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Accelerating the scale-up of treatment for severe acute malnutrition

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

Saul Guerrero is the Director of Nutrition at Action Against Hunger UK (ACF UK). Prior to joining ACF, he worked for Valid International supporting UN agencies, NGOs and national governments in the design, implementation and evaluation of community-based management of acute malnutrition interventions in over 16 countries in Africa and Asia. In 2012 he co-created the Coverage Monitoring Network (CMN), an inter-agency initiative to evaluate the reach of nutrition services worldwide.

Erin Boyd is a Nutrition Advisor and instructor with experience in emergency nutrition response and covers policy, programme management, monitoring and evaluation, coordination and operational research. She has worked in nutrition surveillance, emergency nutrition interventions, and coordinated responses in locations such as Darfur, Ethiopia, Haiti and Pakistan. She has also worked with donors and at the Friedman School of Nutrition Science and Policy at Tufts University.

Claire Harbron is a Manager at the Children’s Investment Fund Foundation. She oversees CIFF’s strategy and programme portfolio on the prevention and treatment of severe acute malnutrition.

Diane Holland is Senior Nutrition Advisor at UNICEF New York and has a focus on scaling up programming to treat severe acute malnutrition and addressing nutrition emergencies. She has over ten years’ experience in public nutrition, including support 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 Leader at the Department for International Development, UK. A nutritionist with extensive experience in development and emergency work, Abi has previously worked in a variety of technical roles for different NGOs and as a Research Associate at UCL.

Sophie Whitney is working as a Global Nutrition Expert for the European Commission Humanitarian Aid and Civil Protection (DG ECHO). She has extensive experience in nutrition, having worked for over 15 years in both headquarters and field positions in programme design, monitoring and implementation. In her current role she is monitoring innovation and informing the nutrition policy to ensure aid efficiency in humanitarian crises.

The last decade has been one of the most exciting in the global efforts to treat Severe Acute Malnutrition (SAM) at scale. In that period, we have seen a community-based model to treat SAM go from a small-scale but innovative pilot to a large-scale intervention in over 70 countries worldwide. We have seen the availability of revolutionary, ready-to-use therapeutic foods (RUTF) increase, with reductions in cost and a wider range of producers at global, national and regional levels. This has led to a rise in the number of SAM children accessing life-saving treatment worldwide from just over one million in 2009 to over three million in 2014. And all of these changes have occurred against a backdrop of increasing political support for addressing malnutrition worldwide, through platforms like the Scaling-Up Nutrition (SUN) movement and the formal inclusion of wasting as a key target in both World Health Assembly (WHA) and Sustainable Development Goals (SDG).

When we take stock of these and other achievements, we feel optimistic about 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 base for the prevention of acute malnutrition, in particular, remains limited and often inconclusive, hampering efforts to effectively link prevention and treatment efforts. The number of children accessing treatment has tripled in just five years, but is beginning to stagnate; today only one in every five children suffering from SAM has access to treatment, leaving the large majority of those affected at increased risk of mortality from associated illnesses.

This has to change, and the nutrition community, together with colleagues across health and other sectors, needs to do whatever it takes to ensure that a higher proportion of children have access to effective treatment. No single approach or solution will be sufficient and critical challenges across nutrition programming, policy and financing will need to be addressed.

Programmatically, community-based approaches for treating SAM must continue to be integrated into health systems and basic emergency packages. To do so, the specific measures required for these efforts to fully succeed need to be identified. For us, there are five key elements that must be at 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, including for 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.

4.      Optimise the specifications and dosage of specialised nutritious foods. To make significant improvements in the cost-effectiveness of treatment, efficiencies and improvements 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 factors that lead to acute malnutrition, the scale of the problem and the performance of the services dealing with acute malnutrition is either missing or inaccessible. As the Global Nutrition Report has highlighted, greater investments in SAM information, and the right platforms to make this information easily accessible to those who need it, are urgently needed.

Addressing these and other questions will require investment in innovative and bold ideas, and the capacity to generate evidence and identify what works in a timely manner, so that innovations can be mainstreamed in years, not decades.

The challenge of SAM treatment scale-up might often be defined in programmatic terms, but the solutions are, more often than not, political. At a time when the nutrition movement is gathering pace, the issue of SAM is often lost in policy debates at a global level and fails to be included in national nutrition targets. To make SAM a political and public health priority, the nutrition community must do what we have recognised for years: get out of the echo chamber and start engaging consistently and actively with the wider public health community. Doing that will require us to be clear about what we want to see happen, in concrete terms, and to ensure that the benefits of putting SAM into child survival policy and practice are made explicit. This conversation is particularly critical at national level, for it is there that the impact of scaling-up SAM treatment will ultimately be most profound. Repositioning SAM as a key aspect of accelerating child survival will be about high-level dialogue, but it will ultimately be about translating dialogue into action and measurable commitments.

Delivering SAM treatment at scale will come at a cost. The recent projections made by the World Bank, Results for Development, 1,000 Days and others, have generated valuable insights into exactly how much will be needed to deliver SAM treatment at scale ($1.8 billion a year) and how much is currently being made available ($450 million in 2014). Addressing the deficit will require a step-change and the capacity 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 commitment from national governments to include SAM treatment costs into multi-year health budgets. Business, private sector companies and foundations also have a critical role to play, but in different ways to national governments and bilateral donors. Determining the added value of each in covering different components of treatment services (e.g. commodities, research & development and health system-related costs) will be the key to optimising the contributions of each actor and getting us closer to the mark.

And when all is said and done, that is our lasting answer: to unlock the global and national challenges we will need to bring our different skills, knowledge, geographical reach and diverse networks to bear on this very pressing problem. Only if efforts are coordinated and dialogue sustained on the opportunities and challenges we face, will we maximise the influence and impact we can leverage, and bring others on board to drive change. In this, the UN-designated Decade of Nutrition, we need to ramp up and coordinate our collective efforts to tackle severe acute malnutrition, thereby unlocking the wider benefits for child health and global development.

Watch this space…www.nowastedlives.org

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Saul Guerrero, Erin Boyd, Claire Harbron, Diane Holland, Abi Perry and Sophie Whitney (2016). Accelerating the scale-up of treatment for severe acute malnutrition. Field Exchange 53, November 2016. p54. www.ennonline.net/fex/53/acceleratingtreatmentformalnutrition