An IRC staff member in Somalia measures Amina’s son’s arm to show that his condition is improving after receiving treatment for malnutrition through IRC’s combined protocol approach. Photo: Harrison Thane/IRC

The IRC’s ambitious plan to scale acute malnutrition treatment

Nearly 80% of malnourished children are still not receiving the treatment they need to recover. A simpler, community-centered system could reach millions more children.

50 million children around the world suffer from acute malnutrition, and nearly 18 million of those children live in conflict and crisis-affected contexts in which the IRC operates [1]. For children, being malnourished can lead to a range of health problems and can be fatal — when severely malnourished, their risk of death increases up to eleven-fold. A cure exists — a package of peanut-based paste, delivered through daily doses over a few months — but the system to deliver it is inefficient, making treatment inaccessible for 80% of the children who need it. We believe we can transform the sector and reach more malnourished children by simplifying life-saving treatment and putting it in the hands of affected families and communities.

What is acute malnutrition and why is it a serious problem?

Acute malnutrition — also known as wasting — is a life-threatening condition defined when a child’s weight is too low for their height. It’s caused by a myriad of factors including a combination of communicable diseases (measles, pneumonia, diarrhea, and malaria) and inadequate diets. It mostly affects children under five and it can be deadly. In 2019, 14.3 million children suffered from severe wasting. “Wasting” is a biological coping mechanism that also causes the child’s organs and systems to conserve energy and nutrients in order to survive, compromising their immune function and making them more likely to become ill and suffer from recurrent infection. The relationship between childhood infection and wasting is a vicious cycle, with each leading to the other, leaving the child increasingly vulnerable over time.

Poor nutrition not only leaves children vulnerable to a range of life-threatening conditions but also has serious social and economic implications, preventing children from reaching their full developmental potential. In 2019, more than two thirds (32.6 million) of these children live in Asia and more than one quarter (12.7 million) live in Africa. At this rate, the world will fall short of the Sustainable Development Goal target for wasting, with only 20% of countries globally on track.

Great strides have been made in treating malnutrition, but there is still a long road ahead

Just over two decades ago, treating acute malnutrition required around-the-clock medical care at specialized hospitals called therapeutic feeding centers. At these centers, healthcare professionals would rebalance their metabolism, supply electrolytes and antibiotics, and treat the child with therapeutic milks, which required safe preparation, clean water, and proper storage. These health centers were often located far from the communities making them inaccessible to many.

Several innovations have now enabled children with uncomplicated cases of acute malnutrition to be treated outside of hospitals, expanding coverage and reducing the risk of contracting diseases during treatment. First, the development of Ready-to-Use Therapeutic Foods (RUTF) — a nutrient-rich, peanut-butter-like paste inspired by a jar of Nutella that a child eats in daily doses over a few months — enabled children to recover at home. Second, was the introduction of a new approach for community-based management of acute malnutrition, which brought care directly into the communities by training community volunteers to detect malnutrition in children, to administer RUTF, to support caregivers monitoring their child’s progress through home visits, and to refer more severe cases to health facilities when needed.

If these treatments work, why is malnutrition still a problem?

While these developments have led to remarkable progress, nearly 80% of malnourished children are still not receiving the treatment they need to recover.

First, the current treatment system and protocol is complicated, inefficient, and burdensome for families. Acute malnutrition is a continuum condition, meaning the severity of a child’s condition improves or deteriorates continuously along a single spectrum. But today, children suffering from acute malnutrition are divided into two categories, severe or moderate, based on statistical measures of weight-for-height, even though the dividing line between them is arbitrary. The difference between children who are close to that dividing line between moderate and severe malnutrition is minor, but access to treatment depending on their categorization is drastically different. Different United Nations agencies provide different treatment products based on which category a child is in. Having multiple treatment systems and protocols complicates where treatment is available, who is eligible for which kind of treatment, and often leaves children with moderate acute malnutrition untreated until their condition worsens. It can also lead to relapse as children and their families are unable to navigate the complicated pathway to recovery.

Second, with limited exceptions, treatment for acute malnutrition is only available at health facilities, meaning caregivers often travel long, sometimes dangerous, distances to reach the life-saving care their child desperately needs. And because health systems are weakened or even disrupted in humanitarian settings, even if caregivers make it, facilities are often unable to meet the growing demand for care. As a result, less than half of children living with acute malnutrition are ever diagnosed and so do not even have a chance to receive treatment. While mobile clinics are becoming more popular, they still rely on trained healthcare workers.

To create a future in which every malnourished child is treated, the IRC is proposing a simpler system that enables treatment within communities.

Our approach empowers families and community health workers to deliver a simplified protocol for treatment with an easy-to-use toolkit. The result is a package of care that can be adapted to different contexts, rolled out quickly during times of emergency, and scaled across humanitarian crises. In this way, we can reach more children at less cost.

Simplifying treatment

To optimize treatment, researchers from the IRC, Action Against Hunger, London School of Hygiene and Tropical Medicine, Washington University School of Medicine, and University of Tampere/University of Copenhagen analyzed data from approximately 10,000 children in five countries by looking at their average rate of growth, and determined how much RUTF a child would need to achieve recovery and when treatment could be stopped. Together, we redefined what it means to be malnourished in terms of how well a child is likely to respond to treatment, ignoring the strict line between moderate and severe acute malnutrition since children move fluidly between them. This research showed that different doses of the same product (RUTF) could be used to treat children with both moderate and severe acute malnutrition, simplifying the existing protocol based on two different products.

The IRC and partners have tested this combined, simplified protocol in Kenya and South Sudan, and found it to be as effective as the standard care while requiring less RUTF sachets (122 versus 193 sachets). Another study in Somalia achieved a recovery rate above global standards for children with severe acute malnutrition. Preliminary results from completed and current pilots in Mali, Chad, and Somalia further validate the safety, feasibility, and cost-effectiveness of these approaches.

Bringing treatment to communities and caregivers

By empowering community health workers and families to treat children where they are, we’re also reducing the burden, risk, and opportunity cost of seeking treatment in often faraway health facilities. Community health workers are often trusted, well-known figures in their communities, allowing for more comprehensive care and providing choice to caregivers.

The Mid-Upper Arm Circumference (MUAC) tape, a band that wraps around a child’s arm to measure lean muscle mass, is a key tool to diagnose a child’s malnutrition status, and to monitor its progression over time. However, interpreting and recording readings from the original MUAC tape requires strong literacy and numeracy skills, and not all community health workers or caregivers can read or count. Based on this reality, the IRC led a process to develop simplified tools and aids for low-literate community health workers to more easily diagnose and treat acute malnutrition. This included redesigning the MUAC tape so that numbers were removed and colors were highlighted, making the tape easy to read and reducing the chance of error, and a treatment register containing a unique illustrated identifier for each child, making it easier for community health workers to record their findings and match patient cards with register pages. One study in South Sudan showed that community health workers were effectively able to adhere to a simplified treatment protocol using these adapted tools.

Taking innovative approaches to global scale

To reduce the burden of malnutrition, we also need to transform the system. This requires stepping up IRC’s evidence-based advocacy and applying pressure on the international community to see these approaches adopted into national and global policies with sufficient financing. Through an ambitious advocacy campaign, the IRC is elevating acute malnutrition as a priority among global donors and policy makers, coordinating with peer organizations, and working directly with the U.N. to build the consensus and political will needed to see these approaches put into action at scale.

In March 2020, the UN published the Global Action Plan on Child Wasting and has announced plans to publish comprehensive, updated WHO guidelines on preventing and treating acute malnutrition by the end of 2021. Furthermore, UNICEF recommended simplified approaches for treating malnutrition as a component of their global recommendations for nutrition programs during COVID-19 response. These initiatives represent critical progress toward policy reform which the IRC helped to accelerate through its strategic advocacy targeting the highest levels of the UN system.

Continuing to innovate

Designing for caregivers to screen malnutrition

Earlier analysis and modeling by the IRC and the No Wasted Lives Coalition showed that one of the biggest bottlenecks to children receiving malnutrition treatment was a lack of screening, and as a result, their condition wasn’t identified. One approach to tackling this challenge is empowering caregivers to quickly spot the signs of malnutrition by giving them tools, like a simplified MUAC tape that can be used at home (an approach originally developed by the Alliance for International Medical Action), and compelling motivation to seek treatment in a timely manner.

To scale this approach, IRC teams in Mali and Chad are using human-centered design and behavioral insights to better understand caregivers’ behaviors and barriers to ensuring they can successfully screen their children. This includes looking at the moment caregivers become aware of the MUAC tape to when they seek treatment for their malnourished child. From this analysis, we can brainstorm specific mechanisms that could aid caregivers, for example, developing a reminder system to help them remember to screen their child once a month using the MUAC tape.

Accelerating funding and reshaping supply chains

When there’s a new crisis, funding often comes too late, meaning children at risk of malnutrition do not receive the needed treatment early enough and risk having their condition deteriorate. One solution the IRC is exploring is “crisis risk financing.” This means identifying risks and preparing funding and contingency plans in advance, so we can act more quickly and effectively when a new displacement, drought, or other crisis hits. If we move quickly enough, this approach could even prevent some children from wasting altogether. Our aim is to pilot risk financing for malnutrition in one country and eventually pool funds among a set of protracted crises that represent a majority of emergency funding for food assistance.

Supply chain constraints also pose a challenge to malnutrition treatment. Key products such as RUTF are currently produced in the global North, then procured by UN Agencies for distribution to countries primarily in Sub Saharan Africa and Southwest Asia. The complexity of the supply chain, coupled with the difficulty of predicting demand for RUTF and inevitable delays in distribution and delivery to health facilities and communities, means there are often stockouts and an unmet need for care. The case for local production is clear; from lowering greenhouse gas emissions during transport, to stimulating local economies through job creation. Local production is also key to developing alternative RUTF formulas that appeal to local taste preferences, since the peanut butter-like flavor and consistency of the current RUTF formula may not be desirable to all children. For example, in Bangladesh, RUTF was created using local ingredients with flavors familiar to children — rice, lentils, and chickpeas — with promising initial results. Valid Nutrition, operating in Malawi, has come up with a plant-based RUTF formula incorporating amino acids, which has demonstrated efficacy as well as overall cost reduction in clinical trials.

The IRC is currently researching ways to structure investment capital to serve local producer lending needs, address the larger RUTF investment ecosystem, and stimulate local formula research and development at the market level. The RUTF supply chain is just one piece of the overall malnutrition system, but deploying finance to solve its inefficiencies has the potential to build more sustainable business models, reduce cost, enhance quality, and unlock innovation. Ultimately, this means that over the long-term more children can be treated effectively within available budgets.

Capturing and analyzing data in real-time

A major challenge in conflict-affected settings is the lack of available data, which makes decision-making and planning difficult. Last year, the IRC developed a system to enable the use of real-time data that facilitates patient-centered evidence-based decision making. This system can analyze metrics such as average RUTF dosage over time and the number of visits over time for a given patient, which improves our ability to monitor whether patients are on target for treatment and enables us to make rapid adjustments to our services to reach more children in need.

Delivering impact

As an organization, we are poised to deliver on these ambitions. We have adapted to COVID-19, maintaining a continuity of services and developing new solutions for this moment. We have elevated malnutrition as one of the critical areas we are focusing our services on during COVID-19, and we have integrated it into our upcoming 13 year strategy as a key organizational priority.

We believe this is the time to invest even further in the transformative, simplified approaches to treating malnutrition: not only will we be able to reach more children to meet the rising need, but we’ll be able to build resilience into our model and test delivery during a global emergency, better preparing us for the future.

Co-authored by Alex Bandea, Communications Manager, and Jeanette Bailey, Nutrition Research and Innovation Lead

[1] IRC estimate, 2020

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The Airbel Impact Lab designs, tests, and scales life-changing solutions for people affected by conflict and disaster. Our aim is to find the most impactful and cost-effective products, services, and delivery systems possible.

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Alex Bandea

Alex Bandea

Communications Manager at the Airbel Impact Lab (Research and Innovation) at the International Rescue Committee.

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