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