Effectiveness and policymaking surrounding combined protocol for treatment of acute malnutrition in food-crisis affected contexts

Principal Investigator: Naoko Kozuki, International Rescue Committee

What did the study set out to achieve?

The combined protocol for acute malnutrition simplifies the existing treatment protocol of community-based management of acute malnutrition (CMAM) by:

1. treating severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) as one condition on a spectrum
2. providing one product for treatment (ready-to-use therapeutic food, RUTF)
3. diagnosing children on mid-arm circumference and oedema
4. simplifying the dosage protocol (two RUTF sachets/day for MUAC <115mm, one RUTF sachet/day for MUAC 115-<125mm).

While this is protocol is endorsed by the World Food Program (WFP) in emergency contexts, there is limited evidence on its effectiveness and a lack of understanding of the barriers to adoption in crisis-affected contexts. This study tested the combined protocol to determine if acutely malnourished children (6-59 months) treated under it met the Sphere minimum standard of 75% recovery rate in a nutrition clinic in Karaan District, Somalia.

Additionally the study conducted a policy analysis in four food insecure contexts in Niger, northeast Nigeria, Somalia and South Sudan to describe how the protocol was presented regarding its benefits, requirements for implementation, and boundaries. The aim of the policy analysis was to understand requirements for adaptation and adoption of the protocol in different contexts, and examine the factors that influence policy change.

What were the key findings?

The study found that the performance, coverage and cost effectiveness of the combined protocol is comparable to standard SAM and MAM protocols. The recovery rate among children diagnosed with SAM was 98%, exceeding the Sphere Minimum Standard of 75%.

The policy analysis showed that while combined/simplified protocols are being used in emergency situations in all four countries, there is widespread confusion about protocol terminology and content, and diverse rationales for modifying them across the different settings. Lacking standard global guidance, combined/simplified protocols are often used on an ad hoc basis. Confusion at the national level appeared to be partially driven by global actors; global stakeholders admitted that lack of clarity around the vocabulary of adapted protocols was largely driven by themselves. National stakeholders were open to the idea of adapting protocols, but many reported waiting for more evidence. The analysis highlighted the importance of ensuring future nutrition research is aligned with national priorities.

What does this mean for policymakers and practitioners?

The finding that the protocol meets Sphere humanitarian standards means that it can be rolled out in more contexts where logistical challenges prevent or hinder effective implementation of CMAM. Under the dire conditions of the food crisis-affected contexts, an effective and efficient integrated treatment model has potential to increase treatment coverage, reduce severe cases, decrease cost, and reduce preventable deaths without a need for dramatic changes to the current infrastructure or logistical systems.

The study team made recommendations to the Ministry of Health in Somalia, UNICEF and to IRC health experts based on these findings, influencing their approach to the management of acute malnutrition. Research tools such as standard operating procedures and data collection tools were adapted and used for subsequent IRC-run operational pilots in Chad and Mali. Several key humanitarian stakeholders – including Action Against Hunger, Médecins Sans Frontières and Save the Children – have used the study findings in their own advocacy work on simplified approaches to managing acute malnutrition.