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NO WASTED LIVESAccelerating action for children

with acute malnutrition

By Saul Guerrero, Nancy Aburto, Erin Body, Diane Holland,Guy Holloway, Abigail Perry and Sophie Whitney

Saul Guerrero is the Director of InternationalNutrition Initiatives at Action Against Hunger USAand interim Coordinator of the No Wasted Livescoalition. He previously worked for Valid Internationalsupporting the design, implementation andevaluation of community-based management ofacute malnutrition (CMAM) interventions. In 2012 heco-created the Coverage Monitoring Network (CMN).

Nancy Aburto is the Chief of the nutrition-specificunit of the Nutrition Division of the World FoodProgramme (WFP) based in Rome, Italy. She has morethan 15 years of experience in public health nutrition.

Erin Boyd is a Nutrition Advisor at USAID/OFDA. Shehas over ten years of experience in emergencynutrition response, covering policy, programmemanagement, monitoring and evaluation,coordination and operational research.

Diane Holland is Senior Nutrition Advisor at UNICEFNew York with a focus on scaling up programming totreat severe acute malnutrition and emergencynutrition. She previously worked in public healthnutrition with non-governmental organisations(NGOs), UN agencies and in academia.

Guy Holloway is interim manager of the severe acutemalnutrition portfolio at the Children’s InvestmentFund Foundation (CIFF) and has extensive experiencein delivering child-centred health programmes acrossSub-Saharan Africa and South Asia.

Abigail Perry is Senior Nutrition Adviser at DFID.Shehas extensive experience in development andemergency work and previously worked in a variety oftechnical roles for different NGOs and as a ResearchAssociate at University College London.

Sophie Whitney is Global Nutrition Expert for theEuropean Commission Directorate-General forEuropean Civil Protection and Humanitarian AidOperations (ECHO). She has extensive experience innutrition, having worked for over 15 years inprogramme design, monitoring and implementation.

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In Field Exchange 53 (November2016) colleagues from ActionAgainst Hunger, UNICEF, theChildren’s Investment Fund Foun-

dation (CIFF), the Department for In-ternational Development (DFID), theEuropean Commission and the UnitedStates Agency for International Devel-opment (USAID) made a collectivecase to scale up services to manage se-vere acute malnutrition (SAM) aroundthe world. In that joint op-ed theauthors recognised that “to unlock theglobal and national challenges we willneed to bring our different skills, knowl-edge, geographical reach and diversenetworks to bear on this very pressingproblem. Only if efforts are coordinatedand dialogue sustained on the opportu-nities and challenges we face, will wemaximise the influence and impact wecan leverage, and bring others on boardto drive change”.

Since then other agencies, includingthe World Food Programme (WFP),the innocent foundation, the Interna-tional Rescue Committee (IRC) andALIMA, have come forward to answerthis call and together we have createdNo Wasted Lives, a coalition to accel-erate action for children with acutemalnutrition.

The coalition aims to double thenumber of children receiving treatmentfor SAM to six million per year by2020 as a critical step towards achievinguniversal coverage by 2030. Recog-nising that focusing on treatment alonewill not result in the elimination ofmalnutrition (Sustainable DevelopmentGoal (SDG) target 2.2), the coalitionalso has a long-term vision of im-proving prevention options to reducethe number of children becomingacutely malnourished so that treatment

caseloads are manageable. Over thenext few years, the coalition will worktowards achieving a series of outcomes,including:• e cost of curing a child suffering

from SAM reduced to US$100 or less (from the current US$150-250);

• e cost of ready-to-use foods per child cured reduced by 50%;

• New treatment approaches proved capable of reaching over 70% of cases in areas of intervention (from the current 30-40%);

• Five key high-burden countries to adopt reduction and treatment coverage targets;

• Nutrition policies of all key bilat-eral donors to support scale-up of acute malnutrition programming, including treatment for SAM and prevention;

• All key high-burden countries to have national nutrition policies that promote prevention of and community-based treatment for SAM; and

• New financial pledges to be made that support actions to address acute malnutrition.

To achieve these ambitious aims andoutcomes, the coalition will work onthree key areas:

Advocacy agendae coalition will engage governmentsand other actors to support them inmaking the best decisions about pre-vention of and treatment for SAM. ecoalition aims to facilitate the provisionof evidence, intelligence and data thatgovernments and other key actors needto make informed decisions. To thisend, the coalition is currently developinga multi-year advocacy strategy sup-ported by a US$2.3 million grant fromthe CIFF.

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Source: Field Exchange 55, July 2017. www.ennonline.net/fex

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Technical acceleratore coalition will invest in cutting-edge ideasand bold hypotheses to drive forward globallearning and action on prevention and treatmentof acute malnutrition. To guide and support theseefforts, the coalition has created an independentCouncil of Research and Technical Advice onSevere Acute Malnutrition (CORTASAM), whichbrings together over a dozen of the world’s leadingacademics, practitioners and policy-makers inthis area (see article in this edition of Field Ex-change). e coalition has already invested overUS$8 million in operational research projects,including pilots on the integration of SAM treat-ment into the integrated community case man-agement (iCCM) of childhood illnesses (Mali,Pakistan and Kenya); reduced dosage of ready-to-use therapeutic foods (RUTF) (MANGO projectin Burkina Faso); simplified protocols for treatmentof moderate acute malnutrition (MAM) and SAM(COMPAS project in Kenya and South Sudan,non-inferiority test in Burkina Faso); and settingup the new website e State of Severe Malnutrition(see www.severemalnutrition.org and feature inthis edition of Field Exchange). e coalition isalso supporting the ongoing prioritisation of re-search questions on acute malnutrition, using ev-idence gaps and opportunities for improving cov-erage as a primary step in the creation of a global

research agenda on acute malnutrition (see articlefor headline findings).

Donor forume coalition will convene and host a forum fortraditional and non-traditional donors and gov-ernments with a view to increasing the overallamount of money available, improving coordinationof existing investments, unlocking new health andlong-term funding and bringing new donors andbusinesses to the table. is will include health/de-velopment departments of donors with prior historyof supporting SAM treatment through their nutri-tion/humanitarian departments as well as founda-tions, bilateral and multilateral agencies and indi-vidual donors with no history of investing in thisarea. e forum will help donors align their mes-saging, approaches and priorities to ensure coherence.By facilitating information exchange, the coalitionwill encourage better integration of funding forSAM into global and domestic health budgets andwill give donors, governments and service providersthe best chance of driving down costs and max-imising economies of scale.

Over the coming months the coalition willwork with UNICEF and its national partners inthe development of regional scale-up plans forSAM management services as part of, and tocomplement, nutrition costed plans currentlybeing developed in many of these countries. e

UNICEF-organised multi-stakeholder meetingsin East Africa (16-18 May), South Asia (18-20May)1 and West Africa (19-21 June) providedthe basis for these regional plans by identifyingkey challenges and opportunities for scaling upservices across a range of contexts. e meetingsbrought together UNICEF country and regionaloffice representatives and ministry of health del-egates from virtually all countries in these regions.

No Wasted Lives will continue to build onexisting efforts, create and maximise synergies andbring new players on board to accelerate progressand overcome the programmatic, technical, policyand financing challenges to addressing the globalburden of acute malnutrition. We have conveneda coalition of partners to begin this journey but wecannot do this alone: the success or failure of thisinitiative will rest on our ability to engage and mo-bilise governments, civil society, business and otherstakeholders to push this ambitious agenda.

If you or your organisation would like toknow more and to explore ways to support andcollaborate with No Wasted Lives, visit our website(www.nowastedlives.org) or reach out to us oninfo@nowastedlives.org.

NO WASTED LIVES

DRIVING EVIDENCE TO ACTION:The Council of Research & Technical

Advice on SAM (CORTASAM)

By Amy Mayberry, Saul Guerrero, Mark Manary and Noel Marie Zagre

Amy Mayberry is Head of Evidence at Action AgainstHunger, where she supports the technical andresearch activities of No Wasted Lives, includingCORTASAM. She previously worked on the Evidence,Measurement & Evaluation Team at The Children’sInvestment Fund Foundation (CIFF).

Saul Guerrero is Director of International NutritionInitiatives at Action Against Hunger USA and interimCoordinator of the No Wasted Lives coalition. Hepreviously worked for Valid International,supporting the design, implementation andevaluation of community-based management ofacute malnutrition (CMAM) interventions. In 2012 heco-created the Coverage Monitoring Network (CMN).

Dr Mark Manary is Associate Professor of Paediatrics atWashington University School of Medicine and Lecturer atMalawi School of Medicine in Blantyre, Malawi. He has beeninvolved in nutrition and metabolism research in Malawi for thepast two decades and served as principal investigator for theready-to-use therapeutic food (RUTF) studies there. He is currentCo-Chair of CORTASAM.

Dr Noel Marie Zagre is Regional Nutrition Advisor for UNICEF inthe West and Central Regional Office (WCARO), based in Dakar,Senegal. He has worked with UNICEF across Sub-Saharan Africa,East Asia, the Pacific and South Asia for the past 12 years andpreviously held senior roles at Helen Keller International and theNational Health Sciences Research Institute in Burkina Faso. Heis current Co-Chair of CORTASAM.

An estimated 52 million children underfive years of age suffered from acutemalnutrition, of which 16.9 millionsuffered from severe acute malnu-

trition (SAM) in 2016 (UNICEF, WHO andWorld Bank, 2016). Treatment for acute mal-nutrition, which puts the lives of millions ofchildren at risk each year, is effective and sig-nificant advances have been made in the pastdecade to improve the quality and coverage ofprogrammes. More children are being successfullytreated for SAM than ever before, yet less than

20% of children with SAM currently receive thetreatment they need (UNICEF, 2015).

As part of the global efforts to address thesegaps and improve the prevention and treatmentof acute malnutrition, the No Wasted Lives coali-tion was formed with the aim of doubling thenumber of children receiving treatment to sixmillion per year by 2020. is is a critical steptowards achieving universal coverage of all SAMchildren by 2030, while concurrently workingtowards improved prevention measures and re-ducing the number of children who fall into

acute malnutrition. One of the biggest challengesto achieving this scale-up of treatment is evidence,both in terms of generating new evidence andusing existing evidence effectively to improveprogrammes and policies. Despite advancesmade to date, significant gaps remain in the ex-isting evidence base to support the successfuland meaningful scale-up that will achieve theseambitious goals.

To address the gaps, the No Wasted Livescoalition founded the Council of Research &Technical Advice on SAM (CORTASAM) in

1 See Stunting & Wasting in South Asia – Reflections from a Regional conference by Charulatha Banerjee, ENN Regional Knowledge Management Specialist (SUN Movement) in the region. www.ennonline.net/mediahub/wastinginsouthasia

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2016. Comprised of leading experts in childhealth and nutrition across the world and rep-resentatives of regions with the highest burden,the Council’s goal is to drive the use of evidencefor action in order ultimately to reach morechildren with effective treatment and preventionprogrammes. e Council aims to do this inthree ways:1. Set research priorities: Identify research

and knowledge gaps to guide global researchpriorities in the prevention and treatment of acute malnutrition;

2. Drive the use of evidence in programmes: Provide a systematic and transparent reviewof the emerging evidence, resulting in interimadvice on the operational implications and application; and

3. Drive the use of evidence in policies: Coor-dinate with the World Health Organization (WHO) to ensure critical evidence gaps are filled and result in integration of emerging evidence into normative guidance.

A critical first step for CORTASAM was to iden-tify key research priorities across acute malnu-

trition. By taking a comprehensive review ofthe research questions across the sector andthen prioritising, we can better support theprocess of filling critical gaps in the evidenceand improve coordination and action to scaleup evidence-based prevention and treatmentprogrammes. e research prioritisation exerciserecently led by CORTASAM is presented in thisedition of Field Exchange . e exercise used awell-established methodology developed by theChild Health and Nutrition Research Initiative(CHNRI), a systematic and transparent approachthat has produced a set of research prioritiesand, we hope, a critical strategic steer and lead-ership in this area.

Looking ahead, the aim of CORTASAM isto expand on these priority areas and developclear action plans to progress them betweennow and 2020. To do this we will need to usereviews of the available evidence, a mapping ofongoing research that will produce new evidencein these areas (already underway; see below)and global and regional consultations to identify

the critical gaps that need addressing to drivethe use of evidence for action. Our commitmentis to continue our work to advocate for and usethe research and evidence needed to truly makean impact. But we cannot do this alone. NoWasted Lives and the work of CORTASAM area platform to guide and coordinate global effortsand we rely on the experts, researchers, and im-plementers like you to help us achieve this goal.

More information and updates on the workof CORTASAM and No Wasted Lives can befound at www.nowastedlives.org

An initial mapping of ongoing research acrossthe research areas and priorities is now availableon e State of Severe Malnutrition website;see: www.severemalnutrition.org/en/content/on-going-research

ReferencesUNICEF, WHO and World Bank. Joint child malnutritionestimates – levels and trends (2016).

UNICEF (2015). UNICEF Annual Results Paper.

PRIORITISING ACUTE MALNUTRITION RESEARCH:preliminary results of a CHNRI survey

AmyMayberryis Head ofEvidenceat ActionAgainstHunger,

where she supports thetechnical and researchactivities of No Wasted Lives,including CORTASAM. Shepreviously worked in theEvidence, Measurement &Evaluation Team at theChildren’s Investment FundFoundation (CIFF).

Members of the Council ofResearch & Technical Adviceon SAM (CORTASAM) are:Nancy Aburto, TahmeedAhmed, Paluku Bahwere,Robert Black, André Briend,Elhadj Issakha Diop, SteveJarrett, Marko Kerac, FerewLemma, Mark Manary, MarieMcGrath, Susan Shepherd,Zita Weise Prinzo and NöelMarie Zagre.

These are preliminary findings.The final findings are currentlybeing prepared for publicationin a peer-reviewed journal.

BackgroundAs you will have read in the preceding articles in thisissue of Field Exchange on No Wasted Lives and theCoalition of Research & Technical Advice on SevereAcute Malnutrition (SAM) (CORTASAM), our ambitionsare large. A critical pillar of this effort to accelerateglobal action is driven by the generation and use of evi-dence. CORTASAM was founded to help fill gaps in theexisting evidence base to support scale-up of effectiveprogrammes and drive the use of evidence for action.At the outset, it became evident that a set of researchpriorities would provide a fundamental platform toguide the work of the Council, as well as other researchers,implementers, policy-makers and donors. Where time,capacity and financial resources are limited, researchpriorities can focus efforts on the critical areas that willultimately translate into meaningful action across pro-grammes and policies. However, to be truly useful theseresearch priorities need to reflect the opinions of theexperts, the researchers and the implementers, like you,who are working every day to advance this field.

e scope of this exercise focused on research prioritiesrelated primarily to treatment across the continuum ofacute malnutrition in children under five years of age.Given the state of evidence and other technical groupsworking on prevention, this exercise only included pre-vention where it was linked with treatment. e aimwas to produce a set of research priorities that arecritical to achieve measurable improvements in thequality, effectiveness, scale and sustainability of pro-grammes addressing acute malnutrition in childrenunder five years of age that will ultimately result inscaling up treatment by 2020.

MethodsTo achieve this, CORTASAM led an exercise using theChild Health & Nutrition Research Initiative (CHNRI)methodology (Rudan et al, 2008) for setting researchpriorities. is exercise provides a robust and transparentframework to collect global, regional and country-levelstakeholder feedback by scoring a set of research questionsagainst a set of pre-defined criteria.

A long list of research questions was identified bycollating published research questions and prioritiesfrom across the sector, including those previouslyidentified by the World Health Organization (WHO),other technical interest groups and in a consultationwith CORTASAM and additional regional stakeholders.is list of hundreds of questions reflects the breadthand depth of research areas and opportunities to supportimprovements and scale-up of cost-effective programmesfor acute malnutrition, including new and innovativeareas that are emerging.

e long list of research questions was grouped into53 research areas which, while focused, would likely notbe answerable by a single research study but could becollectively answered by a group of inter-related researchstudies.

An online survey was made available from 3 April to5 May 2017. While CORTASAM members were invitedto participate, the survey was also shared with globaland regional staff in the No Wasted Lives coalition andwith other researchers, implementers, academics anddonors working in the sector.

e survey collected basic information on country/re-gion of work, organisation and type of work for all re-

NO WASTED LIVES

By Amy Mayberry andCORTASAM members

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Figure 1 Breakdown of respondents

Globalrank

Research area West &CentralAfrica

EastAfrica

SouthAsia

1 What are the most effective tools to diagnose acute malnutrition inchildren 6-59 months of age by community members, includingcommunity health workers and caretakers?

X X

2 What are effective therapeutic feeding approaches for themanagement of severe acute malnutrition in children 6-59 months ofage with diarrhoea?

X

3 What are effective and safe strategies and protocols to support thescale-up of treatment of acute malnutrition in infants <6 months of age?

X

4 What are the causal factors of relapse after treatment of acutemalnutrition in children 6-59 months of age and how can they beminimised?*

5 What is the relationship between the nutrition and health status ofmothers and acute malnutrition in their children and how can interventions within the 1,000-day window reduce the risk of acutemalnutrition?

X X X

Table 1 Top five global research questions and their regional prioritisation

LAUNCH OF THE STATE OF SEVEREMALNUTRITION WEBSITE

A new website, the State of Severe Malnutrition,has been launched by the No Wasted Lives Initiative(www.nowastedlives.org), providing a compre-hensive overview of all qualitative and quantitativeresources on acute malnutrition. e websiteaims to link malnutrition discussions to widerpublic health and child survival debates, highlightthe progress that has been made globally ontreatment coverage, and provide a global per-spective and country-specific overviews of mal-nutrition treatment outcomes. It also provides aplatform to support coordination and commu-nication across key research areas, amongst re-searchers and those interested in using emergingevidence for programmes and policies.

e site brings together information from arange of sources, providing the most up-to-dateinformation on acute malnutrition. Sourcesinclude UNICEFs 'Global SAM Management Up-

date Tool (Nutridash)’ data, Coverage MonitoringNetwork, e CMAM Forum, WHO/UNICEF/World Bank Joint Estimates, Global NutritionReport, WHO mortality database, WHO Malariadatabase, UNAIDS HIV database as well as Centrefor Disease Control (CDC) databases. e websitealso links with WHO’s Global Database on theImplementation of Nutrition Actions (GINA)and ENNs periodic publications (Field Exchangeand Nutrition Exchange). Technical questionsare directed to en-net, the established onlineforum hosted by ENN.

Content is shared in a user-friendly format,using interactive maps and visuals. Resources,events and ‘state of play’ at country level are or-ganised by the following themes:• Enabling environment: includes policy and

guidance documents, as well as financing data points and information.

• Supply: includes data on products and rou-tine medicine, human resources, geographi-cal coverage and community mobilisation.

• Demand: includes quantitative data on the burden of acute malnutrition, nutrition and infection (including malaria and HIV) and health-seeking behaviour.

• Quality: includes data on treatment admis-sion and exits, treatment coverage, lives-saved estimates and cost-effectiveness.

Ongoing research is shared through an interactivediagram that maps current ongoing research re-lated to severe malnutrition (www.severemalnu-trition.org/en/content/ongoing-research). estudies and information included draw frompublicly available research protocols and researchdatabases as well as additional information sub-mitted by the research teams involved. Informationis provided at thematic, sub-theme and individualstudy level.

Individuals are invited to join the discussionson data or submit resources, research and eventsas part of the website’s ongoing development.

To find out more, visit www.severemal nutrition.org or contact: info@severemalnutrition.org

*This question ranked number 8 in West and Central Africa, 11 in East Africa and 13 in South Asia

spondents. e bulk of the survey focused on the re-search prioritisation, where each research area wasscored against each of the following criteria:• Impact: Would the research lead to interventions

and solutions that provide the maximum potential impact (e.g. on global burden of acute malnutrition or mortality due to malnutrition) by 2020?

• Effectiveness: Would the research lead to inter-ventions and solutions that are effective (e.g. under routine programme conditions) and deliverable (e.g. taking into account the health system infrastructure, human resources, safety)?

• Answerability: Is it possible to answer the ques-tion (is it feasible to implement within the givencontext and timeframe (by 2020)? Is it ethical?)

• Sustainability: Would the research lead to interventions and solutions that are sustainable (e.g. considering cost and financial affordability,

cost-effectiveness, favourable political climate)?

Each of the 53 research areas received four scores(one per criteria) between 0 and 1. ese wereaveraged to produce a single research priority score(RPS) that was used to produce the analyses. Aglobal ranking analysis was done using all responses.In addition, regional analyses for West and CentralAfrica, East Africa and South Asia were undertakenusing only responses from those regions.

FindingsA total of 313 unique responses were received; 143(46%) of these were fully completed. ese responsesrepresented 63 different countries and 167 differentorganisations globally (see Figure 1). Nearly half ofrespondents (46.7%) identified their work as beingprimarily operational or programmatic; others re-ported to be working in academia (15%), government(11%), policy (2.2%), or in another type of work(23%). A full list of countries and organisations rep-resented can be found athttp://www.nowastedlives.org