The Hunger Crisis is Devastating for Communities and Especially for Children: The world is seeing a hunger crisis of unprecedented proportions. More than 900,000 people[1] across the globe are one step away from famine, caused by the current global food security crisis, climate change, and conflict. This is particularly dangerous for children.
East Africa is experiencing its worst drought in more than 40 years after five consecutive years of failed rainy seasons. Increased temperatures, severe droughts, locust invasion, and flooding, have damaged agricultural land, reduced grazing pastures for livestock, and devastated livelihoods and diets. Millions of people are barely able to meet minimum food needs by depleting essential livelihood assets or through crisis-coping strategies. At the end of last year, around 20 million children[2] across Ethiopia, Kenya and Somalia were facing the threat of severe hunger, thirst and disease.
In times of severe food insecurity and famine, malnutrition surges, especially among children under five years old, can have lifelong health and sociological impacts.[3] Globally, up to 60 million children are currently experiencing wasting or acute malnutrition (too thin for height), the deadliest form of malnutrition, increasing their risk of death up to eleven-fold. Cases continue to rise rapidly in near-famine contexts, like Somalia.
An effective treatment exists but few malnourished children receive it. Treatment with ready-to-use therapeutic food (RUTF), an easy-to-administer, shelf-stable fortified peanut butter paste has shown to be highly effective for more than 20 years. The majority of malnourished children who receive this treatment fully recover within weeks. And yet globally, just 20 percent[4] of children suffering from wasting can access this treatment, leading to 1-2 million deaths annually.[5]
The current global system for the treatment of wasting is not working for children and their caregivers, nor for health systems. It is unnecessarily complex, heavily reliant on hard-to-reach health centers, underfinanced, siloed, and challenging to scale. Currently, treatment is delivered through a bifurcated system that treats severe and moderate forms of acute malnutrition with different products, different supply chains, and different delivery points, supported by UNICEF and WFP respectively. In addition, children are diagnosed and treated according to complex weight-based calculations, primarily through formal health facilities. When fuel and food prices are surging, and cash-strapped families are facing impossible decisions, the need to travel to a health facility can prove an insurmountable barrier.[6]
This is exacerbated by a lack of sustainable multi-year funding, distributed in short-term bursts of emergency funding. RUTF supply chains have been unreliable, and lack transparency. Additionally, there is no cohesive, flexible global guidance on treatment protocols, preventing national governments from procuring and selecting among all evidence-backed tools.
A body of research shows a more cost-effective and scalable way to deliver treatment for acute malnutrition: Over nearly 10 years of research,[7] the implications of various simplifications to the wasting treatment protocol have been tested, and demonstrate that a simplified, combined protocol using a single product, simplified MUAC-based diagnostic criteria, and simplified dosing is equally effective and in fact more cost-efficient than the standard, more complex, approach. The simplified approach can be delivered at the last mile, including by community health workers with tools adapted for low levels of literacy and numeracy. Simplified approaches are an important piece of the solution to closing the treatment gap.
According to data in Mali,[8] for the same resources, you can treat 31% more children with severe acute malnutrition (SAM) or 66% more kids suffering from moderate acute malnutrition (MAM) using a simplified protocol. UNICEF reports that to date, 52 countries have used[9] some form of simplified treatment approaches.
The ComPAS trial,[10] a 4,000 patient randomized control trial in South Sudan and Kenya published in 2020, concluded that simplified, combined treatment for SAM and MAM provides at least the same benefit as standard care. 76.3% of children treated with the combined protocol recovered compared to 73.5% recovery with standard treatment protocol. The rate of deaths was 1.8% for both the combined and standard protocol, while both protocols had a recovery time of about 10 weeks. No evidence of a difference in additional secondary outcomes including non-response, default and average daily weight gain was found.
The simplified, combined protocol has been tested in different operational settings, following over 100,000 children across 5 countries. Our operational research shows the simplified protocol is effective across multiple countries and contexts. Data shows that the protocol achieves high recovery rates ranging from 85%-95%, well above the humanitarian SPHERE standard of 75%. This effectiveness is sustained among children who are particularly vulnerable. Recovery rates are over 80% even among children with severe wasting, concurrent wasting and stunting, and the youngest patients.
Community health workers (CHW) can effectively deliver treatment, further enabling reach and decentralization. Simplifications to the traditional protocol can enable CHWs to treat children with uncomplicated wasting who live far away from health centers, increasing coverage in hard-to-reach areas. Research in Mali 2022,[11] showed that treatment by CHWs resulted in high recovery (94%), similar to the treatment by formal health care workers, and low RUTF consumption per child recovered, and can safely be adopted by CHWs to provide treatment at the community-level. Similarly, a study in South Sudan showed that deploying CHWs to treat SAM in areas with high prevalence and low treatment access leads to higher recovery, and shorter treatment time. Proper adaptations of tools and protocols can empower CHW cadres with low literacy and numeracy to successfully complete treatment steps.
Ready to Use Therapeutic Food is both a major cost driver of treatment and a binding constraint to scale. (1) Currently, many countries are facing product shortages in the face of food insecurity and increased demand. The product is often in short supply, leading to stock-outs; (2) There are long, unpredictable lead times from producer to health facility; (3) The product is expensive, and its price limits coverage. This is a well-documented problem, with key issues on price and availability discussed in UNICEF’s 2021 RUTF Supply Market Outlook.
Unprecedented influx of financing for wasting treatment led to an increased demand for production in 2022 and 2023, but the RUTF manufacturers cannot keep up with ongoing demand. The standard formulation of RUTF is derived from raw materials shipped from all over the globe, manufactured primarily in western countries, and then shipped at expensive rates to high-burden countries. There is a lack of transparency in the supply chain that makes it challenging for governments and implementers to scale treatment accordingly. Simplified approaches and alternative formulations of RUTF provide multiple opportunities to enhance efficiencies in the supply chain.
Using the simplified, combined protocol is one treatment approach that notably increases the cost-efficiency of malnutrition treatment in two key ways. First, the simplified protocol reduces the dosage of RUTF for some children with SAM. Following a standard protocol, the current weight-based dosage for SAM children can result in children receiving up to 5 sachets of RUTF per day. The simplified protocol effectively recovers SAM children with a consistent dosage of 2 sachets per day. As RUTF expenses are often the most significant single cost of malnutrition treatment, a simplified protocol uses 39% less RUTF to treat children with SAM than the standard protocol. Second, treating MAM and SAM cases at a single delivery point can lead to efficiencies when more children benefit at each site while site level fixed costs remain the same. The simplified, combined protocol enables scale by maximizing limited resources to avert preventable child deaths.
Another option that may impact the supply chain includes using alternative formulations of RUTF that optimize local ingredients and improve local production opportunities. Currently, production is primarily in the global north, and shipping, import taxes and delivery raise the costs associated with procuring RUTF. Bringing production closer to the communities affected by malnutrition simplifies the supply chain and generates income-producing opportunities.
Despite the evidence of more cost-effective, scalable approaches, treatment coverage has not significantly improved. We have seen progress with global and national guidelines evolving to allow the use of simplified approaches, but primarily “in exceptional circumstances”. This includes the MAM Decision Tool for Emergencies,[12] the UN Joint Call to Action[13] on Child Wasting, the Guiding principles for scaling-up wasting programming[14] note from US AID Bureau of Humanitarian Affairs and the Global Nutrition Cluster, and the Covid-19-specific implementation guidance by UNICEF and WHO. Global guidance and financing should support national efforts to adapt simplified and cost-effective approaches to treatment. This will facilitate the ability to maximize resources in each context and is critical to enable scale.
Global guidance and financing should facilitate the flexibility for national governments to select among all evidence-based approaches to treatment. Three things would lead to real movement: first, we need to set targets with teeth, such as flipping the 80% treatment gap to 80% treatment coverage by 2030. We need a set of clear goals linked to sustained funding and transparent accountability to provide an organizing principle, and a galvanizing mission across all stakeholders. Second, we must drive the uptake of innovations through nationally-led strategies and plans. National and subnational programs have the greatest context knowledge and the most direct accountability to clients. They should serve as the convening point – setting a strategy that gets costed and funded as a single plan, then galvanizing the constellation of national and international partners actions to achieve that strategy. Lasty, it is critical to lock-in sustained, predictable funding through both global and domestic investment. One of the challenges of wasting is that a significant and growing proportion of the funding is short-term, unpredictable humanitarian assistance. While humanitarian crises exacerbate wasting, this has been a steady state global crisis with tens of millions of children affected annually, even in years without major global food insecurity.
The 2023 Global Report on Food Crises[15] estimates that, in the 13 USAID-UNICEF priority countries, there are approximately 26.5 million wasted children. The back of the envelope cost of treating 80% of all children with wasting in these 13 countries is approximately $1.7B annually. This is achievable – we’ve seen it done before with U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund in the fight against AIDS. PEPFAR increased treatment rates for AIDS from four to 75 percent globally – largely by increasing the accessibility of anti-retroviral therapies. Twenty-five million lives were saved.
We need a global coalition to help end wasting and reduce child mortality as a global injustice. Time and again we have seen the power of faith-based activism to bring about change on global social justice issues – from the HIV/AIDS response to debt relief – especially where existing solutions fail to reach the most vulnerable.
We need a movement to bridge the gap between the science and policy change needed to drive lasting change. Wasting is the sharpest end of the problem – the greatest danger to the most vulnerable children – and the area with the clearest set of solutions.
Faith-based partners can lend solidarity in rallying leadership, resources and transparent accountability for acting on the science and scaling known solutions.
Most global problems do not have clear solutions, but this one does. With national governments in high-burden contexts in the lead, alongside global strategic leadership, political will, and sustainable financing, we can achieve the reform needed to address this decades-long public health emergency.
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López‐Ejeda, Noemí, et al. “Can Community Health Workers Manage Uncomplicated Severe Acute Malnutrition? A Review of Operational Experiences in Delivering Severe Acute Malnutrition Treatment through Community Health Platforms”. Maternal & Child Nutrition, vol. 15, no. 2, Nov. 2018, p. e12719. PubMed Central, https://doi.org/10.1111/mcn.12719
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[1] https://www.wfp.org/global-hunger-crisis
[3] https://www.unicef.org/nutrition/child-wasting
[4] https://www.rescue.org/article/why-do-most-children-affected-acute-malnutrition-go-untreated
[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587873/
[7] https://www.rescue.org/report/simplified-combined-protocol-evidence-overview
[8] https://pubmed.ncbi.nlm.nih.gov/36432609/
[9] https://www.simplifiedapproaches.org/
[10] https://www.ennonline.net/fex/53/thecompasstudy
[11] https://www.mdpi.com/2072-6643/14/22/4923
[12] https://www.nutritioncluster.net/resources/decision-tool-mam-emergencies-2014-updated-2017
[13] https://www.childwasting.org/
[15] https://www.wfp.org/publications/global-report-food-crises-2023