrangements for thedelivery of nutrition programmes at country level. TheSUN secretariat would be well suited to take a lead onthis global forum, given the need to span developmentand emergency focused donors. The process couldstart with a small group of interested donors, perhapsinvolved in the SUN movement, with the UN StandingCommittee on Nutrition (UNSCN) brought in as apartner to the process.

the arrival of the new vertical funds was notaccompanied by mergers, closures or acquisitions ofexisting organizations, they also contributed to agreater fragmentation of an already highlyfragmented organisational framework.”7 Indeed, theoutcome document of the Fourth High LevelMeeting on Aid Effectiveness (the ‘Busan PartnershipAgreement’) seeks to address this, stating: “We willmake effective use of existing multilateral channels,focusing on those that are performing well. We willwork to reduce the proliferation of these channelsand will, by the end of 2012, agree on principles andguidelines to guide our joint efforts.”8

The ENN conclude that an economic and risk analysisshould be undertaken to compare the transaction(and opportunity) costs of having several UN agenciesand implementing partners responsible for acutemalnutrition, with having a single agency with overallresponsibility. The analysis will need look at theadvantages and disadvantages of different options forensuring optimal coverage for the treatment ofacutely malnourished children. Based on thesefindings and a review of programming experiences ina number of countries, a high level meeting with UNorganisations and donor organisations could beconvened to agree a set of recommendations on UNagency responsibilities in this area. It will then bepossible to identify how programmes to addressacute malnutrition can be better aligned andcoordinated within national contexts.

7 Keith A. Bezanson and Paul Isenman. 2012. “Governance of New Global Partnerships: Challenges, Weaknesses, and Lessons.” CGD PolicyPaper 014. Washington DC: Center for Global Development. http://www.cgdev.org/content/publications/detail/1426627.

8 Busan Partnership Agreement’, Fourth High Level Meeting on Aid Effectiveness, 2011

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