ACF International White Paper

8/7/2019 ACF International White Paper

1/52

taking actionnutrition for Survival, growth & Development


2/52


3/52

Cover photography Jae Eve A, Aee V

This White Paper is the result of contributions from a wide range of Action Against Hunger | ACF International

staff membes and senio manaes in its headquates in London, Madid, Montal and Pais, and eldprogrammes around the world. The document was prepared by Dr. Ellen Girerd-Barclay, Public Health andNutrition Advisor to ACF, based on a working draft by Claire de Menezes. The technical contributions fromRebecca Brown and Amador Gomez are gratefully acknowledged. Bernadette Cichon, Nutrition Researcher,atheed bacound infomation, developed tables and desined ues. The document was developed un -der the general direction and vision of Mariana Merelo Lobo, Samuel Hauenstein Swan and Jean-Michel Grandof ACF-UK.

acknowleDgmentS

Action Against Hunger | ACF International is a global humanitarian organisation committed to ending hungerand acute malnutrition. ACF works to save the lives of malnourished children while providing communitieswith sustainable access to safe water and long-term solutions to hunger. With 30 years of expertise in emer-ency situations of conict, natual disaste and chonic food insecuity, ACF uns life-savin poammes insome 40 counties benettin 5 million people each yea. Ou ultimate oal is to ealise ou vision of a woldwithout hune, a wold in which all childen and adults have sufcient food and wate, equitable access tothe resources that sustain life, and are able to attain these with dignity. ACF believes that acute malnutritionis a problem too great to ignore.

action againSt hunger

White Paper May 2010

Taking Action: Nutrition for Survival, Growth and Development White Paper 1


4/52

Acknowledgments 1

IntroductIon 4

ExEcutIVE SummAry 5

I. mAlnutrItIon: A problEm too grEAt to IgnorE 6

II. dEfInIng thE problEm 7

III. tAkIng ActIon: AddrESSIng thE cAuSES of AcutE mAlnutrItIon

III.1 Diagnosing, treating and preventing acute malnutritionIII.2 Improving coordination and partnershipsIII.3 Secuin adequate human and nancial esouces

14

173336

IV. tAkIng ActIon: nutrItIon for SurVIVAl, growth & dEVElopmEnt 39

References for Maps 40

Bibliography 41

Annexes:1. Acronyms2. Key Messages3. ACFs Strategic Approach to Nutrition Action

444546

Taking Action: Nutrition for Survival, Growth and Development White Paper2


5/52

figureS

Figure 1 pevaee (%) SAm i S-ea Asia a s-Saaa Aia 10

Figure 2 pevaee () SAm i S-ea Asia a s-Saaa Aia 10

Figure 3 unIcEfs cea fae 14

Figure 4 te tie A Aa casa Aasis: Assesse, Aasis, Ai 15

Fiue 5 Acf cea fae nii 16

Figure 6 Acfs Saei Aa nii Ai 17

Figure 7 Acf Sae teae Ae maii 22

Figure 8 Ia he a maii e lie ce 29

Figure 9 Acf fae e pevei maii 30

Figure 10 Acfs nii a hIV mii paae 32

tableS

Table 1 ws ee (i iis) 19902015 9

Table 2 Esiae s cmAm Sevee Ae maii, as a eeae gdp i seee i-e ae aii ies

13

Table 3 who eee ess ii ieveis i eeeies 19

Table 4 cs teae i e 10 cies i e hies ne SAm cie 24

boxeS

Box 1 ueii i es 6

Box 2 wa ae e iee eees eii? 8

Box 3 Se ees aii ea a ei sas 12

Box 4 te miei devee gas 12

Box 5 SmArt Saaise mii a Assesse reie a tasii 18

Box 6 bii cmAm Sae 23

Box 7 pess is ei ae Sai cmAm 25

Box 8 pi Ae maii hi e Ieaia Aea 34



6/52

Food pice spies in 2008, followed by the lobal -

nancial crisis in 2009 have brought food and nutri-tional security into the public view. Analyses of thepotential and real effects of economic hardship onthose families around the world who are alreadypoor have revealed greater needs than ever before.At the same time, progress towards the MillenniumDevelopment Goals (MDGs) has slowed and, in someof the most affected countries, reversed. Worldwideattention on food and nutrition concerns has also re-vealed that the current level of resources investedin addressing hunger and malnutrition are far from

adequate. While ecent ues indicate that huneaffects up to a billion people, the world communitycontinues to inoe the pliht of most of the 55 mil-lion children affected by acute malnutrition.

DFIDsi. The Neglected Crisis of Undernutrition: Evidence for Action; Mdecins Sans Frontires Malnutrition: How Much is Being Spent? An Analysis ofNutrition Funding Flows 2004-2007; Save the Childrens The Next Revolution: Giving Every Child the Chance to Survive and Hungry for Change: Aneight-step, costed plan of action to tackle global child hunger; USAIDsA Call to Action on Nutrition, and the forthcoming World Bank and nutritionpartners Global Action Plan for Scaling-Up Nutrition Investment.

introDuction


For the past 30 years, ACF has worked in over 40 coun-

ties, povidin assistance to some 5 million peoplesuffering from hunger and malnutrition. Yet, with-out vastly increased resources, ACF has little chanceof reaching all the children in need. For this reasonACF initiated a pocess of intenal eection in 2008aimed at identifying the actions required to resolveacute malnutrition.

Taking Action: Nutrition for Survival, Growth & De-

velopment adds ACFs voice to a number of recentpublicationsi in advocating for increased attention

to the problem of undernutrition. This White Paper,however, focuses on the urgent and life-threateningissue of acute malnutrition and is intended for policy-makers at global and national levels.

ACF

-P.CrahayDarfur


7/52

Taking Action: Nutrition for Survival, Growth &

Development attempts to unravel a complex pic-tue, encouain all potential patnes in the htagainst malnutrition to commit to one or more es-sential actions. Taking Action suggests a practicalapproach for local, national and global forces, us-ing the solutions at hand, to resolve the persist-ing problem of acute malnutrition. It calls for ex-panded efforts to detect and analyse the causes ofacute malnutrition; for setting priorities in eachaffected geographical area; and for developingcomprehensive plans for treatment and preven-

tion to save lives and avert life-long disability. Inaddition to improving and expanding the routineassessment of malnutrition in countries that arehardest hit, this White Paper calls for scaling uptreatment of those most severely affected usingavailable and tested methods. The White Paperalso contends that actions must be taken both toprevent existing cases from worsening, and to ad-dress the root causes of acute malnutrition, thuspreventing well-nourished individuals from becom-in undenouished in the st place.


Development begins with a short overview of theintensity and scope of acute malnutrition, a review

of its possible causes and potential effects on soci-

ety and an outline of how ACF proposes that bothglobal and local communities might address it. Tak-ing Action then outlines three key areas of priority:diagnosis, treatment and prevention. Diagnosis,treatment and prevention of acute malnutritionmust be carried out by a wide range of agenciesand institutions, working together in partnershipto achieve results. Coordination of action is essen-tial to ensure that fruitful working relationshipsare developed and nurtured at local, national andinternational levels, eventually constituting an ef-

fective global architecture for nutrition. In a worldof competing priorities, strong, evidence-basedadvocacy is needed to convince decision-makersthat nutrition and well-being are the foundationsfor all development, and thus worthy of greatlyincreased human and nancial resources.


Development biey pesents ACFs poposed stat-ey fo endin acute malnutition, detailin vepioity aeas and poposin 25 essential actionsto address acute malnutrition. The White Paper isthus an urgent call for a worldwide response toacute malnutrition to ensure survival, growth anddevelopment.

executive Summary



8/52

The 2008 Lancet article on nutrition states:

Malnourished children tend to become adults withworse health and lower educational achievements. Their

own children also tend to be smaller. Hunger was previ-

ously seen as something that exacerbates the problems

of diseases such as measles, pneumonia and diarrhoea.

But, malnutrition actually causes diseases as well, and

can be fatal in its own right (Black, et al., 2008).

These ues, quoted fom the 2008 Lancet seies on nutition, exclude washioo, and theefoe undeestimate the tue lobal buden of acuteii.malnutrition.The ue will vay by season, and is an aeate of suveys in diffeent counties at diffeent time peiods.iii.Determining the estimated percentage of children with Severe Acute Malnutrition receiving treatment each year, ranging from 3 to 9 percent is basediv.on quantities of RUTF produced in 2008, and considers estimates of both prevalence and incidence of SAM.

malnutrition:i.a problem too great to ignore

ESimiandBurundi


The United Nations Standing Committee on Nu-

trition (UN SCN) asserts that hunger poses thegravest single threat to the worlds public health(The Economist, 2008). According to Jean Ziegler,former United Nations (UN) Special Rapporteur onthe Right to Food, the number of people suffer-ing from hunger has increased every year since1996: Every five seconds, a child under 10 diesfrom hunger and malnutrition-related diseases.(Ziegler, 2008). At the November 2009 World Sum-mit on Food Security, UN Secretary General BanKi-moon stated, more than 1 billion people are

hungry; six million children die of hunger everyyear - 17,000 every day (Ban Ki-moon, 2009).

About 55 million childen unde 5 yeas of aearound the world are acutely malnourished orwasted as a result of sudden decreases in nutri-ent consumption, absorption or retention. ii Ovea third of these children an estimated 19 mil-lion children suffer from severe acute malnutri-tion known as SAM (Black, et al., 2008). Withouttreatment, they are at imminent risk of dying. iiiEnsuring their access to treatment should be ofthe highest priority in the global fight againsthunger. Yet, only about 3 to 9 percent of thechildren who need treatment actually receive it(MSF, 2008).iv

b 1: ueii i es

55 Million of childen unde 5 yeas of aeaffected by acute malnutrition in the world(The Lancet b; 2008)

19 Million of childen unde 5 yeas of aesuffer from severe acute malnutrition (SAM)(The Lancet b; 2008)

Maternal and child undernutrition is theundelyin cause of 3.5 million deaths(The Lancet b; 2008)

Severe acute malnutrition (SAM) contributesto 1 million child deaths every year(UNICEF / WFP / WHO / UNSSCN; 2007)


9/52

wa is ae aii?

Hungerrefers to a global measure of food depriva-tion and food insecurity that takes all populationgroups into account. Malnutrition or undernutri-

tion is the physiological outcome of hunger and/orillness and manifests itself in numerous macronu-trient and micronutrient deciencies. Maconuti-ents, including proteins and carbohydrates, supplythe bodys basic food requirements, while micro-nutrients such as vitamins A and C, and mineralssuch as iron, iodine and calcium are elements re-quired in tiny amounts to ensure a broad range ofbody functions, such as growth and healing. Threeforms of hunger-related malnutrition can be deter-mined using body measurements or anthropometric

data, and are described in detail in the box over-leaf: 1) acute malnutrition or wasting, 2) stuntingor chronic malnutrition, and 3) underweight. Acutemalnutrition or wasting occurs when an individualsuffers from current, severe nutritional restric-

tions, a recent bout of illness, inappropriate childcare practices or a combination of such factors. Itis characterised by extreme weight loss, resulting inlow weight-for-height. A severely wasted individual

suffers from marasmus and looks extremely thin,except in the case of Kwashiorkor, whee uid e-tention results in swelling, giving a deceptive im-pression of healthy weight. The White Paper focuseson undernutrition.

The high number of undernourished individuals inthe world today is unacceptable with young chil-dren, who are the most vulnerable, bearing thebunt of the poblem. In total, 55 million childensuffer from Global Acute Malnutrition (GAM), a

term that includes both moderate acute malnutri-tion (MAM) and severe acute malnutrition (SAM).Only about 3 pecent less than one million of the19 million severely malnourished children - receivethe lifesaving treatment they desperately need.

Defining the problemii.

Today, 55 million children under 5 years of age around the world areacutely malnourished. Over a third of these children, an estimated 19million, suffer from the most severe form of acute malnutrition. Without

treatment these children are at imminent risk of dying and of neverachieving their full growth potential. Only 3 percent of these children arereceiving treatment, even though acute malnutrition can be prevented andtreated successfully. Solutions are known, tested and feasible.



10/52Taking Action: Nutrition for Survival, Growth and Development White Paper8

DEFININg THE PrOBLEM

b 2: wa ae e iee eees eii?Undenutition esults fom insufcient food intae, inadequate cae and infectious diseases, o a com-bination of these factors. This comprehensive term includes being underweight for ones age, too shortfo ones ae (stuntin), daneously thin fo ones heiht (wastin) and decient in miconutients.Severely acutely malnourished individuals are very susceptible to infections and death. Although dataon mortality related to SAM is scarce, case fatality rates of children hospitalized for acute malnutritioncan range from 10 to 40 percent (Bejon et al.,2008).

1. Ae aii eii eects ecent weiht loss as hihlihted by a small weihtfor a given height. A child suffering from acute malnutrition or undernutrition can be categorizedas being either moderately or severely thin or wasted. Moderate wasting, also known as ModerateAcute Malnutrition or MAM is indicated by a weight-for-height


11/52

of the HIV (Human Immunodeciency Vius) and AIDS(Acquied Immune Deciency Syndome) pandemic.

In 2007, an estimated 854 million people suffeedfrom chronic hunger and undernourishment. In 2008the number had risen to 923 million, and by mid-2009had surpassed 1 billion. Worldwide, the numbers ofhungry and undernourished people are on the rise,despite the fact that the world already producesenough food for its 6 billion inhabitants and in theorycould feed double that ue (Ziele, 2008).

The global prevalence rate of SAMv ranges from about3 to 5 pecent, affectin about 19 million childen in

total (WHO, 2007), while the estimated pevalencerate of GAM is about 13 percent (UNICEF 2009).

tae 1: ws ee (i iis) 19902015 (fAo, te Sae f Isei i e w

2002-2009)

yea 1990 1995 2005 2007 2008 2009 2015 gas

h ee i

e (iis)

842 832 848 854 923 1,000 600vi

Weight-for-height Z score of less than 3v.vi. 1 billion hungry people today make up about 1/6th of the worlds population of 6 billion. MDG 1, to halve the proportion of hungry people between

1990 and 2015, would equal 1/12th of the estimated population in 2015, o 7.2 billion, which is 600 million people.



wa is e sae e e?

In the past two decades, the world has seen fewerand fewer large-scale food emergencies. While thedisappearance of the devastating famines that domi-nated headline news in the 1980s might mean thatmalnutrition in developing countries is no longer anissue of concern, this is far from todays reality. Hun-dreds of millions of people worldwide continue togo hungry, with their access to food and nutrition-al status threatened by conditions that are far lesswell-publicised than severe famines. In addition toconicts, both lon-tem and acute, unstable maetprices, natural disasters and the negative effects ofclimate change continue to prevent households from

ndin enouh to eat. Many counties suffe addition-ally from the devastating social and economic impact


12/52

Figure 2 below provides a glimpse of the estimatednumber of severely wasted children in the most af-fected countries in Asia and Africa. By region, south-central Asia has the highest number of children withSAM, with 29 million, o ove 52 pecent of the de-

veloping country total. In India alone, there are anestimated 8 million severely wasted children, whileBangladesh and Ethiopia have up to 1 million each.Between 1 and 1.5 million seveely wasted childenare found in Nigeria, DRC and Pakistan.

fie 2: pevaee () SAm i S-ea Asia a s-Saaa Aia

No data

Ove 8 million

1 million -1.5 million

500,000 - 1 million

100,000 - 500,000

50,000 - 100,000

10,000 - 50,000

5000 - 10,0001000 - 5000

Less than 1000



fie 1: pevaee (%) SAm i S-ea Asia a s-Saaa Aia

No data

11 - 12%

9 - 10%

7 - 8%

6 - 7%5 - 6%

4 - 5%

3 - 4%

2 - 3%

1 - 2%

Less than 1%

The map below (Figure 1) shows the SAM prevalenceamon childen below 5 yeas of ae at county lev-el in the two most affected regions. Countries with

the highest SAM rates include the Democratic Re-public of Congo (DRC), Burkina Faso, Sudan, India,Cambodia and Djibouti.


13/52Taking Action: Nutrition for Survival, Growth and Development White Paper 11


Malnutrition kills: every minute up to 7 children die from acutemalnutrition and related illnesses.

Malnutition is diectly implicated in between 35pecent (Blac et al, 2008), and 56 pecent (Pelle-tie et al, 1994; 1995) of all deaths amon childenbelow the ae of 5 each yea.

Malnutrition can kill directly. More commonly, how-ever, it weakens the immune system, increasing thechances of death from infectious diseases, particu-larly diarrhoea, pneumonia, malaria, HIV/AIDS andmeasles. Ove half of all child deaths fom diahoea

(61 pecent), malaia (57 pecent) and pneumonia(52 pecent) ae due to the pesence of undenuti-tion. Oveall, WHO estimates that 11 pecent of thetotal global disease burden is linked to some form ofmalnutrition (Black et al., 2008).

Mortality rates linked to severe malnutrition areshockingly high. Children who are severely wastedor underweight are 9 times more likely to die thanwell-nourished children. In countries facing severeesouce decits, and/o hih HIV pevalence ates,

the percentage of severely malnourished children dy-ing can reach 30 to 40 percent.vii Maternal and childundenutition is the undelyin cause of 3.5 milliondeaths (The Lancet b; 2008). Severe acute malnutri-tion (SAM) contributes to 1 million child deaths everyyea (UNICEF / WFP / WHO / UNSSCN; 2007).

The risk of death is not limited to children sufferingfrom severe acute malnutrition, for whom the risk ofmortality, according to Collins et al (2006) equates

to 73 187 per 1000 per year. Mortality rates are alsohigh among moderately malnourished children withestimates of between 30 and 48 deaths per 1000 peryear. As the prevalence of moderate malnutrition isgreater than that of severe malnutrition, deaths ofchildren as a result of malnutrition can actually besaid to be attributable more to moderate, ratherthan severe malnutrition (Black et al., 2008).

Up to 97 percent or over 18 million of the severely

malnourished children lack access to any treatmentwhatsoeve. Of those who do each ovenment-unclinics o hospitals, nealy 1 in 5 dies because nec-essary supplies and equipment are desperately lack-ing. Arriving too late is also a common constraint tosuccessful treatment, especially for children withcomplications such as poor appetite, infections orillness. When treatment is delayed, even by a matterof hours the chance of dying increases dramatically.

To complicate matters further, the opportunity cost

of treating acute malnutrition can be too great forpoor families to bear. Such costs, in terms of timeand money, of hospital stays or even of transportinga child and his or her mother or caregiver to andfrom local clinics create enormous economic bur-dens. As resources are drained to care for one familymember, the risks of prolonged bouts of malnutri-tion, frequent recurrences or more severe malnutri-tion in other household members increase, resultingin even further lost income-earning opportunities.

ACF programme experience supporting government resourced hospitals in Malawi and Zimbabwevii.


14/52

b 3: Se ees aii ea

a ei sasI Ias a cie:

Diminishes the ability to ht infectionImpairs the immune system and increasesthe risk of some infectionsImpairs growthIncreases the chance of infant and youngchild mortalityHeightens fatigue and apathyHinders cognitive and mental developmentReduces learning capacity

I we:Increases the risk of complications duringpregnancyIncreases the risk of spontaneousabortions, stillbirths, impaired foetal braindevelopment and infant deathsIncreases the risk of death fromspontaneous abortion, stress of labour andother delivery complicationsIncreases the chance of producing a lowbirth weight baby

Reduces work productivityIncreases the risk for some kinds ofinfections, including HIV and reproductivetract infectionsResults in additional sick days and lostproductivity

Se:Adapted from: Baker J, Martin L, Piwoz E. A Time to Act:Women are Nutrition and its Consequences for Child Survival

and Reproductive Health in Africa. SARA. December 1996.

Nutrition is the foundation for humandevelopment a pre-condition forachieving the Millennium Development

Goals.

te seqees aii

Malnutrition has dire consequences, causing criticalhealth problems that lead to growth retardation andimpaired cognitive development. Without treatment,individuals who are affected by moderate or severeacute malnutrition during the critical stage of lifebetween conception and age 2 may bear the scars forthe remainder of their lives (Victora, 2008).

Malnutrition has global repercussions: not only doesit harm affected children, but the societies they livein also suffer. Nutrition indicators at age 2 have beenshown to be accurate predictors of adult height,educational attainment and other aspects linked toeconomic productivity (Bhutta et al., 2008). Childrenwho suffer from malnutrition at an early stage oflife scoe lowe on tests of conitive sill, with de-cits persisting into adulthood and thus diminishing

income-earning potential (World Bank, 2006). Linksbetween malnutrition and increased susceptibilityto disease in the long term are well documented(World Bank, 2006), and include a greater likelihoodof adult-onset chronic disease for those who havesurvived malnutrition and experienced rapid weightgain in later childhood.

The Millennium Development Goals (MDGs), adoptedin September 2000 by 189 countries, include 8 goals,divided into 18 quantied taets fo addessin ex-

treme poverty. All the MDGs and their targets are in-terrelated, thus requiring a comprehensive approachto tackle the massive issues of poverty, hunger,health, education, gender and sustainable develop-ment. Achievement of any of the MDGs could playan important role in ending both acute and chronicundernutrition. Attaining the MDGs highlighted in thebox below, however, will also depend on the availa-bility of high-quality nutritional services for mothersand young children in addition to food security andaccess to a healthy diet.



b 4: te miei devee gas

mdg 1 Eradicate extreme poverty and hungermdg 2 Achieve universal primary educationmdg 3 Promote gender equality and

empower womenmdg 4 Reduce child mortalitymdg 5 Improve maternal healthmdg 6 Combat HIV/AIDS, malaria and other

diseases

mdg 7 Ensure environmental sustainabilitymdg 8 Develop a Global Partnership for

Development


15/52

Malnutrition negatively affects economic develop-ment by reducing productivity and increasing healthcosts. The World Bank (WB) estimates that malnu-trition costs between 2 and 3 percent of the GrossDomestic Product (GDP) in most affected countries,which in turn has a negative impact on progress to-wards achieving the MDGs. (World Bank, 2006)

According to UNICEF the global cost of malnutri-

tion to poor economies each year is between US$20and US$30 billion. The cost of basic treatment forSAM is just a fraction of this amount. An estimatedUS$80 to US$160 per child covers the cost of treat-ment with Ready-to-Use Therapeutic Food (RUTF)through Community-based Management of AcuteMalnutrition (CMAM).viii Appoximately US$225 pechild would allow for in-patient care with supporting

medical treatment and associated costs for childrenwith complications. The total predicted cost forreaching the 19 million severely wasted children isestimated to ane fom US$4.5 to US$9.1 billion. ix

The estimated cost, usin the lowe ue, of teat-ing all severely wasted children through CMAM inthe 10 highest burden countries, as a percentageof each countrys GDP, is found in Table 2 below.

Only in DrC, whee gDP is elatively low, wouldestimated treatment costs be greater than a merefraction of the 2 to 3 percent of GDP estimatedby the World Bank as the alarming price-tag ofuntreated malnutrition for national economies. Inother words, treating SAM through CMAM appearsto be cost-effective, and thus a good investment ineconomic terms.

Ready to use Therapeutic Foods (RUTF) and Community-based Treatment of Acute Malnutrition (CMAM) are described in detail in Section III.1.3viii.MSF estimates scale-up of CMAM to address all SAM cases to cost about US$1.1 billion, including the production of 28,000 tons of RUTF per year, using the lowerix.ue, US$80/case of SAM. ACFs ue of US$4.5 - US$ 9.1 billion is based on pevalence of SAM as well as estimated incidence of >3 episodes of malnutition/yea/child. The Wold Bans Scalin up Nutition: What will it Cost? (Wold Ban, 2010) estimates US$11.8 billion/yea is needed to addess undenutition, with US$1.5billion to be borne by private households, leaving a funding gap of US$10.3 billion. Scaling up complementary and therapeutic feeding programmes forms the secondof a 2- step approach, after capacities are built up in Step 1 to deliver nutrition services. Step 2 involves an estimate of US$3.6 billion for complementary food to pre-vent and treat MAM in children under 2 (US$40-80/child), and US$2.6 billion to treat SAM (US$200/episode), and an additional US$0.1 billion for improved monitoringand evaluation of lae-scale poammes and opeational eseach fo delivey stateies. Step 1 consists of US$5.5 billion (US$1.5 billion fo miconutients anddewomin (US$5/child); US$2.9 billion fo Behaviou Chane inteventions (US$7.50/child); US$0.1 billion fo M&E, opeational eseach and technical suppot.

tae 2: Esiae s cmAm Sevee Ae maii, as a eeae gdp i seee i-

e ae aii ies

c cs teae e ea( esiae)

c gdp(ofcialexchangerate)

cs eae( esiae) as % gdp

Iia US$ 2,131,819,200 US$ 1.21 trillion 0.2%

drc US$ 329,639,520 US$ 11.59 billion 2.8%

nieia US$ 278,231,040 US$ 214.4 billion 0.1%

paisa US$ 267,425,760 US$ 167.6 billion 0.2%

baaes US$ 158,894,400 US$ 81.94 billion 0.2%

Eiia US$ 120,739,680 US$ 25.66 billion 0.5%

Iesia US$ 109,640,160 US$ 511.8 billion 0.02%

Sa US$ 94,141,440 US$ 57.91 billion 0.2%

bia fas US$ 59,154,480 US$ 8.103 billion 0.7%

yee US$ 57,952,320 US$ 27.15 billion 0.2%

Se aa: https://www.cia.gov/library/publications/the-world-factbook/geos/et.html

An annual investment of US$9 billion in the Community-based Managementof Acute Malnutrition (CMAM) will cover the treatment of all children withsevere acute malnutrition.




16/52

taking action: aDDreSSing the cauSeSiii.of acute malnutrition

Despite common depictions of malnutrition in thepress, most malnourished children do not live ina conict zone but ae instead victims of muchmore mundane factors in their daily lives. In gen-eral, acute malnutrition is caused not by one-offhazards or disasters, unpredictable drought, pestsor war, but by the sum of multiple everyday hard-ships cyclical maet uctuations, yealy climatic

patterns, periodic entitlement failures such as re-stricted access to land, or disease patterns manyof which erode the resilience of a population.

The causes of malnutrition are interlinked, asshown in UNICEFs Conceptual Framework (Figure 3)and range from immediate causes to basic causes(UNICEF, 1990).

Acute malnutrition is the result of everyday deprivation and seasonal

hardship and is not caused only by one-off crises as is commonly perceived.

fie 3: unIcEfs cea fae

Inadequate education

Economic structure

Political and ideological factors

maiesai

Ieiae

ases

uei

ases

basi ases

ci maii

Iaeqae iea

iaedisease

Iaeqae aess

Iaeqae ae

ie a e

Insufcienthealth

sevies & eaevie

reses a c

ha, eis a aisaia eses

peia eses



17/52

Situation assessments can examine the multiple causesof malnutrition, and these can then be analysed in or-de to weiht and pe-empt as many causes as possi-ble. Once the causes ae discened, action plans can beestablished and implemented for treatment and pre-vention. The Tiple A Appoach of Assessment, Analysisand Action (Figure 4) works in tandem with the Concep-tual Framework and encourages agency staff, serviceproviders and community members to assess and carryout causal analyses throughout the programming cycle,rather than only at the planning stages (UNICEF, 1990).

Identifying the causes of malnutrition is a prerequisiteto determining the most appropriate responses. In one

example, the 2008 Global Hunger Index (GHI)x

showsthat sub-Saharan Africa and South Asia share the high-est regional scores for malnutrition and hunger. By us-ing three weighted indicators, the different causes ofmalnutition in these eions have been identied. InSouth Asia, widespread acute malnutrition is related tohigh levels of underweight stemming from the lowernutritional and educational status of women. In sub-Saharan Africa, however, high malnutrition rates are of-

ten the outcomes of high child mortality and morbidity,and the low proportion of the population able to meettheir energy needs (Von Grebmer, 2008). Determiningthe causes of malnutrition can help to determine themost appropriate interventions in each region, zone,community or household.

The Global Hunger Index (GHI) is a combination of three equally weighted indicators used to measure hunger and malnutrition: 1) The proportion of undernour-x.ished as a pecentae of the population; 2) The pevalence of undeweiht in childen unde 5, and 3) The motality ate of childen unde 5. The gHI thenates counties on a 100 point scale, with zeo bein the best scoe (no hune) and 100 indicatin the hihest incidence of hune. Values fom 5 to 9.9 eectmodeate hune; fom 10 to 19.9, a seious poblem and fom 20 to 29.9 a cause fo alam. Counties with values exceedin 30 ae cateoised as extemelyalarming. The 2008 gHI, which uses actual ues up to 2006, identies an incedible 33 counties with alamin o extemely alamin levels of malnutition.

fie 4: te tie A Aa casa Aasis:

Assesse, Aasis, Ai (unIcEf 1997)

Assesse

Aasis

Ai


TAkINg ACTION: ADDrESSINg THE CAUSES OF ACUTE MALNUTrITION


18/52

ACFs adaptation of the Conceptual Framework (Fig-ue 5) outlines the vaious immediate, undelyin obasic conditions required for adequate nutritional

status and well-being. The Framework establishesthe basis for a multi-sectoral, integrated approachto achieving good nutrition and well-being.

fie 5: Acf cea fae niii



xi. Adapted from UNICEF Conceptual Framework (1990) and ACF Framework of Causality (2004).

basi fas

uei fas

Ieiae cases

g nii a we-ei(For child survival, growth

and development)

oia cae paies

Care for pregnant andbreastfeeding women

Breastfeeding, responsivefeeding of infants and children

Psychosocial care andcognitive stimulation

Positive hygiene practices

Positive health behaviours

Iai, Eai aciai

Behaviour ChangeCommunication

Pre-and In-serviceNutrition Training

piia, Ei a Ieia Ses

Absence of conict and discimination

Democratic governance systems

Respect for and promotion of human rights

Economic growth and sustainable development

Environmental protection and renewalof resources, etc.

f reses

Food production

Income

Work

Owneship of/access to land

Seasonal measures

hea Sevies ahea Evie

Aeqae diea Iae

Saia reses

Water supply

Sanitary facilities

Availability of health services

Home and environmentalsafety

hse f Seia liveis

g hea Sas


19/52

Scaling up interventions to treat and prevent acute malnutrition must beat the forefront of responses to hunger (MDG1) and child mortality (MDG4).

tai Ai: Acfs Saei Aa Aess-

i Ae maii

Oveall, poess in educin malnutition has beendismally insufcient, as shown in the cuent statusof the MDGs. Despite expenditures of billions of dol-lars on food security interventions every year and

continuing economic and agricultural growth in manyof the worlds poorest countries, hundreds of mil-lions of children continue to suffer from some formof malnutition. The ht aainst hune has beendominated by various forms of food security assist-ance such as agricultural investments, cash trans-fers, and interventions to improve livelihoods. Whilethese interventions are critical, and should be ex-panded to reach all in need, they will not succeedin eliminating malnutrition, particularly severe wast-ing, on their own. In addition, a variety of nutrition

and nutrition-supportive interventions, implementedat scale, are needed.

The ultimate aim of efforts to end hunger and acutemalnutrition must be to save lives and promote op-timal growth and development by preventing malnu-trition-related morbidity. Interventions that directlydiagnose and treat child and maternal malnutritionmust theefoe be at the foefont of the htagainst hunger. Action for nutrition is needed now,

to identify and reach women and children who aremalnourished, and to treat them before it is too late(Standing Committee on Nutrition, 2008).

ACF currently implements programmes in over 40countries to address acute malnutrition, in partnershipwith an array of institutions, organisations and indi-viduals including affected populations, local serviceproviders from a variety of sectors, national govern-ments and international agencies. ACFs ultimate goalis to identify and address the causes of malnutrition,

while ensuring that children and other individuals suffering from malnutrition are identied and treated

promptly and effectively. Cental to ACFs effots is

its Saei Aa nii Ai, illustratedbelow in Figure 6, consisting of the diagnosis, treat-ment and prevention of acute malnutrition, working ina coordinated manner and through partnerships, withadequate human and nancial esouces.

iii.1 taking action: DiagnoSing, treating anD preventing acute

malnutrition

fie 6: Acfs Saei Aa nii Ai

Fo each of the ve components of the Stateic Ap-

poach to Nutition Action, ACF has identied 5 PioityActions. While there is no set order for carrying themout, the 25 Pioity Actions should be based upon anaccurate assessment and comprehensive analysis of thecauses of malnutrition. First, childrens (and womens)nutritional status must be assessed and concerns accu-rately diagnosed. This involves surveying the nutritionsituation in a geographic zone, estimating the extentof existing problems, and/or screening individuals toidentify specic nutitional concens. The second stepinvolves planning and implementing high-quality nutri-

tion interventions, ideally through the existing healthsector, in order to save lives, or, in the absence of func-tioning health services, through external agencies. Fi-



Aemaii

humanr

esources

finan

cialr

esou

rces

diagnosis

preventio

n

treatm

ent

coord

inati

onandpartnersh

ips


20/52

nally, multi-sectoral programmes and services designedto tackle the diverse causes of malnutrition must beinitiated or strengthened to prevent malnutrition. In-terventions could include measures to improve foodsecurity and build livelihoods, ensure adequate WASH,promote optimal care practices for women and chil-dren, and/or address a host of other issues. In additionto the diagnosis, treatment and prevention of acutemalnutrition, ACF also advocates for coordination andpartnerships, supported through adequate human andnancial esouces.

To provide stakeholders with quick and reliable in-formation on the levels and severity of malnutrition

as well as risk of malnutrition and its causes, with

ACF priorities for programming driven by acute mal-

nutrition rates and risks.

Diagnosing malnutrition and targeting interventionsare both essential steps in ensuring that nutrition ac-tions are relevant, timely and reach all in need. Ac-curate assessments are a key component of diagnosingacute malnutrition. In order to facilitate quick, reliable

and comparable assessments for timely decisions, es-pecially important during emergencies, standardiseddata-collection techniques must be used in a consistentmanner. ACFs Standardised Monitoring and Assessmentof Relief and Transition (SMART) methodology simpli-es the collection of eliable anthopometic data by

establishing a standard survey methodology. SMART isdesigned to improve the quality of nutrition and mor-tality surveys through greater accuracy.

III.1.1 tai Ai: diasi Ae maii

b 5: SmArt Saaise mii a

Assesse reie a tasii

Since 2006, ACF has conducted more than 220nutrition surveys in over 40 countries, andhas been a key player in the developmentand promotion of the SMART (StandardisedMonitoring and Assessment of Relief and

Transition) methodology. SMART has improvedcondence in nutition suvey data on the

part of actors in the nutrition and donorcommunities worldwide. ACFs expertise inSMART, including developing SMART capacityamon hundeds of national NgO staff, UNstaff, and national Ministry of Health managersand staff, has greatly increased the resourcesavailable worldwide to implement the newmethodology. SMARTs nutrition and mortalityindicators will soon be complemented by a foodsecurity component, and, in the future, withmeasurements designed to cover a broad array

of causes of acute malnutrition. Eventually,pertinent child development indicators, alongwith education and Water, Sanitation andHygiene (WASH) indicators will be incorporatedinto SMART surveys.

ACFCourtesyBernad

etteCichon



PreventionDiagnosis Treatment Coordination andPartnershipsHuman and

Financial Resources

ACF STrATEgIC APPrOACH TO NUTrITION ACTION


21/52

Once the nutition situation has been assessed, therelevant data can be analysed to determine the mag-nitude and severity of acute malnutrition within thetarget population, and to estimate the actual numbersof individuals in need of assistance.

The WHO ecommended thesholds fo uidin de-cision-making regarding nutrition interventions dur-in emeencies, pesented in Table 3 below (WHO,2002), recommend action based on MAM and SAMpevalence ates of childen unde 5. As a esult, thethresholds largely ignore the actual number of individ-uals affected (caseload) and the number of times anindividual becomes malnourished (incidence) within a

given period.

When malnutrition rates are found to be below therecommended threshold for action of 10 to 14 per-cent SAM/MAM, inteventions may be difcult to jus-tify. In population-dense regions such as urban slumswith high morbidity and elevated mortality, however,even lower rates of acute malnutrition may involvehundreds of thousands of children. In some cases,unacceptably high rates of malnutrition that meetecommendations fo action fail to meit specic in-

terventions because they have either persisted for alon peiod, o because they occu seasonally, is-ing every year around the same time. Failure to act,either to treat or to prevent acute malnutrition, re-gardless of the prevalence level and the duration ofthe problem, is simply unacceptable. Revised criteria

are therefore needed to ensure adequate responsesto moderate rates of acute malnutrition, even in non-crisis contexts such as those existing at any given mo-ment in India, Bangladesh and Niger, for example.

The Spherexii minimum coveae standads (WHO,2002) have been developed to encourage relief agen-cies to reach at least a minimum number of thosein need (SPHERE, 2004). Sphere minimum coveragestandads fo nutition poammes ae >50 pecent inual aeas, >70 pecent in uban aeas and >90 pe-cent in camp situations (SPHERE, 2004). Yet, nutritioninterventions often fail to reach even such minimallevels because of the difculty of attainin hih cove-

age through centre-based feeding programmes and thecurrently weak system of accountability for achievingresults through nutrition treatment.

Managing health and nutrition data from health careand other basic services, and analysing the results ofnutrition activities and programmes constitutes a ma-jor challenge in most developing countries. Due to thealready heavy burden facing health service providersand NgO staff, often unde advese conditions andwith few resources, opportunities for using nutrition

data are often missed. Information CommunicationTechnology (ICT) systems that reduce the workloadinvolved in the collection, processing and analysis ofnutrition programme data could vastly improve thequality of that data, which in turn will mean betteruse of the programme results in decision-making.

tae 3: who eee ess ii ieveis i eeeies

taee Seea feei / teaei feei

paes

bae Seea feei /

teaei feei paes

Large numbers of malnourished individuals 10-14% MAM/SAMamongst children

SAM/MAM ate of 15% o above

Large numbers of children predicted to become malnourisheddue to factors such as poor food security or high incidence ofdisease 5-9% SAM/MAM plus aavatin factos*

SAM/MAM rate of 10-14% plusaggravating factors

*Aggravating factors are dened as absent or inadequate general food rations; crude mortality rate above 1/10,000/day; epidemics of

measles or whooping cough and high prevalence of respiratory or diarrhoeal diseases.

xii. The Sphee Poject, launched in 1997 by a oup of humanitaian NgOs and the red Coss and red Cescent movement, is based on two coe beliefs: st, thatall possible steps should be taen to alleviate human suffein aisin out of calamity and conict, and second, that those affected by disaste have a iht to lifewith dignity and therefore a right to assistance. Sphere is three things: a handbook, a broad process of collaboration and an expression of commitment to qualityand accountability. The Sphere Handbook is currently undergoing a revision process, aimed at updating the qualitative and quantitative indicators and guidancenotes, enhancing linkages between sectors, and addressing a variety of issues with the 2004 edition. The new edition is planned to be published in late 2010.



Se: WHO 2002


Financial Resources



22/52

Tools exist for assessing acute malnutrition statusfor all members of society. Nutrition assessmentprotocols and programmes focus mainly on chil-den and infants between 6 months and 5 yeasof age, and to a lesser extent, pregnant and lac-tating women due to their increased vulnerability,and because resources are limited. Although mal-nutrition in adults has been addressed in some con-texts, nutritional challenges are rapidly increasingin conjunction with tuberculosis (TB) and HIV andAIDS.

Low birth weight (LBW) and/or inadequate breast-feeding are potentially serious threats to good

nutritional status in newborns and young infantsunder the age of 6 months, but there has been noconsensus as to appropriate diagnosis and treat-ment protocols for acute malnutrition in this ageoup. Youn infants and childen ove 5 yeas, ad -olescents, especially girls, older adults and any in-dividuals suffering from chronic illness such as HIVand TB, may need systematic screening for mal-nutrition and other health problems. As nutritionservices expand, thousands more health servicesstaff and community members will require train-

ing in simple malnutrition screening methods, suchas Mid-Upper Arm Circumference (MUAC) and theidentication of oedema.

While recognising the need for more research onMUAC, ACF nonetheless supports the use of thetool for assessing nutritional status of children be-tween 6 and 59 months, both fo admission to anddischarge from treatment. ACF also agrees thatMUAC, together with weight-for-height indicators,

may be appropriate for assessing acute malnutri-tion in adults, particularly in the context of HIVand as an alternative tool to weighing scales andheiht boads in emote, difcult to each eo-graphic zones.

Using a MUAC measurement of less than 110 mmas a criterion for admission to therapeutic treat-ment fo childen below 5 may exclude a numbeof severely malnourished children. ACF thereforeendoses the use of 115 mm as the cut-off point fo

admission to treatment.xiii

For over 30 years, the United States NationalCenter for Health Statistics (NCHS)/WHO owthreference was used to chart childrens growth.Intoduced in 2006, the new WHO IntenationalChild Growth Standard (ICGS) is based on growthpatterns of children around the world who are fedaccodin to cuent WHO ecommendations on in-fant feeding, including exclusive breastfeeding forthe st 6 months of life. The ICgS bins cohe-ence fo the st time between the tools used toassess growth and national and international infantfeeding guidelines, allowing accurate assessment,measurement and evaluation of breastfeeding andcomplementary feeding.

The ICgS denes hihe weiht cut-off points foclassifying children with SAM than the former NCHSreference. As a result, more children in any givenpopulation will be identied as seveely malnou-ished using the ICGS. The ICGS will increase thenumbes of seveely wasted childen identiedthrough screening, and therefore test the capacityof donors, agencies and service providers to meetexpanding needs.

Measuring MUAC has advantages for screening children toidentify malnourished individuals because it does not require

expensive equipment; it is simple for community volunteers to

do with a little training; the tape can be colour coded so that it

is not even necessary to make a measurement; no calculations

are required; the measurement is transparent to a community

when used to identify children to be given supplementary

food; and low MUAC measurements are associated with the risk

of dying. MUAC is a simple way to screen large numbers of

children and identify those who need supplementary food.Se:pess Ae ha (esa iai).

Because children with a high risk of death whocould benet fom timely teatment may be identi-ed soone with the ICgS, the peiod of teatmentmay be shorter, and they may even have higherrates of recovery.

xiii. One study involvin thee counties found an inceased case load of 80 pecent if the cut-off was aised to 115 mm.




Financial Resources



23/52

Acfs pii Ais diase maii:

Sae- SmArt1. , using it systematically inemergency, transition and development con-texts to provide data for formulating appropri-ate responses to acute malnutrition.xiv In orderto facilitate quick and reliable assessments ofacute malnutrition for timely decision-making,in both emergencies and development settingswith high risk of malnutrition, SMART must beused consistently together with integratedreviews. If possible, SMART should be imple-mented within an overall framework of a nutri-tion surveillance system, allowing for the early

detection of deteriorating nutrition, healthand livelihood situations at local and nationallevels.

Esais a Sse maii Ae raes2.

(mArs) to estimate the number of children atrisk, even in non-crisis settings. Using MARswould estimate the number of children atrisk in each context with the aim of trigger-ing more timely nutrition interventions. UsingMARs, appropriate treatment and prevention

interventions could also be established in non-emergency settings, addressing situations ofpersisting, high levels of acute malnutritionthat ae consideed nomal simply becausethey are common, seasonal, and/or last forlong periods of time. MARs could be includedin existing standards and guidelines such asWHO and Sphee, to institutionalise considea-tion of the scale of nutrition problems, basedon, among other factors, prevalence rates,

pevalence, uctuations in pevalence, popu-lation density, numbers of wasted and severelywasted children, death rates, food insecurityand vulnerability to disasters, both within andoutside emergency settings.

revie a uae giae deisi-3.

ai nii Ieveis so that nu-trition interventions take into account preva-lence rates and the magnitude and incidenceof acute malnutrition. Nutrition survey resultsshould be presented in terms of estimated to-tal numbers of malnourished children and,depending on the situation, other members ofthe population including adults, older childrenand adolescents, and infants under 6 months in order to determine potential caseloads forprogramming. The decision-making process fornutrition interventions should also be reviewedto ensure greater accountability in terms of ex-

pectations for programme coverage, results andimpact, and timeliness.

Ive diasi meies a ts4.

Iivia Assesse: Acutely malnour-ished individuals must be identied as ealy aspossible, using appropriate tools to ensure rapidentry into the correct treatment programmes.Diagnosis efforts should focus on geographicareas where unacceptably high rates of malnu-trition persist, whether seasonal or year round.

Minimum acute malnutrition programme cover-age standards must be met, and agencies anddonors held accountable when this is not thecase. Depending on the situation, the targets ofnutrition assessments may need to be expandedto include infants, adults and adolescents.

cie e tasii e ne who I-5.

eaia ci g Saa (IcgS): Thenew standard should be adopted for diagnosis

and assessment, as it presents an opportunity todiagnose more malnourished children in a cross-sectional survey, and, if used for growth moni-toring, a possibility to identify and treat acutemalnutrition earlier.

xiv. SMART (Standardised Monitoring and Assessment of Relief and Transition) is an inter-agency initiative, launched in 2002 by a network of organisationsand humanitarian practitioners. SMART provides a standardised method of undertaking surveys to collect information on the two most vital, basicpublic health indicatos to assess the seveity of a humanitaian cisis: nutitional status of childen unde-ve and motality ate of the population.




Financial Resources



24/52

To increase access to nutritional treatment and

care, and expand coverage substantially through

community-based programmes and through the use

of new treatment methods and products.

Malnourished individuals both children and adults canbe treated as in-patients, in a clinic or hospital, or as out-patients, in their homes. Figure 7 below outlines ACFs2-pronged strategy for treatment, known as Community-based Management of Acute Malnutrition or CMAM.If acutely malnourished children are taken into a hospi-tal or clinic and it is usually because they have an un-

derlying health problem such as oedema or an infection,or because they have no appetite. The mother or othercaregiver must stay with the child while he or she isecovein, a situation that may be paticulaly difcultif there are other children to care for or if the parenthas work to do. Usually known as a Therapeutic Feed-ing Programme (TFP), in-patient care for severely mal-nourished children requires specialist nutritionists whoae aely available o may not be sufciently tained.

If the severely malnourished child does not have any

underlying health problem and has a good appetite,the mother can be given sachets of highly nutritiousready-to-eat food known as RUTF to take home (ENN/FANTA, 2008). Treatment through outpatient care ispreferable for both the child and the mother. By re-ceivin cae at an Outpatient Theapeutic Poamme

III.1.2 tai Ai: teai Ae maii (OTP), the seveely malnouished child can eat rUTFat home, which frees the mother to get on with othertasks. Up to 80 percent of all severely wasted childrenmay be treated in their own communities. Communi-ty-based OTPs ae less heavily eliant on medical staffand facilities and are therefore less expensive thantreating a child in a clinic. RUTF distribution points,where children are monitored for health and nutritionstatus on a regular basis can be located within com-munities for easy access. Endorsed by key UN food,nutrition and health agencies, CMAM, including theuse of rUTF, has been found to sinicantly educethe numbers of severely malnourished children requir-ing in-patient care (ENN/FANTA, 2008).

Ideally, of course, it would be best if children did not be-come seveely malnouished in the st place. One wayto try to achieve this is to provide food rations to a moth-er to prepare and give to her children who are moder-ately malnourished, or at high risk of malnutrition. Suchfood supplements are intended to be eaten in additionto the childs regular diet. Although some Ready-to-UseFoods, referred to simply as RUF, are used, supplemen-tary foods usually consist of a blend of wheat or maizeou with powdeed soya beans, fotied with vitamins

and mineals, alon with vitamin-A fotied veetableoil to add to the blended ou to incease its eneycontent. Known as a Supplementary Feeding Programme(SFP), the intervention may target all households in acommunity, particularly during the lean or hungry sea-son, or households with moderately wasted children.

fie 7: Acf Sae teae Ae maii



ci-ase maaee Ae maii veae s ii ie, ias e

6 s, ea a aai e a plwhA

mi-sea AaAddressing underlying causes through public

health + WASH + FS&L (& food and/o cashassistance where appropriate)

o-aie teaei pae (otp) a/Seea feei pae (Sfp)

Community outreach and MobilisationLink with TB/ART Programmes

Mobile ClinicsCare Practices and Mental Health

I-aie aSaiisai cae

Day CareMedical Care

Link with Infectious DiseasesCare Practices and Mental Health

caai-ii la paesIeai i hea Ses


Financial Resources



25/52

SFPs are generally less expensive per individual thanTFPs because the treatment is far less intensive, thefood products are cheaper than RUTF, and requirementsfor staff, facilities and equipment are far lower. Thesuccessful treatment of moderate malnutrition throughSFPs also depends on external factors, however. Thepresence or absence of insecurity and unrest, and theavailability of nutritious food, healthcare, and care forwomen and children, WASH and other conditions neces-sary for nutritional recovery at home are key factors af-fecting the outcomes of SFP. Seasonal factors may alsohave a direct impact on nutrition, as SFPs are usuallyimplemented in times of general food shortages, dis-ease outbreaks or humanitarian crises.

An alternative to SFP is to give families cash to buyfood. Cash distributions are more successful if thereis food available to purchase at a reasonable price,allowing the families to decide for themelves whatis best for the family. Cash is also easier to transportthan heavy bags of food for the government service,aid agency and the mother.

CMAM offers a potential solution to the constraints oftraditional TFP and SFP. The coverage of nutrition in-

terventions can be expanded, and at the same time,patients opportunity costs reduced by shifting the fo-cus fom centes to communities. Lae-scale invest-ments to expand CMAM and improve accompanyinghealth services for the acutely malnourished children

who require them could save the lives of millions ofchildren worldwide in a very short period of time. Suchefforts, however, require consistent, adequate fund-ing and must also be accompanied by a well-plannedapproach to strengthen local health services, throughsystems development, training and supervision.

b 6: bii cmAm Sae

Since 2004, ACF has treated over 600,000 childrensuffering from acute malnutrition. A massivelyscaled-up response is needed, however, to reachthe 19 million severely malnourished children

in need of uent help, and an additional 35million moderately malnourished childrenwho are in danger of deteriorating. Treatinga severely malnourished child through CMAM isestimated to cost between US$80 and US$160.The total predicted cost for reaching 19 millionseverely malnourished children thus ranges fromUS$4.5 and US$9.1 billion. While this amountwould initially be required on an annual basis,malnutrition rates would eventually fall, asinterventions to alleviate poverty bore fruit. With

scaled-up resources for nutrition, for example,public health services and facilities would beconsiderably strengthened, addressing a numberof key underlying causes of malnutrition.




Financial Resources



26/52

Even within well-functioning Primary Health Care(PHC) facilities in developing countries, nutritioninterventions are often absent. While PHC pro-grammes are designed to provide both curativeand preventative care, many facilities are under-staffed and poorly equipped, and focus limited re-sources on infectious diseases, with an emphasison medical diagnosis and the delivery of essentialmedications. Training for health care personnel,both pre- and in-service, in nutrition, malnutri-tion and micronutrient deficiencies and in ana-lysing their causes and determining solutions, iseither insufficient or non-existent. With littlenutrition expertise, health care service providers

often have difficulty assessing nutritional statusand may overlook clinical signs of malnutrition.Equipment for weighing and measuring childrenmay not be available and even when present, staffmay not be trained to use them correctly. Health

centres may lack both the resources needed to of-fer high-quality in-patient care to individuals withcomplications, and supplies for outpatient treat-ment and prevention.

The population of severely wasted children under5 in the 10 hihest buden countiesxv representsalmost 80 percent of all SAM cases. In order toscale up CMAM in these countries targeting over15 million seveely malnouished childen an in-vestment of between US$3.6 and US$7.2 billionwould be required (see Table 4 below). The great-est potion of the fundin 75 pecent wouldcover the costs of outpatient treatment, while the

remainder would establish malnutrition treatmentthrough health facilities.xvi A successful scale-upof CMAM in these countries would mean substan-tial progress in the fight against hunger and acutemalnutrition.

xv. Malnutrition based on SAM rates.xvi. The ues ae meely estimates, as it is unnown whethe o not tain inteventions to scale would educe o incease costs. The numbe of welfae

payments would most likely increase over time, but other interventions would naturally decrease.

tae 4: cs teae i e 10 cies i e hies ne SAm cie

c SAmpevaee

ne ie

i SAm

Esiaeases ve

a ea

cs teae( esiae) (uS$)

cs teae(i esiae) (uS$)

India 7 8,882,580 26,647,740 2,131,819,200 4,263,638,400

DRC 11.9 1,373,498 4,120,494 329,639,520 659,279,040

Nigeria 4.8 1,159,296 3,477,888 278,231,040 556,462,080

Pakistan 5.9 1,114,274 3,342,822 267,425,760 534,851,520

Bangladesh 3.5 662,060 1,986,180 158,894,400 317,788,800

Ethiopia 3.8 503,082 1,509,246 120,739,680 241,479,360

Indonesia 2.1 456,834 1,370,502 109,640,160 219,280,320

Sudan 7.2 392,256 1,176,768 94,141,440 188,282,880

Burkina Faso 9.7 246,477 739,431 59,154,480 118,308,960

Yemen 6.8 241,468 724,404 57,952,320 115,904,640

ta 15,031,825 3,607,638,000 7,215,276,000




Financial Resources



27/52

b 7: pess is ei ae Sai

cmAm

The Landscape Analysis on CountriesReadiness to Accelerate Action to ReduceMaternal and Child Undernutrition, currentlybein undetaen by WHO, is desined toidentify gaps, constraints and opportunities forscaling-up nutrition actions in 36 high burdencounties. Of these, only ten counties ae ontrack to achieve MDG 1, 17 are progressing butat an insufcient ate, and nine have madevirtually no progress at all with an averageannual ate of eduction less than 0.5 pecent

(a rate of 2.6 percent or more is required).Preliminary results of desk reviews from theLandscape Analysis show a strong correlationbetween being on track to achieve MDG1 andindicators for nutrition outcomes such as lowbirth weight and breastfeeding and othercare practices.

The first steps are underway to initiatethe scale-up of CMAM: 38 countries havefinalised or drafted integrated action plans

for reducing malnutrition, and trainingmaterials have been piloted and disseminatedin patneship with WHO, ACF, ConcenWorldwide and other agencies. In 2008,UNICEF procured 10,000 metric tonnes ofRUTF to support national programmes, anincrease of 63 percent over 2007. Increasingthe production of RUTF threefold, to about28,000 tonnes per year, is expected tocost about US$1.1 billion. Producing vast

quantities of RUTF at an affordable costwill necessitate global improvements inproduction and distribution, such as high-quality local production, increasing localdemand and helping to improve coverage oftreatment and prevention programmes.

Acfs pii Ais tea Ae maii

Sae ci-ase Ieveis 1.

Aess Ae maii: CMAM and relat-ed health services must be scaled up to meetthe needs of all acutely malnourished childrenthrough:Improved nutrition survey methods aimed atidentifying the needs and individual characteris-tics of hard-to-reach communities (e.g. nomadicand transhumant pastoralists), and quantifyingexpected caseloads and targets for nutrition in-terventionsInnovative techniques for mobilising community

members and for ensuring high-quality communi-ty-based malnutrition diagnosis, treatment andrelated health services and prevention activitiesTraining in growth promotion techniques in-cluding assessment of malnutrition, the causalanalysis of acute malnutrition, counselling, andstandardised malnutrition treatment guidelines(WHO, 2002)Technical support in nutrition and related ar-eas for national structures and services in bothemergency and non-emergency contexts

High-quality programme monitoring and techni-

cal supervision

See hea Sevies s cmAm:2.

Medical services that support CMAM must be fullyresourced in terms of facilities, equipment, sup-plies and skilled staff. Healthcare service provid-ers must have the capacity to treat acutely mal-nourished individuals who have complicationssuch as insufcient appetite o medical condi-

tions requiring close supervision and treatment.The standard of specialised care and treatmentmust be high enough to ensure that malnourishedchildren who suffer from potentially life-threat-ening illnesses are not put at greater risk of mor-bidity and mortality when they enter treatmentfacilities.




Financial Resources



28/52

the three diseases HIV and AIDS, TB and malaria account for approximately 6 million deaths peryea (Lawson, 2005). Ove half of all deaths dueto pneumonia (52 pecent), malaia (57 pecent),and diarrhea (61 percent) can be attributed tomalnutrition (Morris, 2003). The diagnosis, treat-ment and prevention of acute malnutrition shouldtherefore take this into account. The areas of inter-vention include WASH, PHC services, such as MCHclinics, immunisation programmes and essentialdrugs programmes, including malaria prophylaxisand treatment,Anti-Retroviral Therapy (ART) forHIV, and TB treatment, as well as HIV and AIDS andTB counselling, screening and referral.

tea Ae maii i As, Aeses a5.

Ias: National nutrition guidelines and programmesmust be developed (or existing ones revised) to iden-tify and meet the nutrition needs of other vulnerablepopulations besides pre-school children. These includeat-risk adults, adolescents and older adults, especiallyin countries with high HIV and TB prevalence, and in-fants below 6 months of age, who should be screenedsystematically, and if necessary, included in acutemalnutrition treatment and prevention programmes.

Ieae nii i heaae Iase3.

a Sevies:Anessential health and nutrition caepackage, comprising a set of high-quality servicesfor promoting adequate nutrition and well-beingshould be offered at health facilities in accordancewith a national health and nutrition policy. The pack-age could vary, depending on the type and locationof health facilities. Maternal and Child Health (MCH)clinics and other PHC facilities could offer opportu-nities to provide advice and education to familieson care practices, including infant and young childfeeding, growth promotion and treatment of simpleinfections such as diarrhoea, malaria and respiratoryinfections. Periodic, high-quality growth promotion

sessions offered either through clinics or throughcommunities can provide a means to assess and mon-itor health and nutritional status; to identify malnu-trition as early as possible; to determine, togetherwith caregivers and the community, possible causesof acute malnutrition; to provide timely home- andcommunity-based treatment; and to refer compli-cated cases to in-patient health-care facilities.

Ieae Ae maii teae i hIV4.

a AIdS, tb a maaia paes: Combined,



NatachaSouryAfghanistan


Financial Resources



29/52

Combined with treatment, helping households to achieve food security,access to water, sanitation and hygiene and optimal care will preventacute malnutrition.

To reduce the risk of malnutrition and incorporate

multi-sectoral strategies to prevent all types of un-

dernutrition acute, chronic and underweight, and

vitamin and mineral deciencies - (through blanket

feeding, micronutrient activities, communication on

positive maternal and child care practices, training

and other forms of capacity-building, and actions to

improve food security, public health, hygiene and

access to potable water and sanitation).

Insufcient access to food, poo-quality health cae in-frastructure and services, poor environmental sanita-tion, inadequate care of children and women (includinggender inequities), and the low educational level of car-egivers, are all underlying causes of malnutrition. Andwhile food, health and care are essential for nutrition,none of these alone is sufcient. All thee must be avail-able for survival, and optimal growth and development.

Food security is achieved through a combination offood availability and an individuals access to it. TheUN Food and Agricultural Organisation (FAO) denesfood security as all people, at all times, having physicaland economic access to sufcient, safe and nutitiousfood to meet their dietary needs and food preferencesfo an active and healthy life (FAO, 2006). Food secu-rity is adversely affected by poor agricultural systems;lack of investment in agriculture; civil strife leading tohigh numbers of refugees and displaced persons who

have lost access to their land; HIV and AIDS and otherdiseases that leave people too weak to work their land;lack of access to water; lack of land ownership; anda variety of other interrelated problems. Food insecu-rity can occur at several levels: individual, household,community and population. Food security crises mayesult fom man-made disastes and conict, natualdisasters, and other ongoing adverse conditions, withseveral factors affecting people simultaneously.

Food security crises are increasingly related to acces-

sibility to food, rather than food availability, as de-

pendency upon markets has increased over the last 20yeas. Pice uctuations ae theefoe a citical issuefor food security in both urban and rural contexts. Thespike in food and fuel prices experienced in 2008, forexample, added unprecedented additional pressureon poor households food security and livelihoods. Theafter-effects may undermine years of progress on theMDGs as high prices aggravate other causes of malnu-trition. Richer countries are currently acquiring farm-

land in developing countries to ensure their own foodsupplies a new phenomenon arising from the recentfood price crisis. While such deals may inject much-needed nancial esouces into aicultue and ualareas in poor developing countries in the short term,they may also have a negative effect on the poor inthe long term by using farmland on which they depend(Von Braun, 2009).

The majority of the worlds poor work in rural agricul-ture, and are thus exposed to seasonal cycles of hunger

and malnutrition, poverty and disease. Almost 600 mil-lion 7 out of every 10 hungry people in the world aresmall farmers or landless farm workers in regions whereit is virtually impossible to produce multiple harvestsdue to climatic, soil and economic constraints. Duringthe months before the annual harvest, when food re-serves are often exhausted and market prices increase,many populations are in a state of constant food inse-curity (ACF, 2008). Each year, ACF and other nutritionservice providers treat hundreds of thousands of mal-

nourished children during these crucial months.xvii

Environmental health is a key factor in disease pre-vention, and safe water a mandatory component of ahealthy diet. Yet, water remains a low priority in pub-lic expenditure, with the WASH sector budget totallingless than 1 percent of Gross National Income (GNI).As a esult, 1.5 billion people do not have access topotable wate, and ove 2.5 billion people includin980 million children do not have access to basic sani-tation facilities. Eighty-four percent of this population

lives in rural areas.

III.1.3 tai Ai: pevei maii

xvii. Seasonal hune is well hihlihted in the ACF Hune Watch publication, Seasons of Hune.




Financial Resources



30/52

ing extends to six months can reduce infantmortality by 1.4 million deaths per year by provid-ing a safe, clean and nutritionally perfect food forinfants (Black et al., 2008).

Women and girls are more likely to be malnour-ished than men in most societies (Ransom, 2003),not only due to their role in reproduction but alsoto their lower social and economic status, and lackof education. Social and cultural factors, includingtraditional practices and beliefs regarding food,feeding and care, and gender-related differencesin workload and resource distribution also contrib-ute to womens and girls poor nutritional status.

About half of all pregnant women are anaemic andover 100 million women in poor countries are un-derweight, reducing their productivity and makingthem more vulnerable to illness and prematuredeath. Poor women are often stunted, and there-fore at higher risk of complications during child-birth. Each week, 10,000 women die from treat-able complications related to pregnancy and birth(Morris, 2003), emphasising the absolute necessityfor access to high quality antenatal and postna-tal care for all mothers. For babies left without

a mother, the chance of becoming acutely mal-nourished escalates and the likelihood of survivalsharply decreases.

Emergency situations related to WASH are likelyto increase due to the negative effects of climatechange and environmental degradation. Challengesto environmental sustainability have huge implica-tions for developing countries, with climate changeposing new and serious threats to global nutrition.About 250 millionxviii people per year are affectedby natural disasters which leave them food insecureand vulnerable to acute malnutrition (IFRC, 2007).Achievement of MDG 7, with Target 10 aiming toreduce by half the proportion of people withoutsustainable access to safe drinking water and basicsanitation by 2015, equies povidin 110 millionpeople pe yea with access to sufcient potable

wate, and 185 million people pe yea with basicaccess to sanitation.

Infants, children and other family members sub-jected to long-term poverty, natural disasters,conicts and othe taumatisin events that lead topoor health and nutritional status including vio-lence in the home may suffer from psychologicaldisturbances. Trauma- and stress-related disorderscan also profoundly diminish the caring capacity ofcaregivers, resulting in inadequate care for women

and children, an underlying cause of malnutrition.On the othe hand, ensuin that the duation ofone essential care practice - exclusive breastfeed-

xviii. This ue ives the aveae of people affected between 1997 and 2006.



SusanaVera


Financial Resources



31/52

Se: modied fom SCC/SCN

Higher mortalityrate Impaired mental

development

Inadequatefoetal

nutrition

Higher maternalmortality

Inadequate food,health and care

Inadequatecatch-up growth

Reduced physical capacityand fat-free mass

Inadequate food,health and care

Reducedmental

capacity

Increased rick of adultchronic diseae

Untimely/inadequateweaning

Frequent infectionsInadequate food,health and care

Girls nutritional requirements increase during adoles-cence as a result both of the growth spurt and iron lossduring menstruation. Pregnancy during this period createsan additional nutritional burden and places the unbornchild at risk of low birth weight and premature death.Stunted or underweight girls are more vulnerable to com-plications during delivery, such as obstructed labour. Mal-nourished girls and women are more likely to give birth to

poorly nourished babies, who in turn face greater risk ofmalnutrition and poor health. They may become acutelymalnourished children, and then stunted adolescents,who later gain too little weight during pregnancy, andgive birth to babies of inadequate weight. Malnutritioncan thus be handed down fom one eneation to thenext, unless treatment and prevention are available atcritical periods to halt the cycle of malnutrition.

fie 8: Ia he a maii e lie ce




Financial Resources


oe peemalnourished

balow birth weight

cistunted

Aesestunted

ciwasted

Reduced capacityto care for child

Inadequatefood, health

and care

wamalnourished

pealow weight gain


32/52

The educational level of caregivers is related to so-cial and cultural beliefs and practices. Early mar-riage, teenage pregnancy, female genital mutila-tion, gender-based violence, and harmful healthand infant feeding behaviours, such as discardingcolostrum and giving tea and other liquids afterbirth are examples of cultural practices with poten-tially lifelong consequences. Education also has a

direct impact on earning potential, and the abilityto povide a household with sufcient nutitional in-take. While a thorough, high-quality education doesnot translate automatically into improved nutritionand well-being, literacy and access to informationconcerning preventing malnutrition can be a crucialcornerstone in safeguarding good health and ensur-ing adequate nutrient intake.

ci miisai

Community empowermentEaly detection & efealthrough volunteernetworks coverage

Promotion of appropriateinfant feeding practicesImproved access to HIV,TB and primary healthcare servicesNutrition education,counsellin & suppot focaregivers and families

Ieae, i-sea

aa

Integrated causal analysisand response with FSL,WASH & cae pactices

Link with HIV, TB andPrimary Health Careservices

bae isiis

Link with HIV/TB actionsinclude:

RUF Micronutrient

supplements

fie 9: Acf fae e pevei maii

Reduce risk and prevent early deterioration of nutritional status in vulnerable groups (children,infants less than 6 months, pregnant and lactating women, people living with HIV and AIDS,adolescent girls)

Reduce complications and associated diseaseAct against the causes of malnutrition




Financial Resources



33/52

Acfs pii Ais peve maii:

Ieae f a nii Sei i pv-1.

e rei Aaes: Improving food secu-rity through more successful in terms of produc-tion and pot aicultual development is nowbeing promoted on a large scale to help achievethe MDGs. With 70 percent of the worlds poor liv-ing in rural areas, rural agricultural developmentis a primary means to address food insecurity andto prevent malnutrition among the worlds poor-est people (IFPRI, 2004). Approximately US$109billion in agricultural investments is needed toachieve the MDGs, with credit for agricultural in-

vestments at local level a key consideration (IF-PRI, 2004).

Iei a tea Ae maii Ea:2. Interms of resources required, preventing acutemalnutition is fa moe effective and efcientthan treating it. Community-based programmesto screen for acute malnutrition and refer casesfor treatment in its earliest stages may help toprevent deterioration into its severe form. Duringseasonal peaks of malnutrition, or to avert poten-

tial nutritional crises, RUF can be distributed asa preventive measure. Prevention strategies musttherefore form an integral part of every acutemalnutrition treatment programme, with a focuson CMAM.

Iee mi-Sea paes3. that ad-dress food insecurity, inadequate WASH, poor carepactices, and insufcient health and nutitionservices: Multi-sectoral programmes for nutrition

must forge a link between emergency relief, re-covery and rehabilitation, and development. Theyshould be founded on community mobilisation andparticipation and could include:Water, Sanitation and Hygiene (WASH)a. , with ac-tivities carried out in all nutrition programmesand particular importance given to health cen-tres, schools and marketplaces.Household Food (and Nutrition) Security and Live-b.

lihood (FSL) interventions, permitting populations

to provide for their basic needs at all times, with-out dependence on external assistance. Activitiesto improve food availability such as support forfood production, or food aid and food accessibil-ity, cash-based interventions and income-generat-ing activities should be combined with WASH andPHC. Care should be taken to ensure that the nu-tritional quality of food aid is adequate, particu-larly that targeting young children and mothers.Livelihood diversication and social protectionc.

activities, to strengthen households capacity toresist shocks,xix aimed at ensuring that people passthrough periods of food insecurity without hungerand with their livelihoods intact.

Promotion of care for children and womend. ,through nutrition education and Behaviour ChangeCommunication (BCC) for caregivers, based onuse of locally available and accessible foods.Psychosocial assessment of children and women,and treatment should be integrated into nutritionservices.Disaster preparedness and Disaster Risk Reductione.

(DRR), including measures to address the effectsof climate change and to protect the environmentagainst potentially harmful policies. At-risk re-

gions should be targeted, to ensure improved andtimely responses to natural disasters.Human rights-based programmingf. , based on theright to food as the right of people to healthyand culturally appropriate food produced throughecologically sound and sustainable methods, andthei iht to dene thei own food and aicul-tural systems (Via Campesina, 2007).Practical applied research and innovation:g. Appro-priate solutions to ever-changing nutrition needs

are crucial. By establishing strong links with ex-pets fom the scientic eseach communityxx

and the private sector, agencies and service pro-vides can benet fom cuttin-ede discoveies.Focused, well-planned and professionally imple-mented operational research in nutrition andhealth, FSL and WASH can actively contribute toimpoved inteventions. Lessons fom eld expe-ience can also be studied and used to inuencepolicy, programmes and procedures.

xix. The ACF report, Seasons of Hunger explores the critical question of seasonal hunger and proposes concrete solutions for emergency measures toht malnutition, emphasisin the essential notion of the human iht to food, which should be at the heat of all national o intenational policiesfo the pevention and the ht aainst malnutition.

xx. ACFs Scientic Committee, compised of academic expets in health, wate and aicultue, meets eulaly and advises the oanisation on cuentapproaches to operational research and the feasibility of proposed studies.




Financial Resources



34/52

PreventMicronutrientDecienciesandReduce4.

Documents

ACF International White Paper