USAID has power to push UN for malnutrition treatment reform, NGOs say

Turf wars and inefficiencies have long hindered the way malnutrition is treated by the biggest global humanitarian organizations, slowing the work desperately needed to prevent the deaths of millions of starving children even as they are awash with cash. Last year, the U.S. Agency for International Development helped raise a historic amount — over half a billion dollars — for treatment for severe acute malnutrition, the worst form of hunger which kills many. Children with SAM are given ready-to-use therapeutic foods, a high-calorie, nutrient-dense paste, but only about 25% of them globally receive the life-saving RUTFs. So NGOs are now urging USAID to push the United Nations agencies responsible for transforming the money into lives saved to overcome yearslong disagreements between UNICEF and the World Food Programme that threaten to stymie a rare financial opportunity to save more children from starvation. UNICEF and WFP have long disagreed about how to divvy up the responsibilities when it comes to treating the two forms of malnutrition and delivery of the different supplements used. Neither wants to cede its role — and the associated funding — to the other. The sheer size of the global malnutrition problem, and the two agencies, also means changing decadeslong distribution methods will take time and considerable coordination. NGOs argue that USAID’s donor role enables it to get the two agencies to settle their differences over roles and responsibilities and ensure the new funding is as effective as possible. Anything else just prevents aid reaching the desperate children. “They’re probably in the most unique position to help bring everybody to the table because they are the biggest funder,” Maria Kasparian, executive director of Edesia, a nonprofit manufacturer of RUTFs, told Devex. “I think USAID does acknowledge it and I think they have a role to play. I don’t think they have fully played that role yet, but I think they can and should.” In a letter to USAID Administrator Samantha Power, who was integral to last year’s fundraising for RUTFs, NGOs, including Edesia, wrote that they found “the current bifurcated delivery of treatment, in which UNICEF and WFP deliver two products across different supply chains and at different delivery points complicated, inefficient, and difficult to scale." Those products are RUTFs to treat SAM, mainly delivered by UNICEF, and ready-to-use-supplementary foods, or RUSFs, which are usually distributed by WFP. RUSFs are used to treat moderate acute malnutrition. “WFP and UNICEF are more on the same page than they realize. It’s silly … I’d love to see them both play to their strengths.” --— Maria Kasparian, executive director, Edesia The letter, sent in January, said USAID should encourage the U.N. system “to become flexible and responsive” to national plans to reduce malnutrition. It also stated that they should consult countries on whether they need treatment with both products or just one, since children with acute malnutrition are often present alongside those with the more moderate form. “The story of wasting and malnutrition in children has been divided up — there’s so many cooks in the kitchen, there’s so many partners in this game that it’s almost as if no one partner, no one major institution can take a step without the support and collaboration of the other institutions around it,” said Jeanette Bailey, director of nutrition research and innovation at the International Rescue Committee. “It’s a bit like a big co-parenting game.” The letter called for just that. The U.N. should be held accountable “for designing a phased plan to ensure the responsible transition to a cohesive RUTF supply chain,” the NGOs wrote. A spokesperson for USAID said the agency was “engaging with groups on the points raised” in the letter to Power. However, the record amount of funding USAID is programming, along with endemic workforce retention issues, likely don’t leave a lot of capacity for mediating external agency disputes, Kasparian said. “We do get the sense that they’re also overwhelmed,” she said. The severity of the global food crisis is unprecedented, USAID’s spokesperson said when asked about its capacity to respond to increased funding and manage relationships between the agencies. “USAID is responding with urgency to move an unprecedented amount of assistance,” the official said. “This surge in activity has been possible as a result of the partnership between USAID, our implementing partners, and the support of the donor community. We are proud of the work of our dedicated staff, but know there is more to do in the continued face of rising need,” the spokesperson said. UNICEF and WFP did not respond to repeated requests for comment. Heather Stobaugh, a senior research and learning specialist at Action Against Hunger USA, which also signed the letter to Power, said the main focus should be on using the insufficient resources available as efficiently as possible to save children’s lives. “We would love to see the entire U.N. system have a big overhaul, not cutting … any one entity out,” said Stobaugh. “That’s a really big change, and one that might be hard to achieve, so let’s aim for maybe smaller changes.” A USAID staffer, who was not authorized by the agency to speak on the record, said it is important to have a nimble supply chain of the right products to treat malnutrition, but also an accompanying public health approach that can actually ensure help reaches children who need it. Some of the money from USAID for UNICEF and WFP goes towards these parts of the equation, that person said. USAID consistently speaks with both U.N. agencies about the malnutrition treatment landscape, the USAID staffer said, noting that they often attended meetings with UNICEF and WFP. “We’re in the mix with both UNICEF and WFP on a lot of these questions very, very much all the time,” the USAID staffer said. “I don’t know on the supply side, but I would say on the programming side, there’s real interest and commitment and a lot of positive momentum and progress in getting to a place where efficiencies are built upon … I am pretty excited about where things are headed.” A major challenge to ensuring efficient cooperation between the agencies is their sheer size and scope of operations, said Bailey. She recognizes the agencies are “working really hard to work together.” But it can be incredibly difficult to ensure any product delivery agreement reached between UNICEF and WFP on a global level is put into practice in every country where the two are involved with delivering malnutrition treatment, she said. “They’ve got these massive machines that they have to reorient and restructure, and it’s not just at global level. It’s at regional level and country level. So I think the good intentions are there, but it’s been taking a long time to see that trickle-down effect,” Bailey said. “Global MOUs may say one thing but what’s actually happening in any one country, that’s a very different story.” The unprecedented financing and attention on malnutrition treatment also creates an opportunity to push for new treatment options, known as simplified protocols, which seek to treat more children with the same amount of resources. Several field trials have shown great success with some of these options, while some working with malnutrition believe more evidence is needed for the World Health Organization to recommend shifting away from the current guidelines of two distinct products to treat severe and moderate malnutrition. Some simplified protocols involve giving malnourished children different types of products in different quantities over different timelines. These treatments can be easier to administer and ensure children complete them, leading to better outcomes. In research published in 2020, a trial conducted by a group including IRC and Action Against Hunger found that combining severe and moderate acute malnutrition treatments into a simplified protocol is as effective as traditional treatment, but costs $123 less per child. The USAID staffer said the agency is “supportive” of research and implementation of simplified protocols, but stressed that they need to be supported by the country ministry of health. The debate over simplified protocols is tied to the wider battle between UNICEF and WFP. If simplified approaches are more widely adopted, that could lead to just using one product to treat malnutrition. This would leave both agencies competing for even less of the pie. It’s a bit of a Catch-22 when deciding who to prioritize with limited treatment funding and products: If children with SAM aren’t treated, they could die. But if children with MAM aren’t treated, they could develop SAM, increasing the number of the worst cases which need to be treated. “WFP and UNICEF are more on the same page than they realize. It’s silly … I’d love to see them both play to their strengths,” Kasparian said. “There’s really room for both of them to cooperate on this and be an important part of the solution and to let go of some of what feels like turf wars over this. That’s not needed here. There’s room for both of them.”