Aashima Garg : 

If we don't do it right during this critical period, we may not get it right for the growth and development, and possibly throughout their whole life. So, it's a make or break window of opportunity for us, so we really need to act there.

Speaker 2:                           

Welcome to the Emergency Nutrition Network Podcast. In this episode, our host, Eilise Brennan talks to Aashima Garg of UNICEF. They'll be discussing the new Field Exchange edition at its special supplement on complementary feeding.

 Eilise Brennan:                 

Welcome everyone to this podcast. My name is Eilise Brennan. I am a nutritionist at the Emergency Nutrition Network. I am delighted to be joined today by Aashima, who will be talking to me about the complementary feeding in emergency special series that is featured in the latest edition of Field Exchange, which is Field Exchange 68. Aashima, it is great to have you here today. I was wondering, to start us off, would you please just introduce yourself to our listeners?

Aashima Garg :                  

Sure. Hello, everyone. I'm Aashima Garg, a regional nutrition advisor with UNICEF Regional Office for the Middle East and North Africa based in Amman. And I'm really excited to be having this conversation with you, Eilise, on an issue that is really very close to my heart.

 Eilise Brennan:                 

I'm very excited to have you here today, and really excited to be talking about complementary feeding and complementary feeding in emergencies. I know many of you may already be aware, but complementary feeding is the period between six to 23 months when a child's energy and nutrient needs begin to exceed what is provided by breast milk alone, but continued breastfeeding during this period is really critical to help the child survive, grow and develop. So, it's really a time of exceptional change for the child during this period. And for me, this conversation on complementary feeding and complementary feeding in emergencies is really timely given the multiple crises we face in the world. Today. We have the COVID-19 pandemic, the war in Ukraine, which has led to food shortages and rising prices. There's other conflicts and the climate crisis which are all driving up malnutrition, especially in children's six to 23 months. So, my question to you is, given this current situation, why is complementary feeding programming in the context of emergencies so critical?

Aashima Garg :                  

Yeah, actually, I would first want to pick up, Eilise, on something you talked about the exceptional change during the period of complementary feeding to elaborate a bit more on that. What's happening? What's the exceptional change which is happening? This is an enormous physiological changes occur in the child's growth and development during this period. For instance, a child's brain grows to 75% of the adult size. Can we imagine? More than 1 million neural collections are formed every second. Her body weight quadruples and her height increases by 75%. Isn't this phenomenal? And at the same time, these changes mean that the nutrient needs of these young children are extraordinarily high, and we need to take care of that. So, that's a huge challenge for us to address for this age group. And now coming to your question as to why do we need to focus the complementary feeding programming in fragile and emergency context, the answer to that is simple.

These contexts heighten the vulnerability for young children. For example, children have increased risk of morbidity and mortality, especially the young ones, the children under two. They have limited availability and access to nutritious food. They have limited access to essential healthcare and wash services with broken systems. And many instances, they have limited support to caregivers to practice optimal feeding behaviors. So for our programming, in such context, there is no choice for us but to address the nutrition needs of these children during this critical period of growth and development. So, for me, if we don't do it right for our children during this critical period, we may not get it right for the growth and development, and possibly throughout their whole life. So, it's actually like a make or break window of opportunity for us, so we really need to act there.

 Eilise Brennan:                 

It's clear that it's just so critical that we need to get complementary feeding in emergencies right. And it's fascinating to hear you talk about this period of life. And on the programming front, it's really great that we have seen such an increase in the focus on complementary feeding and complementary feeding in emergencies programming. I'm curious to know what have been some of the shifts? And why do you think this series in particular is so timely?

Aashima Garg :                  

Actually, the shift in the focus and programming approach is inspiring and a dream come true for me. The programming on complementary feeding is not new to UNICEF and its partners. It's just that now we are using a more systematic programming approach to holistically address all the key determinants and drivers of children's diets during this critical period. And we have had three major shifts in the way we do our programming on complementary feeding across all contexts, including the emergency context. First is focusing on all the key determinants of young children's diets. That is the focus on food, services, and practices. If we look at our programming over the past decades, the focus of our interventions for this age group has primarily been on improving the practices, like what happens at the level of mother? How can we support the mother? But we haven't talked about the other aspects, like what food is available? How much food she can access? Is the food she's accessing, nutritious, affordable?

The food component and her access to services has not been covered well. So, evidence does tell us that to improve the diets of young children in this age group, we need to address all the key determinants that is access and availability of nutritious and safe foods to optimal services, essential services and optimal practices. So, our programming now focuses on all three key determinants of children's diets. So, that's our first major shift.

The second one is grounding our programming in a sound situation analysis. Looking back, we have learned so much from our programming in the past decades, and the way we have been designing and implementing complementary feeding programs has not been very effective. Our programs have often been scattered, standalone, or may not always be built on a sound situation analysis, which is the key. But now, as we are taking this new approach, having a sound situation analysis has become a non-negotiable for our program design.

It facilitates a need-based design and prioritizing resources and capacities. And in this series, we have some great examples on conducting the regional and country level landscape analysis. And I really love the article from Ethiopia, Tanzania, and Zimbabwe, and I'm sure readers will love that too, but it does talk about the reality of how a sound situation analysis leads to more focused programming.

And the third and the final shift is using a multisystems approach. What do I mean with that? So when, again, we look at the history of our programming, our programming for the complementary feeding period has been delivered primarily through the health system, healthcare facilities, maybe some community. But if we have to address all the key determinants of complementary feeding, we need to leverage multiple systems, like food systems, washed systems and social protection system, in addition to health system, to improve the diets and the outcomes related to that.

So, our approach now focuses on a multisystem response to improving children's diets. And again, this whole series has some excellent examples, which I would encourage readers to find some inspiration for, and across all the four systems, like food health, social protection, and WASH in both emergency and non-emergency contexts. So coming back to the second part of your question, I do agree that the series is very timely. We are at a time where we have started turning the tide on how we design, implement, and monitor complementary feeding programs in all context, including fragile and emergency context. And the experiences which we are sharing in the series will inspire readers across the globe to embrace this programming shift and get out of the comfort zone.

This is what we want. We want people to get out of the comfort zone to replicate the experiences and learn from these lessons.

Not everything needs to be done the same way, but we do have rich experiences coming from different contexts, and people can just pick and see what is relatable. And I'm confident that in the coming years, we will start seeing some concrete results of this shift in our programming approach, which would also mean to me that we would have succeeded in shifting the mindset of programmers, decision makers and donors, which are key to make the change happen.

 Eilise Brennan:                 

Wow. It sounds like the challenge is high, but we're definitely heading in the right direction. And it sounds like there's some real fantastic work going on, which is documented in this special series, so it's really exciting to see and to be able to share those learnings. And you started to touch on this, on how UNICEF is taking a systems approach to improving complementary feeding, particularly with their action framework. So, I was wondering would you be able to tell us a little bit more about the action framework, and what has been the driving force behind it?

Aashima Garg :                  

Sure.  When we hear about action framework, it feels like something enormous or something super complicated. So, that was the first point we had in mind, nothing complicated. So, the driving force behind developing this action framework was providing a simple tool to implement the programmatic shift I just spoke about. How do we convey this to countries in a simple manner? So, the action framework is nothing but  a simple tool that helps the countries in doing three things.

First, it facilitates a systematic analysis of context specific barriers and bottlenecks across the three drivers I talked about. That is a food services and practices of young children's diets.

Secondly, based on this analysis, it helps countries to prioritize their strategic actions for addressing the various levels of barriers and bottlenecks, but through the four systems. The four systems, which I talked about, they have the highest potential to improve children's diets is food, health, water and sanitation and social protection system.

And third, and finally, it helps the countries to identify strategic actions at various levels of influence. In programming, we influence at different levels. We influence at policy, we influence at system delivery or service delivery level, and we influence at community and household level. This all is dependent on programming context, and defining these actions. We are trying to address the key bottlenecks and barriers to good diets of young children. This series is sharing many experiences in applying action framework across varied contexts. And it's impressive how you guys bring all this together in one piece, and everything comes very nicely together to give the diversity but also the commonality about the storyline and the approach. And one of the pieces which I love the most in this regard is the case studies from Sudan, Nigeria, Myanmar, and Yemen. So, really some great lessons there for our readers.

 Eilise Brennan:                 

I agree that it's a fascinating read, and it's also really great to hear you talk about contextual analysis and more localized initiatives and appropriate responses. I just think local context is so important to consider. There really is just no one size that fits all. And of course, the challenges are also different in each context, and this is something that really stood out to me across multiple articles. Were there any examples that really stood out to you in this regard?

Aashima Garg :                  

As you say, Eilise, there is no one size that fits all. So, the programming context is the key, and this series highlights that super well. When we think about programming context, it is informed by the capacity of different systems to deliver essential interventions. It's informed by available resources, it's informed by partnerships. These are some core things which define or separate contexts, or there are multiple contexts which have been covered in this. And these varies across regions and countries, and within countries as well. In the same country, you can have multiple contexts. There can be stable, there can be unstable, there can be emergency, non-emergency context. So, it varies. Context is therefore the key to whatever we decide as an action to move forward. And I feel, reading through all the articles, that the importance of context based programming is quite central to all the articles.

And that's a great achievement because that kind of verifies the importance of context the way it has been highlighted in action framework. But since you asked me what stood out to me, it's difficult to choose, but I would choose... First one, I will say I will really encourage readers to read the regional views piece. Why? Because in 7,000 words, it gives you an amazing overview of the whole world and the diversity of context across the whole world. It highlights how the UNICEF regions, across seven regions, the whole situation analysis has informed the programming approach of complementary feeding within and across the regions. So, I truly encourage readers to read this regional views piece and see how the adjustments have been made across regions. I will pick examples, because as I said, it's difficult for me to choose. If I look at in the context of fragile or emergency situations or emergency response, the experience from state of Palestine, Cox's Bazar in Bangladesh and Yemen, it did stood out to me because these are tough contexts to work in. And the teams have really tried hard, and there are some great lessons.

There is also a theme around countries with political and economic instability, where they have highlighted in their experience the link between humanitarian and development nexus or continuum, the way we use this jargon. But we have great examples from Ethiopia, Myanmar, and Sudan, which I'm sure will give inspiration to people or countries working in the similar context. And at the same time, while we talk of the supplement as complementary feeding and emergency, we really need to remember the importance of emergency preparedness. It's not about implementing programs once the emergency has hit. It is equally important that we work on building the systems capacities and delivery systems and our intervention setting in place, including data, by working before the intervention hits. So, the whole issue of preparedness is highlighted. We have amazing articles, and it's a rich assertion of articles where we are talking about country context with functional system, but varied levels of functionalities and capacities to deliver. And I really love the ones from Egypt. And not just because I'm from Middle East and North Africa region, that's why I'm choosing that, but that's one reason.

But Kenya, Brazil, and Tanzania were also some of the case studies I really loved reading. So, so much for readers to enjoy and cherish and learn, and take it forward too.

 Eilise Brennan:                 

It's definitely hard to pick. There was so many amazing articles. It's interesting that you mentioned Cox's Bazar. So, we're actually going to be doing a second podcast on Cox's Bazar, where we're going to dig a little bit more into this context, and also speak to the authors about that article. So, definitely one for the listeners to keep an ear out for.

Another key theme that has stood out for me in this series is innovation. If we want to change behaviors, if we want to improve feeding and care practices, we really need to look beyond just counseling. We need to make it more enriching, make it more participatory, and also look at other innovations. And there really are so many great examples in this special series. But for me, one of the examples I really liked was the "Bowl and Spoon", because it's such a simple tool, but yet it shows such promise of improving complementary feeding practices, especially and including in emergency and fragile contexts.

So, could you just provide a little bit more information about the bowl and spoon to our listeners, as well as talk to any other innovations that stood out to you?

Aashima Garg :                  

You're right. Actually, when we think about changing behaviors, it requires us to support caregivers and communities with more participatory and innovative approaches. And the series has excellent examples of innovative tools and approaches specifically to boost caregivers knowledge, confidence, and capacity in what, when, and how they need to feed their young children. So, picking on the examples, let me just start with the one you love the most. That is the complementary feeding 'bowl and spoon'. And as you said, it is this innovation, it consists of a simple demarcated bowl and a slotted spoon to help caregivers understand what, when, and how to feed their child. It gives them something visual to relate to and see how they are doing. It also serves as a reminder to them them and empower them to monitor if they're feeding their child right quantity and right consistency, because the way it has been designed, it just makes it very logical for the mother or the caregiver to just see if the consistency is right. Just simple things or simplifying the different dimensions of complementary feeding behaviors we talk about.

So, that's the driving force or intention behind, and that's where it's coming from. But at the same time, it also helps the health workers by serving as a support tool for the counseling sessions, because counseling sessions are more effective by giving in addition to the information. They're also able to explain using the bowl and this spoon, how using a bowl facilitates better understanding of mothers around the frequency, or what does diversity means? The bowl, on the rim, it has different colorful foods which are wearing as for the different regions or countries, so it's easy for the health worker and the mother to understand what is she putting in that bowl. So, it's simplifying the understanding of the mother and empowering and building her confidence to know what she's feeding her child and what she needs to feed her child in the next meal.

So, that's the simple innovation. As UNICEF, we started this innovation last year, together with our Supply Division, and it's being tested in eight countries across varied contexts in Africa and Middle East region. And I'm sure in the next few months or  next year we will see some exciting results. And then we'll see how we can take this forward, but it does look very promising for now. From the initial experiences we have had, the excitement is high in countries, with the government, but also with implementing partners and caregivers. It's just that we still don't have the data to measure the impact or the performance, but we are heading there. So, keep watching this space. And I hope the next documentation would be about results, how we could make this possible. Looking at something similar to the complementary feeding bowl and spoon, one of the articles mentions about this very cute innovation, I would say. That is the banana bag from Myanmar.

And it's a bag filled with variety of tools designed to nudge the caregivers to practice recommended feeding behaviors.  If you visualize a  banana-shape bag  and has all these things filled in. And a health worker just carries it across and counsels the mothers on its uses. It has been tested and was being implemented in Myanmar. And I'm sure we have some great lessons coming in. So how can we enable the caregivers and health workers in simplifying the communication around complemented feeding behaviors? That's the biggest bottleneck we have had in the past. So, these innovations are addressing this bottleneck of communicating and simplifying behaviors and making them feasible.

And mother feels like, yes, I can do it. It's not too complicated. One additional innovation which I had really loved is the  innovative approach that the team in Brazil has done on the use of participatory kitchens, which were established in three shelters to improve the access to nutritious and healthy foods in migrant and refugee settings. And what I like the most about this experience is that they leveraged the network of local food producers and suppliers to address the bottleneck of who are access to nutritious and healthy food. And in a way, they also promoted local economy. So, this is a great food system intervention actually. And just leveraging the local food suppliers and producers, but also linking it to the kitchen, I just like the concept. It's quite novel. It promotes ownership, it promotes sustainability. So yes, some really rich experiences for our readers to get inspired there.

 Eilise Brennan:                

Some really great, and also some really different innovations that  address unique contexts in which they're each in. And you paint such a great and vivid picture as well of the banana bag. I love it. So, thank you so much for taking the time out to chat tasks today. It's been absolutely fascinating and fantastic to hear from you. And for all the listeners who want to go and read the complementary feeding and emergency special series, which we really encourage you to do, it can be found in Field Exchange 68 on ENN's website. So, thank you so much again.

Aashima Garg :                  

It has been a pleasure. Thank you, Eilise.

Voiceover:                           

Thanks for listening to this episode of the Emergency Nutrition Network podcast. Do join us again when we discuss more articles from Field Exchange. In the meantime, catch up with Field Exchange at www.ennonline.net/fex.