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Moving on, an article by Bernardette Cichon
describes ACF nutrition survey findings in the
Philippines, where three consecutive surveys found
large discrepancies in the prevalence of SAM using
either a weight-for-height cut off below – 3 z-scores or
a mid upper arm circumference (MUAC) less than 115
mm. The authors conclude that as long as the risk of
mortality in children with a weight-for-height of less
than -3 z-scores but a MUAC greater than 115mm isn’t
properly understood, all children classified as
malnourished according to both indicators should
receive treatment (in this instance, admission to a
CMAM programme). The authors recognise that using
two indicators complicates programming. Whilst not
the case in this example, this may also have significant
programme capacity implications. Interestingly, a
research summary in this issues research section
based on an old data set from Senegal examines the
risk of dying of children having either a low MUAC or a
low weight-for-height (z score) or a combination of
both in the absence of treatment. Analysis found that
MUAC has a better ability than weight-for-height (z
score) to assess risk of dying. Furthermore, using both
indicators together did not improve the identification
of high risk children.
Also related to CMAM programming, a field article
by Jan Komrska of UNICEF’s Supply Division in
Copenhagen describes how UNICEF has been keeping
pace with the increased demand for Ready to Use
Therapeutic Food (RUTF) as CMAM programming has
been scaled up rapidly across many countries. The
article describes various strategies employed, including
increasing the number of global suppliers in
Europe, identifying local producers in Africa and Asia,
improving forecasting of demand and the pre-positioning
of stocks. Staying with SAM management, a
research summary of work by Tufts describes the
success of a pilot CMAM programme in an Upzila in
Bangladesh where community health workers were
responsible for and supported in diagnosing and
treating SAM children. Programme indicators like
recovery and mortality exceeded SPHERE standards
and an extraordinary coverage of 89% was recorded.
A further three field articles deal with the prevention
and treatment of MAM in different contexts. An
article by Naomi Cosgrove and colleagues working
for ACF in Myanmar describes how reduced daily
rations of RUTF (one sachet instead of two or three
used for SAM treatment) were used to treat successfully
uncomplicated cases of MAM managed within
the CMAM programme. Fuelled by imported supply
constraints and a rising caseload, ACF modified the
treatment protocol and introduced a second phase
of treatment, once the child had improved from a
severe to a moderate (i.e. MAM) stage of malnutrition.
A key conclusion from the article was that the
programme success was partly due to the high quality
ration but also the attention given to programme
design, including well trained staff and good
community mobilisation. Another article written by
Dr Jean-Pierre Papart and Dr Abimbola Lagunju of
Fondation Tdh covers MAM management and the
important role of quality staff in service delivery in
Guinea. Community and facility level screening and
provision of RUTF (for SAM) coupled with cooking
demonstrations, counselling, some food supply (for
MAM) and defaulter follow up were undertaken by
government staff. Urban community health workers
played a key role in service delivery. The authors
concluded that government health facilities can
deliver good results with the appropriate technical,
material and equipment support. On the job training
and supervision, feedback on performance and regular
higher level supervision of nutrition activities
played an important role in service quality. A WFP
pilot blanket supplementary feeding programme
(BSFP) in Kassala State, Sudan is the subject of a third
field article on MAM, written by Pushpa Acharya and
Eric Kenefick of WFP. This article details how intensive
community engagement and sensitisation were key
components of the programme, as were certain key
messages derived from a KAP (Knowledge, Attitudes
and Practices) survey. All pregnant and lactating
women and children under five years of age were
targeted with the BSFP, providing approximately 500
kcals/day. The pilot found that 68% of malnourished
children enrolled in the programme recovered within
four weeks, although the cost of the programme was
at least twice as high per child as the targeted SFP
implemented by WFP. The authors concluded that
when food availability and quality is enhanced
through the provision of small quantities of highly
fortified food combined with the intensive engagement
of the community around harmful feeding
practices, the impact of food aid is significantly
increased. The size of the programme allowed intensive
monitoring by the Ministry of Health and WFP.
The challenge lies in taking the pilot to scale.
A final field article written by Catholic Relief
Services (CRS) in Zambia considers a Food by
Prescription (FBP) programme that targets moderately
and severely malnourished HIV positive adults
with medicalised doses of nutrition supplements
through the home based care programme. Individual
sachets of the supplement are distributed to reduce
household sharing and strengthen the understanding
that the food is a ‘medicine’. Data from the pilot
programme showed that there was an increase in
client Body Mass Index (BMI) between admission and
discharge. Among adult clients, the average BMI on
admission was 17.6 and the average BMI on
discharge was 20.5. The overall average increase in
BMI pre-FBP to post-FBP was 2.9. Most clients
required three to six months of nutrition rehabilitation
to qualify for discharge.
The research section of this issue also covers a
wide range of subjects. There are two articles on cash
transfer programmes. One is a summary of a study of
the national ‘Bolsa Familia’ programme (BFP) in Brazil,
which is the world’s largest conditional cash transfer
programme. It reaches 5,564 municipalities in the 27
states of Brazil and about 11 million families (25% of
the Brazilian population).Once a family enrols, it must
comply with certain health and education conditions
to remain in the programme. The study found that
children from families exposed to the BFP were 26%
more likely to have normal height-for-age than those
from non-exposed families; this difference also
applied to weight-for-age but not weight-for-height.
Another study looks at a cash transfer programme in
Niger using mobile phone technology and found
that in comparison to physical cash transfer
programmes, there was a significantly reduced cost
to programme recipients, as well as reduced implementing
agency’s variable costs associated with
distributing cash. There is also a fascinating article on
the political economy of crop diversification policies
and the policy process at government level in
Malawi. The article explains how the processes of
discussing, negotiating, approving and implementing
policies are as important as the scientific content
of the policies themselves. The experience with crop
diversification shows that dominant stakeholders
almost always have their way and that in Malawi,
implementation of crop diversification has been
constrained by a dominant narrative that equates
food security with maize production.
Other research of note in this issue include a
psychological study to understand how humanitarian
workers remain effective in challenging
environments, a study to assess the effect of performance
based payment of health care providers on the
use and quality of child and maternal care service in
healthcare facilities in Rwanda and a position paper
to guide country-level health clusters on how to
apply IASC (Inter-Agency Standing Committee) civil
military coordination principles to humanitarian
health operations given the “shrinking of humanitarian
space” in many complex crises.
Our opening 2012 issue is a reminder of the
ongoing innovations and inevitable compromises
that are sometimes necessary in humanitarian
programming. You can have the best designed intervention,
but national and sub-national capacity to
deliver on the ground and supply chain difficulties
can make or break a quality programme. The articles
featured also reflect some of the ‘grey’ areas in the
emergency nutrition sector. For example, whilst SAM
management has rapidly developed and improved
through CMAM programming over the past 10 years,
there is a limited evidence base for optimal programming
for the prevention and management of MAM.
The jury is still out on how best to deal with high and
fluctuating levels of MAM and field practice remains
a bit of a ‘free for all’. A news piece by ACF, laying out
the agency’s position on the role of products in the
treatment and prevention of global acute malnutrition,
sets out certain boundaries whilst highlighting
some of the more contentious areas. Our prediction is
that the role of products in the prevention and treatment
of MAM will be one of the big issues in the
coming year. And we hope the SCUK/Oxfam paper
has just generated another - the 2011 Horn of Africa
crisis highlights once again a clear failure of response
at the highest level of the international aid community.
Is it not incumbent upon donor governments to
analyse why that occurred and to work with the rest
of us to address the reasons for this failure as urgently
as possible?
We hope you enjoy this diverse issue of Field
Exchange and wish all our readers a healthy, happy
and productive 2012.
Jeremy Shoham, Editor
Marie McGrath, Sub-editor
We would like to dedicate this issue of Field
Exchange to Kari Noel Egge and Mr Abdikarim
Hashi Kadiye, whose untimely and premature
deaths saddened the whole humanitarian community.
We have included short tributes to both of
them in a new Field Exchange obituary section for
humanitarian workers, which we sincerely hope
remains unused in subsequent issues.
1
Simplified LQAS (Lot Quality Assurance Sampling)
Evaluation of Access and Coverage
2
Semi-quantitative Evaluation of Access and Coverage
Allison Shelley/Concern, Port-au-Prince Haïti, 2010
2