A warm welcome to the 65th edition of Field Exchange. This edition features a range of programming issues that unfortunately reflect that we are still in the midst of the COVID-19 global pandemic. But, on the positive side, the experiences reflect how the nutrition sector continues to innovate to accommodate this new reality, coming up with new ways to ensure continuity of services whilst also ensuring pre-COVID projects and research have continued and, in doing so, are building critical evidence.
Given that, our edition features a special section on COVID-19 nutrition programming adaptations across Asia and Africa. An article from Rwanda describes the characteristics of an effective risk communication and community engagement strategy to address myths and misconceptions around nutrition and COVID-19. Related to this theme of communication, two field articles describe adaptations made to infant and young child feeding (IYCF) programmes in Somalia and Lebanon. In both contexts, more women were reached than in the year prior to COVID-19; in Lebanon due to the use of remote communications and in Somalia due to an increased frequency of counselling meetings. The reallocation of funds through flexible donor funding greatly enabled innovation.
Remote ways of working emerged as a feature in several articles in this special section. A field article from Madagascar highlights the experiences of carrying out a remote Integrated Acute Malnutrition Phase Classification (IPC) exercise for government – the first remote IPC to be undertaken worldwide, while a research article from Cox’s Bazar in Bangladesh describes the experiences of adapting standard SMART methodology to enable SMART surveys to be possible in the COVID-19 context. Remote innovation is also reflected in an article by GOAL where breastfeeding videos were used to support one-to-one IYCF counselling in Ethiopia, applicable to the COVID19 context but, in this instance, implemented to save the time of busy health workers. Rising to the challenge of disrupted food supply chains due to the COVID-19 pandemic, a team from the Philippines describe the ‘move food’ initiative, where a novel non-governmental organisation-led system supported the movement of food from farmers to consumers during a time of restricted movement, also serving to reduce food waste. This has proved so successful that it is set to continue. ‘Innovations’ around COVID-19 programming are a mixed bag. Some of the COVID19 programme adaptations may be a compromise too far in the long term and are a temporary solution until full service can be resumed. Others may be developments that were long overdue but, fast-tracked by the urgency of the crisis, are here to stay. Commitment to documenting learning on processes and outcomes remains critical in order to distinguish the difference.
Field Exchange features some nice examples of multi-sector programming from South Asia embedded in or supporting local government systems and services and with some signs of promising nutrition impact. A mid-term evaluation of the UNICEF-supported Swabhimaan initiative shows promising change in adolescent and maternal undernutrition indicators as well as improved household food security. This programme, integrated within the Government of India’s flagship poverty alleviation programme, Deendayal Antyodaya Yojana-National Rural Livelihoods Mission (DAY-NRLM), mobilises village level collectives of women and strengthens the access of women and adolescents to services. A field article authored by Welthungerhilfe shares the implementation of the ‘SMART nutrition villages’ model in 200 villages in India and Bangladesh. Again, village institutions are used as a platform to support communities to plan and implement multi-sector nutrition activities and access government entitlements. Half of the project villages showed marked improvement in women’s and children’s dietary diversity and in water, sanitation and hygiene (WASH) practices but not in wasting prevalence. A field article from Nepal describes how WASH actions that were integrated across Suaahara II districts through local government coordination and capacity building demand the creation of improved facilities and behaviours and engagement with the private sector on supply chains. Monitoring data showed successful uptake of some promoted WASH behaviours in both non-intensive and intensive areas, with a greater change over time in intensive areas.
These three examples of multi-sector programming show some positive directions but, in some instances, a lack of anticipated nutrition impact, yet again reflecting the complexity of undernutrition. This is further echoed in several articles in this edition, including two from Tufts University that examine the multiple drives of undernutrition in Africa’s drylands. Young et al argue that there is a need for innovative interdisciplinary research and learning to better understand the basic drivers in each context and for researchers, programmers and policymakers to engage more closely to build consensus on solutions. The need for ‘joined up’ thinking and action – this time across wasting and stunting – is reflected in an article by Action Contre la Faim on the drivers of concurrent child wasting and stunting (WaSt) in Liberia. While they found the principle driver of stunting in this context was limited access to markets, the drivers of WaSt were younger child age, recent episodes of diarrhoea, a child being taken care of by a non-immediate family member and reduced coping and support of caregivers. The authors reflect that an analysis of the drivers of stunting alone would not have prompted interventions to address the risks associated with WaSt which is associated with higher mortality.
The global burden of micronutrient deficiencies also continues to demand collective action and innovation for scale. Working with government and the private sector, an article on the USAID-funded RANFOSE describes how this collaboration supported the government of Haiti to legislate for food fortification and worked with private sector companies to influence manufacturing practice. As a result, fortified products are now increasingly replacing unfortified products on the Haitian market.
Accurate nutrition data is critical to inform caseload projections, programme planning and budgets. A field article on Nutrition Information Systems (NIS) in Kenya describes how SMART surveys were streamlined, harmonised and institutionalised under the coordination and leadership of the national Nutrition Information Technical Working Group. The NIS in Kenya is now ‘owned’ and largely funded by government, with greater use of high-quality nutrition data to inform timely nutrition and multi-sector actions. Strong government leadership and coordination and a shift over time in the focus of international agencies and donors from emergency programming to a health systems strengthening approach were key success factors.
The ongoing challenge of estimating people in need in the absence of current data is reflected in an article by UNICEF Afghanistan. In this instance, the team combines historical data, Seasonal Food Security Assessment data and mid-upper arm circumference (MUAC) screening data from Health Management Information Surveys.
By no means coming up with a perfect or simple solution, the authors describe what they are trying in highly constrained contexts. Another longstanding information challenge is our dependence on prevalence data for wasting which underestimates caseloads and limits trend analysis. An article by the World Food Programme describes a new mathematical model to generate an incidence correction factor in six Sahelian countries which accounted for frequent food insecurity, seasonal variation and COVID-19 in the region. As suspected, this led to a higher estimated burden of wasted children (5.35 vs. 4.54 million originally projected). As we go to press, long overdue incidence correction factors for wasting are for imminent release by UNICEF; watch ENN’s home page for updates.
Finally, how to treat wasting at scale is a theme across several articles. This was the focus of the recent global CMAM conference hosted by Concern Worldwide that aimed to facilitate an exchange of evidence and experiences on CMAM scale-up in fragile contexts. A background paper by ENN identified drivers and barriers to CMAM scale-up from global and national key informants. Siloed nutrition and health workforce teams, inadequate investment in community health workers, the need to streamline ready-to-use therapeutic food (RUTF) requirements and the costs of RUTF, as well as shorter supply chains, were also identified as crucial. Related to this, several articles are on the continued ‘hot’ topic of simplified approaches to wasting treatment. This includes a UNICEF review of the use of simplified approaches across 21 different countries and an article by Première Urgence Internationale that describes how Mother MUAC in a CMAM programme in Chad increased screening coverage and the proportion of severely wasted children admitted for treatment. The Simplified Approaches Working Group, co-led by UNICEF and IRC, has also just launched a new website (https://www.simplifiedapproaches.org/) with resources and emerging guidance on simplified approaches.
It takes courage but also requires care to act ‘outside the box’. It is heartening to see the commitment and drive on simplified approaches to treat wasting to improve service coverage, but we must make sure we do not unnecessarily sprint (and trip up) as we run. Evidence on different types of ‘simplification’ is varied; for example, the state of evidence for rolling out Family MUAC is at a very different stage to reduced dosage of RUTF. We are not yet there on the pathway to scale, but our collective narrative does not seem to reflect that. There are still many important unanswered questions, such as what the implications of different types of ‘simple’ adaptations for child growth are for very young and older children. As with the COVID-19 adaptations, we should not shy away from innovation and change but be willing to take steps back as well as forward when it is right to do so. We should also make sure that by convening around the latest ‘buzz areas’ we do not neglect issues to which our attention is overdue, a reminder prompted by a views piece by Fitzpatrick et al that calls for greater investment in research to understand the aetiology, pathophysiology and burden of kwashiorkor.
As always, your experiences spark great discussions amongst the ENN team. Share your thoughts with us – letters to the editor always welcome.
Nicki, Chloe, Marie
Field Exchange editorial team