WASHINGTON — UNICEF and the World Food Programme fundamentally disagree on which agency should do what when it comes to global wasting treatment and prevention. The differences leave the two at odds even in the midst of a reform process that is meant to increase coverage to the 14.3 million children under age 5 who are severely wasted.
Less than 25% of the roughly 47 million children suffering from wasting around the world currently receive treatment, a failure that has been recognized by the NGO community as well as the United Nations, which coordinates global treatment for wasting, or low weight for height.
But fixing the issue is complex; no single United Nations agency is completely responsible for wasting treatment and prevention. UNICEF is the lead coordinating agency, and it treats severe acute malnutrition, or SAM. WFP treats moderate acute malnutrition, or MAM.
Last year, U.N. Secretary-General António Guterres requested that the agencies come together to develop a better way of working on wasting. UNICEF and WFP — along with the World Health Organization, Food and Agriculture Organization, and the United Nations Refugee Agency — developed the Global Action Plan on Child Wasting, released in March, to outline a path to reform.
“That is really what it comes down to: these power dynamics and these long-standing rivalries and really individual egos between these agencies.”— Will Moore, president, Eleanor Crook Foundation
The document, commonly known as the GAP, designates UNICEF as the lead coordinating agency for the operationalization of prevention and treatment of child wasting in all contexts. WFP is to play a “supporting role” to UNICEF, ensuring it can prevent and treat wasting all contexts, with a special focus on fragile contexts. The GAP is also meant to serve as the basis of country frameworks, which will better detail how wasting treatment will be handled in specific places.
But simply laying out responsibilities in the GAP has not fixed inefficiencies in wasting treatment and prevention, several experts close to the issue tell Devex.
“It’s a power struggle, plain and simple — as old as time itself. Like most power struggles, it's really about fortune and fame,” said Will Moore, president of the Eleanor Crook Foundation, for which wasting reform is a priority. “Donors give hundreds of millions of dollars to the U.N. each year to buy and deliver these therapeutic foods.
“But both of these U.N. agencies want those hundreds of millions of dollars to flow through their accounts to pay their people and so also that they can claim impact of these lifesaving foods in their speeches and their marketing materials and their fundraising. That is really what it comes down to: these power dynamics and these long-standing rivalries and really individual egos between these agencies.”
“You need centralized accountability more than anything. I cannot hide behind the failures of another agency to explain why certain things are not being done.”— Saul Guerrero, nutrition specialist in child wasting, UNICEF
Civil society has long pushed for reform in global wasting treatment, with many technical experts signing a December 2019 letter to Guterres demanding UNICEF and WFP work out their differences.
“We have witnessed countless children suffering from the plight of wasting, and the many inefficiencies of a broken system which all too often fails to reach them,” the letter said. “It is within your power to address institutional and operational fragmentation and inefficiencies, and ensure the prioritization of clear, evidence-based guidelines for prevention and treatment, so that every child who needs care receives it.”
The letter made three recommendations: designate a single U.N. agency with overall responsibility and accountability for the provision of a continuum of care for wasting in all settings; review the supply chain of ready-to-use therapeutic foods, or RUTFs, to ensure consistent and adequate provision; and increase WHO technical leadership to develop and update guidance on treatment for wasting prevention.
Children with SAM are largely treated in a health care context with RUTFs, which are energy-dense, enriched with micronutrients, and considered a medicine. MAM is treated with ready-to-use supplementary food and Super Cereal Plus, distributed by WFP, the logistics hub for the U.N. that specializes in delivery to challenging emergency contexts.
Neither UNICEF nor WFP denies reform to eliminate inefficiency is needed — they just differ on how to get there.
As the global hunger index reveals 43 countries with “serious” levels of hunger, U.N. agencies chart strategies to ensure healthy food for the world's population.
Saul Guerrero, a nutrition specialist in child wasting at UNICEF, said reform is needed to develop a single plan to reduce child wasting, which can make a child 11 times more likely to die from an illness. The world is far from reaching WHO’s 2025 global target of keeping wasting levels under 5%, and reforms must be “deliberate” if they have any chance of being met, Guerrero said.
He said UNICEF and WFP have a “fundamentally different understanding” of inefficiencies in the current system. There needs to be one lead coordinating agency for wasting treatment because centralization is more effective, Guerrero said.
“You need centralized accountability more than anything. I cannot hide behind the failures of another agency to explain why certain things are not being done. … Right now, the shared responsibility creates the conditions for that to happen, so we need to close that loophole,” Guerrero said.
“The GAP says in order for the GAP to be executed, everybody’s going to have to play to their strengths. … It did force us to have a conversation about it. It enabled us to say, ‘We can’t postpone this anymore.’ So now that we have agreed — broadly speaking — what the shift is, now we can actually start unpacking it.”
The GAP details 43 priority actions across health, food, and social protection systems that aim to accelerate wasting treatment. A policy and programmatic review will look at how the GAP framework aligns with actions already being taken at the country level and what needs to be improved.
Nicolas Joannic, chief of nutrition operations for WFP, said the agency has three main priorities when it comes to the future of wasting response: ensuring a continuum of care between prevention and treatment, increasing coverage so no one is left behind, and trialing innovative simplified protocol approaches as appropriate in certain contexts.
“It’s always this problem of getting so many different opinions and so many different agendas. It’s never going to be perfect for everyone.”— Anne Walsh, senior nutrition specialist, The Power of Nutrition
WFP and UNICEF do currently work together by using the same partner organizations and conducting joint assessments and targeting. “We want to be good partners,” Joannic said.
“We are not engaging in a street fight with UNICEF. That’s absolutely not our mindset. We are really open to discussion,” Joannic said. “We are trying really to get the lessons from all these experiences, build on that, and develop a new way of working together.”
Both WFP and UNICEF say their positions are a result of what they see as the most effective way to fix delivery gaps and increase wasting coverage — and not of budgetary considerations, representatives told Devex.
‘It’s not a plan’
While there is recognition that the status quo is not sufficient, not all in civil society — just as in the U.N. system — share one view of the best way forward. Some believe that the only way to reduce wasting and effectively reach the missing children is to simplify treatment into one protocol that uses one therapeutic food, an approach supported by limited research findings.
Others say the issue cannot be solved so easily and wasting treatment and prevention must be heavily context-specific, acknowledging the burden of SAM and MAM, health infrastructure, logistics capacity, and U.N. agency operations in each country. Some also want WHO to be more involved in issuing health guidance on potential wasting treatment reform that could streamline products used.
While many in civil society say they are glad the U.N. system is actively having conversations about eliminating inefficiencies, they are largely unimpressed by the GAP as released in March and say further work is needed from the agencies to secure true reform.
“The people involved in the GAP — they’re smart, committed people, and for sure they have to navigate the politics,” said Steve Collins, director of Valid International. “The concept behind it is really positive. What I didn’t like is the execution, in that it’s not practical. It’s not a plan; it’s a wish list.”
Combining severe and moderate acute malnutrition treatments into a simplified protocol costs $123 less per child, according to a study published in PLOS Medicine — and is as effective.
Anne Walsh, a senior nutrition specialist at The Power of Nutrition, called the GAP “fine” but said it did not do anything substantive to move beyond the long-standing issues.
“It’s always this problem of getting so many different opinions and so many different agendas. It’s never going to be perfect for everyone, but it could do better than it has now. To me, it was a very generic thing that was produced,” said Walsh, who signed the civil society letter to Guterres. “I read it thinking, ‘OK, they’re trying to make everyone happy here.’”
Moore of ECF said that while he has no issues with what is in the document, key pieces are absent. Solutions, and how they should be prioritized, remain undefined, he said.
“What are the three to five interventions or three to five reforms that need to be carried through at scale in order to really move the needle? … It’s not an action plan, despite the name, because it lacks those clearly defined actionable steps that could be carried out,” Moore said. “The existence of the document is great. It’s positive. [I] don’t disagree with anything it says in there, but it’s not changing these structural factors.”
A standoff over RUTFs
Although just one of many issues under discussion as part of the GAP process, procurement of RUTFs remains a major point of contention between UNICEF and WFP. WFP Executive Director David Beasley and UNICEF Executive Director Henrietta Fore, who were visiting Syria at the same time in March, have discussed the issue in person, Guerrero said.
Since then, Fore has sent Beasley a letter outlining UNICEF’s rationale for remaining the sole procuring agency for the substance — as currently determined by the agencies’ roles and responsibilities, with few exceptions — arguing that it makes sense to have just one doing so.
Guerrero said the letter clearly outlined why the status quo — sole UNICEF procurement of RUTFs — would remain. Because treatment of SAM is considered a health intervention, UNICEF works closely with national departments of health to develop appropriate treatment plans for each country.
Guerrero said that there are contexts, particularly in emergencies, where health systems do not have the coverage required to treat wasting but WFP’s operational footprint allows them access. But even in these situations, Guerrero said, WFP has no need to procure its own RUTFs.
“We move medicines. They move food,” Guerrero said. “We believe that there is an absolute value in a lot of contexts — in emergency contexts, when health systems can only go so far and our implementing partners can only go so far — to indeed tap into their operational footprint. But we don’t believe that in order for them to be able to play that role, it would require for them to procure the product. We do not see the need for that.”
WFP disagrees and has refused to completely rule out its ability to procure RUTFs in the future. Beasley responded to Fore’s letter, acknowledging the different strengths of the two agencies and emphasizing the effectiveness of WFP’s supply chain in fragile settings where health systems do not reach everyone in need. This reality means separating responsibility by severity — UNICEF responsible for SAM treatment and WFP responsible for MAM treatment — does not work and the division of labor needs to be revised, Beasley’s response said.
As COVID-19 has demonstrated the fragility of global supply chains, WFP says that having one single wasting treatment product is not the best way to reach universal coverage and that it will procure whatever product is considered effective.
“What we are proposing is having a division of labor that will be articulated around the comparative strengths and expertise of each agency. We do believe, in the most fragile settings in humanitarian operations, we are better placed than UNICEF to deliver the goods and services to … the most remote communities, the ones that cannot be reached by the existing health facilities or health system,” Joannic said. “This is what we have replied to UNICEF.”
“WPF programs cannot rely on the capacity of an external stakeholder to procure the goods that we need to support the population. That will not happen.”— Nicolas Joannic, chief of nutrition operations, WFP
WFP proposes a joint tendering process that it says could help shape markets for nutritious foods and drive down prices for beneficiaries but would see each agency establishing its own procurement contracts — WFP in emergencies and fragile contexts, and UNICEF through national governments.
It is unclear what recourse UNICEF would have if WFP went ahead with RUTF procurement, because the agencies’ operational memorandums of understanding are not legally binding.
“We have done everything in our power to justify our vision, to rationalize it, to show that it’s an informed perspective,” Guerrero said.
An uncertain way forward
Ultimately, reform agreements reached by UNICEF and WFP at the global level must have buy-in from agency staffers around the world who are tasked with carrying out wasting treatment and prevention activities. Country teams will work with national governments, which are responsible for eliminating wasting, to improve coverage of both prevention and treatment activities.
“In the field, WFP and UNICEF can often work very well together,” Collins of Valid International said. “If we can show good examples of collaboration in proper community-based programming around the GAP with an integrated program including development and prevention and treatment [as] all part of the same program … that will help to unlock these political-level decisions.”
Development and humanitarian organizations are pivoting to incorporate secondary impacts — such as nutrition and food security — into funding planning and emergency activities.
To increase coverage, WFP and UNICEF must be working to shift more responsibility for treatment to countries themselves, Guerrero said. The agencies aim to complete the country frameworks outlining this process by the end of the year.
But their centrally different understanding of the scope of the disagreement over RUTF procurement means progress on wasting reform may remain elusive, even as the number of starving children increases due to COVID-19.
Joannic called RUTF procurement just “a tiny part” of the GAP discussions between the two agencies and said that on “95% of the nutrition issues, we are in agreement.” Indeed, three of the four outcomes laid out in the plan focus on prevention of wasting and only one on its treatment and the products used.
But WFP does see a role for itself in SAM treatment.
“I know that it is UNICEF’s position on this — they want to be the sole actor procuring RUTF. But the fact is we cannot disconnect the procurement issue to the rest of the supply chain. And WPF programs cannot rely on the capacity of an external stakeholder to procure the goods that we need to support the population. That will not happen,” Joannic said. “We are really, truly optimistic that we will soon reach a consensus with UNICEF on the new division of labor when it comes to the treatment.”
Guerrero sees an impasse.
“What is clear is they do not share neither our assumptions of how to move things forward, or why we need to move forward in a particular way, nor a desire to execute some of the recommendations,” Guerrero said. “The big question then becomes: What happens then, of course, if that’s the state of things?”