Afghanistan

Humanitarian Need

Macro-economic factors and recurrent natural disasters have been impacting on the people’s life in Afghanistan. Infants and young children and their mothers accumulate malnutrition risk factors¹, such as, food insecurity, poor feeding practices, and high morbidity in a context marked by limited access to water, sanitation, and health services. The recent past years have been marked by stagnating high burden of malnutrition, with a paralleled food insecurity situation. More than three million children under five are affected by acute malnutrition every year, i.e., 3.1 million, 3.9 million, 3.2 million in 2021, 2022, and 2023, respectively. The national IPC Acute Food Insecurity (IPC AFI) conducted in October 2021 and in October 2022 reported a proportion of population in phase 3 and above at 47% and 46%, respectively, with a projection at 36% for the period May to October 2023².

The number of children under five affected by acute malnutrition was calculated by district and then summed up, using the globally accepted formula³, which includes both prevalent and incident cases; conservatively, the correction factor of 2.6 to account for the incident cases was used. The findings of the 2022 national, population-based nutrition survey (NNS) using the Standardized Monitoring and Assessment of Relief and Transition (SMART) methodology, and the subsequent IPC Acute Malnutrition (IPC AMN) were used to estimate for 2023. In the absence of population-based survey in 2023, the projections for 2024 accounted for the trends in food insecurity and diarrheal disease burden. Overall, an estimated 2.9 million children under five will suffer from acute malnutrition in 2024, including 857,155 and 2,027,216 children with Severe Acute Malnutrition (SAM) and Moderate Acute Malnutrition (MAM), respectively.

Response Strategy

In 2024, the Nutrition Cluster plans to reach 5.6 million children under five and Pregnant and Lactating Women (PLW) in all provinces with life-saving services. In line with the Cluster’s sectoral areas of need, seven categories of response will be delivered, mainly through static sites, complemented by mobile health and nutrition teams (MHNTs) in particular circumstances, in consistence with the national MHNTs rationalization plan. These response categories include i) treatment of children under five with SAM; ii) treatment of children under five with MAM; iii) treatment of PLWs with acute malnutrition; iv) Blanket Supplementary Feeding (BSFP) for children under five; v) BSFP for PLWs; vi) vitamin A supplementation; and vii) infant and young child feeding (IYCF) counselling to primary caregivers of children aged 0-23 months. To contextualize the learning and inform the strategy and scope for cash into nutrition programming, the nutrition cluster piloted a Cash incentive to compensate mothers and mahram for the transportation and accommodation for reaching to in-patient nutrition treatment hospitals⁴. Lessons learnt from the pilot as well as first year of implementation will guide the scale up of the cash for inpatient treatment.

Hence, treatment services will be complemented by preventative services, so that children and women are not trapped in the repeated cycle of malnutrition. The BSFP will remain at scale to cover all under five children and PLWs in all provinces. Alongside IYCF counselling, BSFP is expected to help promote a well-balanced, diversified, and nutritious diet starting from infancy.

The Nutrition Cluster is committing to enhance institutionalization of management of acute malnutrition into the health system, by first mapping the health facilities and districts with low coverage of nutrition services, then developing and rolling out the capacity strengthening plan. Both public and private health facilities, as well Family Health Houses (FHH) will be concerned by the integration of nutrition services.

Additional to the above-described nutrition specific services, the nutrition cluster will convene health, food security and WASH clusters in prioritized districts for the delivery of an integrated package of community- and facility-based services for improved nutrition outcomes⁵. The Global Clusters call for action on integration heightens inter-sector collaboration and partnership in emergency settings⁶. It entails the use of the nutrition sites as platform to deliver intersectoral Health, Food Security and WASH services. By strategically engaging with clusters and TWGs that have the highest potential impact on the nutrition status of children, the nutrition cluster aims to strengthen the integrated multi sectoral response package of interventions for enhancing the performance of the treatment program, and reaching out to the most vulnerable households with nutrition-sensitive interventions that build resilience and prevent undernutrition:

• In an effort to align with the national strategy for Health Emergency Response (HER) the nutrition cluster is committing with the Health cluster to enhance effective integration of management of acute malnutrition into the health system. The nutrition sites will benefit from a systematic screening for acute malnutrition performed on children 6-59 months and PLW attending health facilities for curative and preventatives services, and referral for treatment as needed.
• From the collaboration with WASH cluster, children 6 to 59 months of age with SAM attending nutrition sites will be provided with WASH kits for household utilization to improve hygiene practices. This will be facilitated by an orientation of nutrition frontline staff on household water treatment and hygiene promotion for improving hygiene messaging to vulnerable households.
• From the collaboration with FSAC, BSFP will continue to be delivered through the GFD to jointly reach all beneficiaries with food distribution and nutrition messaging. The integrated nutrition messaging package, jointly developed with FSAC will be rolled out.

As part of the Integrated Management of Acute Malnutrition (IMAM) Programme, community outreach and sensitization will be conducted, to raise awareness and promote participation for a responsive nutrition service delivery, as per guidelines⁷.

Targeting and Prioritization

Failure to respond to the needs will lead to a disaster, with a dramatic increase in number of deaths. Indeed, malnutrition is one of the top nutrition-related causes of death in children under five, a child with SAM and MAM being associated with twelve and three times more risks of dying compared with a well-nourished child, respectively. Since no other program in Afghanistan provides services that treat acute malnutrition, all provinces are targeted with treatment services by the nutrition cluster. Continuous engagement with stakeholders will be pursued, and informed advocacy messages developed and disseminated.

With a complete failure to respond to the needs for treatment services, 2.9 million acutely malnourished children under the age of five years will be at high risk of death. Applying findings from literature, the cluster further gives indications that 194,000 to 217,000 children among those left behind will die in the course of the year (531 to 594 daily). Key findings from those publications, the most exploitable ones, old and not specific to the context provide the case fatality rate of MAM in the absence of treatment (3.6%), the proportion of MAM that aggravate to SAM in absence of treatment (8.1%), and the case fatality rate of SAM in the absence of treatment, by type of anthropometric measurement, i.e., SAM by MUAC only (13.0%), SAM by Weight for Height only (15.1%), and SAM by both MUAC and Weight for Height (35.0%).

Scaling up nutrition services is resource and time consuming. Because of requirements such as cascading the capacity building from training of trainer down to training of frontline workers, and lead times in procurement of supplies and equipment, achievements are contingent not only to amounts of funding, but timeliness of funding is also as critical to reaching the target that have been set out for the year. Full achievement requires funds released early in the year. The nutrition cluster will be prioritizing services and geographic areas depending on the amount of funds that are released to the partners, as per the table below. The lower the funds and the longer the delay to come in, the lower the target reached at the end.

Quality and Inclusive Programming

Accessing women and children for delivering the nutrition services could be challenged by gender and culture-based restrictions. All IMAM activities, from community sensitization to delivering of quality lifesaving nutrition services will continue to be delivered by trained facility and community frontline male and female workers, consistently with the national IMAM guidelines. The advocacy will continue at the various level for female worker involvement in both facility and community-based service delivery. The intended work on AAP, with a focus on community outreach and sensitization to raise awareness and promote participation as per the IMAM guidelines, together with the counselling of PLW on IYCF through mother-to-mother support groups, will contribute to empowering women for an effective meaningful participation.

By targeting children under five and PLW, the nutrition cluster addresses extreme needs and focuses on households with multiple vulnerabilities. As more and more families face financial hardship, and women continue to face restrictions to their freedom of movement, the Nutrition Cluster will escalate effort to ensure that the neediest are reached, by further emphasizing on decentralized, community-based activities. The Cluster has revised its country-specific guidance on protection mainstreaming and partners will be oriented accordingly. This was a participatory exercise whereby children and PLW at risk have been identified and risk specific risk mitigation measures recommended.⁸ In the context, Child with Disability, Girl child, Child below six months of age, Child with comorbidity, Orphan child, IDP child, and child of underage mother, as well as PLW with disability, PLW in early motherhood, PLW with no mahram, and PLW head of household, were identified as people in need of additional protection measures for access to quality nutrition services. The measures will be closely monitored from national and subnational levels to ensure that service delivery complies with guidance.

Links to basic services and development programmes

Malnutrition is a multi-causal problem which requires integrated and holistic programming for effective results. Therefore, the package of emergency nutrition interventions is designed to take advantage of and is complementary to ongoing, longer-term health and nutrition service delivery mechanisms funded by development actors.

The Cluster advocates that nutrition-sensitive preventative interventions are stretched to address the underlying causes of malnutrition in the various relevant development sectors. Additional to the collaboration with the other clusters, the nutrition cluster will coordinate with the UN agencies Nutrition Thematic Collaboration Group to identify specific areas of convergence and collaboration in establishing the humanitarian and development nexus.

Response Monitoring

The Nutrition cluster will oversee and follow needs through field monitoring visits and the Nutrition Information System. Spot checks, supervision and monitoring visits will be conducted to monitor the program and engage the community and other stakeholders to gauge evolving needs. The use of the nutrition information system entails:

• Data collection from nutrition sites and mobile teams, compilation and analysis to monitor admission of children and women with acute malnutrition and performance indicators of the therapeutic programs. A three-layer quality control system will be applied to ensure reliability of the data.
• Population-based data, including anthropometric data will be collected and analyzed through a national SMART survey, as well as separate surveys in prioritized provinces to determine the prevalence of acute malnutrition among children and women, as well as factors affecting the nutritional status.
• The sentinel site-based surveillance will be expanded, with an increased number of facility and community sentinel sites as well as regular data compilation and analysis for action.

The cluster will also coordinate with other clusters and partners in joint assessments to identify the specific needs of people displaced by conflict, returnees and disaster affected people.