This report is submitted pursuant to Section 7019(e) of the Department of State, Foreign Operations, and Related Programs Appropriations Act, 2024 (Div. F, P.L. 118-47) and Senate Report 118-71, which states
“The Committee recognizes updated international guidance noting the need to address and reform the separate protocols and supply chains for the treatment of acute child malnutrition presently employed by UNICEF and the World Food Programme [WFP]. The Committee encourages the USAID Administrator to work with UNICEF and WFP to develop and implement a simplified, combined protocol for the use of RUTF. Not later than 90 days after the date of enactment of the act, the USAID Administrator shall submit a report to the Committees on Appropriations detailing the status of efforts to implement such a protocol, metrics used by UNICEF and WFP to determine global need for RUTF, and existing gaps between need and delivery.”
2023 WHO Wasting Guideline and USAID’s Partnership with the United Nations Childrens’ Fund (UNICEF) and the World Food Program (WFP)
The World Health Organization (WHO) published a new guideline on the prevention and management of wasting in children under five in November 2023. This provided updated recommendations on the treatment of severe acute malnutrition (SAM), and for the first time ever, provided recommendations for the supplementation of moderate acute malnutrition (MAM), wasting in infants under 6 months, and the prevention of wasting. The development of this guideline included an extensive review of existing evidence by a group of experts in the fields of nutrition and child development. Of the previously named “simplifications,” the new WHO guideline recommends a combination of three interventions to be considered for implementation, where appropriate:
- The use of ready-to-use therapeutic food (RUTF) for the supplementation of children with MAM who have an elevated risk of mortality due to their age, illness history, or societal factors. USAID is supporting UNICEF and WFP to begin to address some of these MAM cases to receive risk stratified treatment in humanitarian settings.
- Reducing the amount of RUTF over the course of treatment for SAM, as children gain weight and their needs go down, contingent on new emerging evidence of cost-effectiveness.
- The use of community health workers (CHWs) to treat wasting at home, facilitating early detection.
The WHO guideline notes that children with SAM or MAM in high risk environments benefit from a specialized nutritious food (SNF). In non-humanitarian settings, while some MAM cases may be treated alongside SAM cases, with RUTF, not all MAM cases require a commercially-prepared specialized nutritious food to recover. Most MAM cases may be addressed with a range of interventions, including supplementation using ready-to-use supplemental food (RUSF), Supercereal+ (a fortified corn soy blend with added milk and sugar), nutritious local recipes or locally-developed RUFs, family foods, and/or vouchers and cash for the purchase of locally-grown foods. The appropriate course of supplementation depends on context and individual child- and household-level risk factors.
The WHO guideline did not recommend a universal dosing regimen of two sachets for SAM children and one sachet for MAM children (informally referred to as the simplified combined protocol), nor did it recommend a reduction in follow-up visits. The guideline does maintain a requirement for a weight-based approach to monitoring a child’s response to treatment.
WHO prepared a briefing note1 regarding the role of protocol simplifications in the new (2023) WHO Guideline on the Prevention and Management of Wasting and Nutritional Oedema in infants and children under five2, describing where and how they align, and where they differ.
Historically, USAID’s Bureau for Humanitarian Assistance (BHA) has funded WFP to implement nutrition programs to treat MAM cases and UNICEF to treat SAM cases in humanitarian settings. Since 2023, BHA has taken a global leadership role in supporting UNICEF and WFP to jointly incorporate the protocol changes found in these guidelines for the management and prevention of wasting into their ongoing humanitarian programs around the world. For example, USAID facilitated UNICEF and WFP to develop a joint strategy to phase in the implementation of the new WHO guideline in fifteen priority humanitarian contexts over three years. This strategy includes shifting a portion of the MAM caseload experiencing the greatest risk of mortality from WFP to be treated by UNICEF with RUTF, where appropriate and feasible, as well as incorporating increasing prevention efforts into the same programming areas, to keep children from becoming wasted in the first place.
In fiscal year (FY) 2024, BHA is prioritizing $200 million in Title II funds to enable key partners UNICEF and WFP to procure and program nutrition commodities in support of this programming transition in a consolidated and global manner. This new approach ensures a minimum level of support for emergency nutrition response in humanitarian settings in FY 2024. Additionally, this approach builds on lessons learned about the value of centralized procurement planning and the benefits of regular, joint engagement with suppliers—including Edesia Nutrition in Rhode Island and MANA Nutrition in Georgia. This represents the first step in a forward-looking strategy for wasting treatment and RUTF planning as part of BHA’s flexible, needs-based approach to responding to emergencies when and where they arise.
