Changing the food the US government supplies as aid could deliver better results and still save money, a new study says. The review for the US Agency for International Development (USAID) by researchers at the Tufts University Friedman School of Nutrition Science and Policy has been welcomed by NGOs and US food aid experts, but the findings have also come in for some criticism.
The two-year review considered if USAID food aid was up to date with current science, especially in its use of blended food and whether programmes matched the right products with expected outcomes.
"What we're recommending is approaches to enhance the many great things already being done with US food aid under the most difficult circumstances imaginable," Amelia Reese Masterson, research coordinator of the review, wrote to IRIN, referring in part to USAID’s budget pressures.
The review came up with 20 recommendations on some of the food products and programmes under Title II of the US Food for Peace Act, which covers food aid provided in emergency and non-emergency situations.
Getting the ingredients right
The Tufts review addressed the issue of the source of protein in food products for children, pregnant and lactating women, and undernourished people on HIV medication.
Médecins Sans Frontières (MSF) has noted that US food aid destined for children usually comprises fortified flours based on grains and pulses such as corn-soya blend (CSB) or wheat-soy blend (WSB) and has lobbied for the inclusion of other sources of protein, vitamins and minerals.
Recent scientific evidence shows that animal-source proteins such as milk, better promote the growth of muscle tissue and resistance to infections, and are critical to children recovering from severe malnutrition, the Tufts review agreed. It also acknowledged that ready-to-use therapeutic foods (RUTF), usually lipid-based spreads, whose ingredients typically include nuts and milk powder, have led to a radical change in the way severe malnutrition is treated.
The review recommended that a wider range of products, offering varying quantities and types of nutrients for different programmatic contexts, be made available.
It is here that the review has contradicted itself, Nathalie Ernoult, Stephane Doyon and Susan Shepherd, members of the MSF's nutrition team, maintained in a written submission to the Tufts academics.
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A la carte or menu fixe?
"The report itself states that there can be no 'one-size-fits-all' food supplement, and we could not agree more," the MSF team said, yet it "focuses primarily on how to improve the nutritional value of fortified blended flours."
The Tufts study argued for a single formulation for a cost-effective, enhanced CSB, which they dubbed CSB14, to meet the minimum nutritional requirements of three key target groups: infants from 6 to 11 months; children between one and three years; and pregnant women.
The MSF team said at least two enhanced CSB formulations would be necessary: one tailored to the needs of infants and young children and those affected by moderate acute malnutrition; the other for older children and adults.
UN organizations the World Food Programme (WFP) and the UN Children's Fund (UNICEF) are also considering experimenting with different formulations of CSB.
"As a field-level agency and occasional implementing partner for UNICEF and WFP, we [MSF] cannot over-emphasize the need for coherence in the nutritional supplements on offer for a given category of beneficiary," the MSF team said. "If the fortified foods provided by WFP, UNICEF and USAID for similar programmes are not interchangeable, nutrition programmes will simply become confused and ineffective."
MSF maintained that the formulation for younger children should have a higher protein content from animal-sourced food; and that the proposed fortification levels of iron and zinc were also too low.
Zita Weise Prinzo of the World Health Organization (WHO) said they were recommending that the diets of moderately malnourished children contain animal-sourced foods, without specifying how much. WHO is expected to release its guidelines for food formulations for moderately malnourished children in June 2011.
According to MSF, the proposed second formulation for older children and adults, would not require animal-sourced ingredients, and the current CSB recipe, with some adjustments to its vitamin and mineral content, would serve the purpose.
However, a senior nutritionist who preferred not be named told IRIN that in many instances it would be hard to imagine relief agencies successfully distributing two or more similar looking products for different segments even within a single family.
"Most large-scale programmes using CSB-type products involve take-home rations. It would be difficult for a programme to ensure the proper use of several similar products at home. The solution could be to have one ‘generic’ option used by most big programmes, similar to that proposed by the [Tufts] paper, and then several other options that would be used by ‘speciality’ programmes."
The CSB14 formulation depends on the addition of oil fortified with vitamin A to provide enough of the vitamin. "Our experience shows that it is difficult to count on the prescribed amounts of oil being added to the porridge in the home, not to mention all the logistical difficulties encountered with the distribution of multiple commodities to constitute a single ration," the MSF team pointed out.
The chemical forms of micronutrient supplements proposed by Tufts also differed from those on the list approved by the WFP, the biggest dispenser of US aid. "It is very important to come to common agreement on a list of acceptable chemical forms for all additives," the MSF team noted.
Programming should "be evidence-based, not driven by simple data on tonnages and 'hungry people fed', but by an understanding of the unit cost of impact," and this included HIV/AIDS-related programmes, said the review. It found that orphans and vulnerable children, and HIV-positive pregnant and lactating women, identified for priority food assistance in the US President's Emergency Plan for AIDS Relief (PEPFAR), were receiving not getting priority compared to other HIV-positive women and adults.
Photo: Jason McLure/IRIN
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The review suggested stronger links between ongoing antenatal, Prevention of Mother-to-Child Transmission (PMTCT), and Maternal and Child Health (MCH) services, and with programmes treating malnourished children.
PEPFAR country coordinators reported that requests to approve the use of funds for food were "commonly met with caution", the review said, which "contributes to low coverage of food assistance within programmes", and PEPFAR needed to send a stronger signal on supporting the allocation of funds to food in HIV support.
Budget-constrained donors were "facing hard trade-offs between feeding as many people as possible and providing higher quality foods to improve nutritional impact per person," said Christopher Barrett, a food aid expert who teaches development economics at Cornell University in the US.
Scarce resources should be put to work more efficiently, and the Tufts review contributed significantly to improving understanding of these tradeoffs by policymakers, operational agencies and commercial suppliers, Barrett commented.
"It's important to move beyond a dollar-per-ton of food metric - the conventional way of looking at things - since that does not take into account exactly what kinds of foods are used for what purposes," said Patrick Webb, principal investigator of the Tufts review project.
"If we become more efficient in treating or preventing malnutrition, then it's the cost per case of malnutrition treated or prevented that matters, and that will go down when the appropriate tools (foods)are used in the right ways, even if unit costs of products rise slightly... because less is needed (over a shorter period of treatment)."
Some of the Tufts recommendations would cost more money - the addition of dairy products, new smaller packaging of some products for mothers and infants to prevent it from being consumed by the entire family - but Webb said the costs would be offset by improved targeting of the enhanced products.
Barrett noted that "With greater bang for the buck, it also becomes easier to defend valuable food aid programmes against those looking to trim budgets."
The review, the issues it covers and its recommendations will be debated at the US government's annual conference on food aid in June.