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A warm welcome to our 63^rd edition of Field Exchange, focused on child wasting in South Asia. The idea for this issue came out of a meeting in New York back in 2018, convened by the UNICEF Regional Office for South Asia (ROSA) team who were feeling somewhat frustrated by the lack of attention and investment in wasting management – especially treatment – in the region. At ENN, we realised we were also guilty of neglecting South Asia; over the years, experiences from Africa have dominated the pages of Field Exchange. To begin to ‘right this wrong’, we embarked on this special edition on child wasting in South Asia, in partnership with the UNICEF ROSA team, to give a greater voice to those working in the region.

The problem

The numbers should speak for themselves. Regional child wasting prevalence and burden is huge – 25.1 million wasted children (14.5%) of whom 7.1 million (4.5%) are severely wasted – twice as high as in sub-Saharan Africa.¹ On top of this, an increase in 3.9 million wasted children in South Asia is predicted as a result of COVID-19.² Even more worryingly, these figures are based on prevalence data and do not take into account incident cases, therefore underestimating the true number of children in need. Recent analyses of large longitudinal cohorts by the Knowledge Integration (KI) initiative of the Bill & Melinda Gates Foundation, summarised in this edition, found that wasting prevalence estimates may underestimate the number of children who have experienced wasting episodes by as high as seven-fold in South Asia (five-fold worldwide).³ Work by UNICEF to update incidence correction factors is long overdue for release – until that time we remain in the dark about the true burden and costs of wasting worldwide. Based on prevalence figures alone, treatment coverage in the region is estimated to be less than 5% – and yet these numbers have not been enough to catalyse action. So, we set out to help bring attention to this crisis and to ask the question, why hasn’t there been more progress and what must we do about it?

Overview of content

In close partnership with the UNICEF ROSA team, we focused on the countries with the highest burden of wasting – Afghanistan, Bangladesh, India, Nepal, Pakistan and Sri Lanka. From here, we sought programme experiences and research on priority themes such as epidemiology of wasting and growth failure, low birth weight (LBW), management of ‘at risk’ mothers and infants under six months of age, integrated treatment and health system strengthening and links between humanitarian and development programming. As programmers wrote articles for this edition, COVID-19 hit the world; this became a cross-cutting theme and emerging adaptations and innovations to both research and programming are embedded in articles from India, Cox’s Bazaar (Bangladesh) and Nepal. Two regional groups – the Wasting in South Asia Technical Advisory Group⁴ and the Asia sub-working group on wasting welcomed ENN to their tables, allowing us listen and learn from their priorities and actions.

Nine months later, we have amassed a rich body of work for you to delve into. We have 12 field articles by authors delivering programmes in India, Bangladesh, Pakistan, Afghanistan and Nepal, two original research articles, three views articles and ‘bonus’ online content.⁵ We have also summarised a selection of peer-reviewed papers that we felt most relevant to inform the policy and programming discourse, with an introductory editorial note to the ‘research snapshot’ section to give to you a steer on the content. We’ve also complemented our written word with ‘live’ voices in the form of podcasts from authors in several countries and regional and global stakeholders closely engaged in the region.⁶

The wasting conundrum

So, where should you start? We suggest you begin with the eloquent reflections on child wasting in the region by Harriet Torlesse and Minh Tram Le from UNICEF ROSA where they try to “unravel the wasting conundrum” in South Asia. Their overview of wasting gets to the heart of helping us to understand why we are in such a predicament on child wasting in South Asia and identifies critical areas for attention and action. Setting the scene, they describe how wasting in the region is not a ‘humanitarian’ problem; the region is certainly affected by emergencies but most wasted children in South Asia live in development settings. Furthermore, wasting (and stunting) persists despite economic growth – with the exception of Afghanistan, all South Asia countries are classed by the World Bank as middle-income. What stands out from the region is how fundamental maternal nutrition and health, LBW

 and early infant growth experiences are to immediate and subsequent growth failure burden, causes and consequences.⁷ The UNICEF ROSA team’s vision for “reimagined care” for wasted children in South Asia has four components: 1) government leadership and ownership of the prevention and treatment of wasting at its core, 2) preventive actions central to national efforts that prioritise maternal health and nutrition, 3) strengthened health system integration and continuum of care to prevent and treat all wasted children and 4) development of an evidence base on the epidemiology of wasting in South Asia and effective models of care. The challenge is how to put this vision into practice.

So why has wasting achieved so little attention? One reason may be the prioritisation of stunting prevention in the region which has fuelled a neglect of wasting and, in doing so, reinforced a siloed approach to both forms of undernutrition. This is despite strong evidence that wasting and stunting are connected in terms of causes, may concurrently affect a child and have severe consequences for survival.⁸ Pooled analysis of 18 longitudinal cohorts (10,854 children) from 10 low- to middle-income countries in South Asia, sub-Saharan Africa and Latin America found that concurrent wasting and stunting was most prevalent in South Asia, with peak prevalence at ages 12-18 months.⁵

On a positive note, there are signs of growing awareness that failing to address wasting may actually be a key factor in the persistently high rates of stunting in the region, as reflected in articles from Pakistan⁹ and Afghanistan.¹⁰ They describe policy development, commitment for collective UN and government action and early stage operational planning to align wasting and stunting preventive and treatment interventions. While this has not yet translated into convergence in these countries, the authors describe political will, policy frameworks and programming opportunities to do so. It remains that the complexities of multiple ministries being responsible for different interventions, along with devolved governance, make coordination and alignment easy in principle but challenging in practice. We have much still to learn on ‘how’ to connect prevention and treatment across the spectrum of undernutrition and what it takes for ministries, departments and administrative structures to do so. We look forward to the learning that we hope will be generated from those countries championing new ways forward.  The current UNICEF-led development of country-led Road Maps for Action for the UN Global Action Plan (GAP) on Child Wasting¹¹ offers a great opportunity to do just that, as is happening in Afghanistan (see below)¹² and the South Asia region.¹³ This also speaks to a key role for the next phase of the Scaling up Nutrition (SUN) Movement for regional and country-centric action to support governments in translating national multi-sectoral nutrition ambitions to connect wasting and stunting into workable plans and to capture the rich learning from doing so.

Short, thin, anaemic and young

A recurring theme in this edition is the need for more focus on interventions to boost maternal nutrition and health. A review of the evidence on maternal nutrition in the region by Torlesse and Murira¹⁴ highlights multiple bottlenecks in the health system that result in low coverage of maternal iron and folic acid (IFA) supplementation (the most common maternal nutrition intervention), gaps in global guidance on dietary supplementation in pregnancy and limited evidence on what is needed and what works in different settings. The authors describe how poor action on maternal nutrition and health fuels the high prevalence of infants with LBW – infants who are more likely to be born wasted and/or stunted and/or underweight and are at higher risk of death, even after they ‘catch up’ in growth. This is particularly pertinent in South Asia since the highest levels of wasting occur at birth and in the first three months of life.⁵ Adolescent girls who become mothers too early are more likely to give birth to babies that are too small, compromising their own health and that of future generations.¹⁵ Torlesse and Murira conclude that “short, thin, anaemic and young” is a defining characterisation of the maternal undernutrition challenge in the region. There is immediate action we can and should take. Multiple micronutrient supplementation (MMS) in pregnancy shows real promise to improve foetal growth and so prevent LBW (especially related to prematurity) ^{16 17} and hence reduce the number of babies being ‘born wasted and/or stunted’. While many argue there is strong evidence to support a transition from IFA to MMS, WHO recommendations continue to adopt a cautious approach due to concerns regarding the risk of use in populations that are not micronutrient deficient and therefore state that countries with a high prevalence of nutritional deficiencies may choose to adopt MMS. In practice, this makes for a protracted process with many governments unclear how to do this, or not keen to embark on what may still be perceived as ‘going against’ WHO recommendations. To help on the ‘how’ of putting WHO recommendations into practice, an article in this edition by Hurley et al summarises key evidence and shares experiences of scaling up MMS use in healthcare systems in Indonesia and Bangladesh using a phased approach.²¹ Further interesting examples of programming on maternal nutrition include a field article by Dalal et al that targets pregnant women and at risk infants in Mumbai¹⁸ and a field article by Ash et al that explores the mainstreaming of maternal nutrition into the government health system in Bangladesh.¹⁹

Scale, sustainability, simplicity

With any intervention, scale and sustainability should be considered from the outset to maximise the likelihood of success²⁰ – the simpler the approach, the better the chances of success. Over the years, we have featured many articles in Field Exchange that describe short-term pilot programmes, without explicit consideration of the potential to scale and sustain. We have also learned that scale up takes a long time. What is notable in many of the articles we feature in this special edition is the consideration given both to integration and to leveraging existing systems and services from the outset. Given this, failure to scale up treatment in the region may partly reflect a reticence to take on treatment when there is no clear vision or plan on how it can be sustained. Having said that, we have some good examples of countries on pathways to scale up  of treatment in India,^24,16 Pakistan¹³ and Nepal²¹ where government leadership and buy-in from the outset has been a key enabling factor that worked towards embedding into existing systems and services. In Pakistan, partners capitalised on the Government’s signing of the Astana Declaration on Universal Health Coverage and successfully advocated to include community-based management of acute malnutrition (CMAM) in the public health system; costing, capacity building and plans for rollout are now underway. We also feature promising pathways to scaled up care: complicated wasting case management is being integrated into in-patient paediatric care in India,²² health workers in India are providing home-based care for children born LBW ²⁴ and programmers in Afghanistan⁴ and India²⁴ are actively exploring approaches to manage nutritionally at-risk infants under six months and their mothers at community level. In India, a vision to “reorganise the health system” to facilitate a continuum of care for newborn and small infants beyond the neonatal period identifies the need for trials on impact and cost-effectiveness and testing for potential to scale up into existing delivery systems.²³

Simplified approaches to wasting treatment are an active area of programming and research being carried out with the aim of facilitating scale-up.²⁴ Simplification of process/indicators/protocols feature in several articles in this edition, such as simpler, reduced dosage schedules in Afghanistan to economise on ready-to-use therapeutic food (RUTF) and so reach more children and use of mid-upper arm circumference (MUAC) in both Cox’s Bazar in Bangladesh²⁵ and India¹⁶ as an adaptation to COVID-19. Simplifications are not necessarily straightforward – use of MUAC in screening in Cox’s Bazar as part of a vitamin A supplementation campaign successfully helped to identify many children in need of treatment. However, expanded MUAC criteria (to try to capture excluded low weight for height (WHZ) children) led to an overwhelming rise in admissions to targeted supplementary feeding programmes that is now under review by the Nutrition Sector in Cox’s Bazaar²⁶. In India, a technical consultation concluded that weight-for-age z-score (WAZ) could “operationally simplify” community-level assessment to identify infants under six months at highest risk of death;²⁷ WAZ was also used as a criterion to identify both infants and children for in-patient wasting treatment in New Delhi.³² Given that WAZ captures concurrent wasted and stunted children,²⁸ LBW infants²⁹ and infants under six months of age³⁰ at higher mortality risk and is measured in growth monitoring programmes throughout the region, this is a direction of travel we would do well to watch and learn from globally. Which indicators best identify children at risk and for which types of care remains the subject of much international research and recurring (often frustrated) debate. The current update of WHO guidelines on the prevention and treatment of wasting in infants and children through 2021³¹ provides a critical opportunity for long overdue progress and clarity.

The cost of treatment

Like many other regions, the shortage of financial resources to sustainably cover the cost of services, including ready-to-use therapeutic food (RUTF) supply and to meet both development and humanitarian needs, is another key barrier to scaled up management of child wasting. By virtue of its ‘non-emergency status’, the region has not drawn the same level of donor support to address wasting as in sub-Saharan Africa where much funding has been secured through UN agencies and short-term ‘humanitarian’ financing. While short-term funding has significant drawbacks, it has catalysed treatment programming and continues to significantly subsidise service delivery in fragile contexts. That’s not to say the South Asia region is unaffected by emergencies – it is and, in fact, progress on community-based treatment of wasting in Pakistan, Nepal, Afghanistan and India (Bihar) all began as emergency responses dependent on humanitarian funds channelled through UN agencies and non-governmental organisations (NGOs). In Nepal, increasing allocations of domestic resources to wasting treatment has been critical in the transition from a programme that was humanitarian-dependent to one that is now nationally driven. In Pakistan, community-based management of acute malnutrition (CMAM) has been included at policy level as part of an essential package of interventions within the public health system that is now being costed to inform stepped rollout. However, Afghanistan continues to rely on short- term emergency funds with considerable shortfalls that are a fundamental barrier to scaled up treatment. Sustainability of funding is also identified as a key challenge to the further scale-up of POSHAN-II, an integrated CMAM programme, successfully implemented across 20 districts of Rajasthan in India. The authors of an article on this subject in this issue¹⁶ consider that the success of a government-funded programme will depend on a robust management information system, a trained healthcare workforce, a strong reporting mechanism and significant resources and supply-chain management for Energy-dense nutrition supplements (EDNS) (the RUTF equivalent used). In their regional wasting overview,³² Torlesse and Le Min conclude that allocation of domestic funding is critical to address wasting but, given the burden of care in the region, the problem is too immense for governments to handle alone. They therefore call for the development community to step up in terms of financial assistance and technical support. 

Ultimately, to advocate for much greater investment to treat wasting in the region, we need to be able to say how much it will cost. We struggled to get a clear answer to this question, even where some degree of scale-up had been achieved. Work is now underway by UNICEF to generate costing guidelines based on a synthesis of existing data and tools and drawing on country experiences, including in South Asia, which should reflect and feed into broader costing tools being used at country level.³³ However, the challenges of answering ‘how much’ remain many; costs are embedded within health system costs (such as staffing) and ‘hidden’ in multiple budgets and even estimating direct costs is rife with difficulties. Estimates become guestimates and are context dependent, making comparisons between countries difficult and global projections even more so.

The high costs of treatment reinforce the need to prevent wasting in the first place. Findings of a sociocultural study amongst a selection of those children enrolled in the POSHAN-II programme identified LBW and poor maternal nutrition as important drivers of severe wasting in their caseloads; the authors call for urgent action on multiple strategies on adolescent and maternal nutrition and health to reduce LBW and more operational research to identify links between CMAM and interventions such as the landmark Maternal and Child Health Integrated Programme (MCHIP) in India.¹⁶ Given this, it is worth reading the article by Rupal et al on an innovative programme by a grassroots organisation to target high risk (LBW) infants with high quality, skilled, sustained breastfeeding support in the slums of Mumbai.³⁴ Operational data suggests they reduced the subsequent burden of wasting and stunting relative to community prevalence. In Afghanistan, prevention has been agreed as critical to reduce caseloads, catalysed by the increasingly unsustainable costs of treatment.⁴ Here, all UN agencies have committed to a ‘One UN for Afghanistan’ strategy that addresses both prevention and treatment and is consistent with the government-led Afghanistan Food Security and Nutrition Agenda (AFSeN-A) Strategic Plan. The development of an Operational Roadmap in Afghanistan for the Global Action Plan on Child Wasting is being used as the opportunity to translate existing intent into programming action throughout 2020.

The ready-to-use therapeutic food (RUTF) question

Nutrition is never without its controversies wherever you go in the world and South Asia is no exception. One area of debate that has significantly hindered scale up of treatment is around RUTF. Sanctioned by government for use in just three countries of the region (Afghanistan, Pakistan and Nepal) where it was introduced on the back of humanitarian programming, barriers to wider national endorsement relate to the financial costs linked to sustainability and scale, cultural acceptance of the product and the availability of local alternatives in existing services. Regional research on this front continues by icddr,b in Bangladesh³⁵ while an article in this issue from India by Achakzai et al describes experiences of testing an alternative formulation for wasting treatment based on a locally adapted product.³⁶ In the India experience, both milk protein content and observed weight gain do not meet current global standards/benchmarks. The authors reflect that, to achieve scale, compromise is needed between the ideal and the real; it is arguably better to reach more children with a financially viable programme with lower but ‘acceptable’ outcomes. This (and similar points raised in global conversations in the context of WHO guideline development on the milk protein content of RUTF) does raise the question of whether there is a need to re-examine benchmarks and standards for how we assess ‘what works’ and is ‘good enough’, where the priority is to provide the most children in need with an acceptable standard of care. It remains that, in the region, the lack of contextual evidence around RUTF use and formulations continues to stifle policy and programme action and, ultimately, the treatment of wasted children.

New focus, stakeholders and narrative

When it comes to the management of child wasting in South Asia, the scope and task at hand looms large. Everything is important but we need to prioritise. For South Asia, the many voices from the region help to spotlight areas where action is urgently needed. In South Asia, the poor nutritional status of women is driving the high prevalence of LBW and child wasting and stunting. What happens in utero and in the early months of life no doubt also has implications for the success of subsequent treatment, child risk and outcomes. Across the world, wasting programming typically intervenes from six months of age and takes no account of growth trajectory to that point – it should be no surprise then that infants don’t all recover at the same pace or that they retain excess mortality risk and fail to thrive when they are ‘cured’ of this wasting episode. Perhaps this is part of the jigsaw of the ‘failure to respond’ and relapse of children³⁷. We have neglected and continue to neglect the health and nutrition and standing of women; indeed, you could argue that the burden of child wasting is a marker of their neglect by the international health and nutrition system and that child undernutrition is part of that collateral damage.

We need to infiltrate these long-term development approaches for stunting reduction with a wasting agenda. Some of the largest stunting prevention programmes are in the South Asia region but, despite considerable overlap between wasting and stunting, wasting is seldom looked at in terms of outcomes. If we are to engage the development community and incite them to pay proportionate attention to child wasting in South Asia, we need to change our narrative. Changing our narrative to one that focuses on ‘risk’ rather than ‘body-size’ is paramount to breaking down silos between wasting and stunting and to clearer, simpler advocacy.^{38 39} Wasting management is really about degrees of prevention – preventing children’s nutrition status from deteriorating in the first place in response to an insult (primary prevention), preventing decline in children with greater or combined vulnerabilities (or lack of successful primary prevention) and, finally, dealing more intensively with those children at greatest risk to prevent death (failed secondary intervention). Treatment is ultimately about heightened, targeted, timely and increasingly sophisticated preventive actions across the lifecycle. The earlier the intervention, the lower the cost per child; a ‘win-win’ in both financial and human terms.

Regional experiences, global relevance

Many of our readership are not sitting in South Asia; you may well question if this content is relevant for you. We assure you it is. Please take the time to delve into this rich body of learning. South Asia offers a wealth of capacity and opportunities to think and do things differently, and to help to drive innovative approaches that may not only inform policies and programmes to prevent and treat wasting in South Asian countries but in other regions too. At ENN, we’ve learned a lot from this experience; our reflections here have drawn on ENN colleagues and will help to inform our relevant workstreams – wasting and stunting concurrence, management of at risk mothers and infants under six months, adolescent nutrition and the humanitarian/development nexus – as well as our future priority directions.

We conclude with warm and deep thanks to Harriet Torlesse and Minh Tram Le for such a great working partnership and commitment to our joint effort, to UNICEF for supporting this endeavour and to all the individuals who somehow made the time to take pen to paper or chat with us in podcasts to share their experiences and learning. Throughout this process, we were continually impressed with the responsiveness and capacity of individuals within the region which we know is just the tip of its rich human capital. We hope this edition marks the beginning of regular contributions to Field Exchange from the South Asia region so that we continue to learn from each other. We welcome your feedback and comments – use our online forum for questions (en-net), letters to the editor or just email informal feedback and suggestions to the team.

Enjoy!

Marie McGrath (Field Exchange Editor)

Chloe Angood (Field Exchange Sub-editor)

With thanks to Jeremy Shoham (former Field Exchange Co-Editor), Tanya Khara (Technical Director) and Emily Mates (Technical Director) for their review of this editorial.

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Podcast list

An interview with Victor Aguayo, UNICEF Chief of Nutrition https://www.ennonline.net/mediahub/podcast/fex63aguayo

Reflections from Zulfi Bhutta on child wasting in South Asia https://www.ennonline.net/mediahub/podcast/fex63bhutta

Reflections from Bob Black on Child Wasting in South Asia https://www.ennonline.net/mediahub/podcast/fex63black

Reflections from Purnima Menon on Child Wasting in South Asia https://www.ennonline.net/mediahub/podcast/fex63menon

An interview with Dr. Andrew Mertens, UC Berkeley School of Public Health, on recently published papers on growth failure https://www.ennonline.net/mediahub/podcast/fex63mertens

An interview with Britta Schumacher, Senior Regional Nutrition Advisor with World Food Programme Regional Bureau for Asian Pacific, on WFP's role and regional approaches for wasting management. https://www.ennonline.net/mediahub/podcast/fex63schumacher

Insights on wasting management from Kedar Raj Parajuli, Chief of the Nutrition Section, Family Welfare Division, Department of Health Services, Ministry of Health and Population Nepal https://www.ennonline.net/mediahub/podcast/fex63parajuli

Thoughts on Pakistan’s approach to wasting management from Dr Baseer Khan Achakzai,Nutrition Director for the Ministry of National Health, Service, Regulation and Coordination, Pakistan. https://www.ennonline.net/mediahub/podcast/fex63achakzai

Reflections on wasting from Dr. Bawary, Integrated Management of Acute Malnutrition (IMAM) Officer, Ministry of Health Afghanistan https://www.ennonline.net/mediahub/podcast/fex63bawary

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Emergency Nutrition Network (ENN) (). Editorial. Field Exchange 63, October 2020. p3. www.ennonline.net/fex/63/editorial

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