Why we must put children first and deliver outcomes

Why we must put children first and deliver outcomes

The following is a fresh version of an opinion article written by Steve that was originally published five years ago. We are featuring it here because, not only has nothing changed in the meantime, but the recent drastic cuts to aid budgets mean that action now is more important than ever.

I believe that our failure to address wasting (acute malnutrition) is symptomatic of a profound misconception at the heart of the aid and development industry.

We misconceive our industry as something primarily benevolent: the ‘charity sector’ supplying ‘aid’ to
‘beneficiaries’ – and we fund it by selling this fallacy to the public and hence to politicians.

The facts are, however, very different.

Those suffering from wasting have rights enshrined in international law that we have a duty to fulfil. They are not passive recipients of our benevolence but active clients who must juggle multiple priorities, constraints and opportunities.

This misconception is profoundly damaging, because it focuses our attention on ourselves, our motives and our strategies, rather than the needs, rights and realities of our clients. In respect of nutrition, it cements a supply-side, central-planning mentality at the industry’s core. It perpetuates renumeration systems related to process and control of resources rather than to outcomes and impact.

Those at the centre receive large, often tax-free salaries, while those who actually deliver products and services to our clients receive very little – and are often even expected to work as volunteers.

Furthermore, the misconception incentivises excessive emphasis and investment in UN agency and NGO profiles – in order to attract funding.

A good example of the corrosive effects of this need for profile and control of resources is the failure of the WHO and UN system to act on VALID’s development of the plant-based RUTF. Our 2017 study clearly demonstrated that the amino acid-enhanced soy maize sorghum RUTF is as effective as the standard peanut-milk RUTF in recovery and superior in the treatment of iron deficiency and anaemia, offering a viable, lower-cost, environmentally superior alternative. Yet instead of encouraging use of this recipe and finally permitting competition, the system has allowed bureaucracy, ideology and vested interests to effectively block innovation.

The inertia and failure to build on existing evidence in the face of the massive scale of unaddressed malnutrition and the suffering it causes, this is just unacceptable and morally wrong. The science on protein quality, amino acid supplementation, and micronutrient fortification together with trials on the acceptability of our plant-based RUTF, have been available for over seven years. In the interim, targets for treatment of wasting have been consistently missed by a distance, year after year.

While technocrats, policymakers, and agencies hold meetings, draft reports, and engage in endless
“harmonization exercises,” millions of children are left without treatment because there isn’t enough RUTF available. Every day that passes without action is another day where children suffer unnecessarily because of institutional inertia.

Enough is enough – after seven wasted years and millions of pounds of taxpayers’ money, acutely malnourished children need outcomes that result in impact.

Money should be going to action-oriented operational research that builds on the published, peer reviewed evidence available and delivers tangible results in treating children and demonstrating the positive outcomes at scale. It should not be directed to endless cycles of discussion papers, reviews, and framework revisions.

Ultimately, this need for profile and control of resources, also fosters risk aversion, discourages transparency and undermines innovation. It also sees profit as distasteful, precluding meaningful engagement with the private sector.

To change all this requires radically different ways of working. In particular, profound collaboration between government, the public sector and the private sector, where each plays to their respective strengths and does not engage in activities for which they are ill suited, even if this means forgoing control of resources and profile.

In almost all other walks of life, it is the private sector that delivers goods and services to people, and we must leverage its scale, capability and capacity to do this along the entire chain of service delivery, up to and including last-mile delivery to those suffering from wasting. The public sector should focus on ensuring that the services delivered meet the needs of those affected by wasting by improving targeting, transferring entitlements to ensure equitable coverage, with nobody left behind, and imposing ethical standards to prevent exploitation. The research agenda must inform us on how best to achieve this collaboration.

Enacting this change will not be easy. There are vested interests perpetuating the status quo and threats posed by increased private-sector involvement, given its history of promoting poor nutrition and exploitation. However, with sufficient will, I am sure that these vested interests can be challenged and the threats addressed.

The bottom line is that, after more than 30 years of failing to reach the vast majority of those affected by wasting, we really have no choice but to fundamentally change how we go about things.

[Dr Steve Collins, March 2025. This is an update of an article originally featured in Field Exchange issue 62, March 2020]

 

Download a PDF of this article here.

The Sudan Crisis

The Sudan Crisis

Steve has been working with Plan International for the last number of months, advising on strategy to deal with the famine in Sudan. He has just returned from providing support and advice on the ground there. It was around 40 years ago that he started his work on treating starvation – actually in Sudan – in the so called Band Aid era. This latest crisis is as bad as ever, with tens of millions of people are already suffering famine or on the brink of famine. 
 

The humanitarian aid operation has a huge funding shortfall.  This means that the specialised RUTF to treat malnutrition is in very short supply and wholly insufficient to meet the levels of need – which are escalating daily. 

This brings the choice by the WHO around whether or not to unequivocally accept lower cost plant-based RUTF (that UNICEF confirm is about 25% lower cost than the standard recipe) into stark focus.  Randomised controlled trials and real-world operational programmes have already demonstrated that soy maize and sorghum RUTF is just as effective as the current peanut and milk-based recipe.

Fully approving and actively facilitating proven plant-based RUTF would allow 25% more starving children to be treated with no additional product cost.  As the treatment infrastructures are already set up, there would actually be almost no additional total cost.  Or, do those in a position to  act continue to listen to vested interests and restrict proven plant-based RUTF recipes, despite the desperate need and evidence supporting use? Surely there is no real choice here and we strongly urge those responsible in the respective UN agencies to act. 

Food Assistance for Nutrition Evidence Summit on June 27th and 28th, 2018 in Washington D.C.

Food Assistance for Nutrition Evidence Summit on June 27th and 28th, 2018 in Washington D.C.

“It is scandalous that a product with several critical advantages and high quality scientific evidence to support it, can be blocked because of bureaucracy and vested interests”

Dr Steve Collins, Valid Nutrition’s Chairman, spoke candidly about his frustration at the shamefully slow pace of innovation and approval of  better products to treat acute malnutrition. He presented the specific example of Valid Nutrition’s new recipe for therapeutic food (RUTF). This breakthrough, which follows from 14 year of research and development (largely funded by RUTF donors), has several clear benefits including: significantly lower cost, far better sustainability profile and is easier to produce in developing countries / regions where these products are needed.

He said it is scandalous that a product with high quality scientific evidence to support it, can be blocked because of bureaucracy and vested interests. He challenged those empowered to allow this recipe to be used, to act now. Doing so, will immediately lower the cost of treatment and allow hundreds of thousands more children to be treated within existing aid budgets.

Global Hunger Today Conference

Global Hunger Today Conference

At the Global Hunger Today Conference held at University College Cork, Dr Steve Collins raised challenging questions about undue delays in the implementation of robust, scientific evidence that can transform the numbers of malnourished children receiving treatment within existing budgets.

At the Global Hunger Today conference in UCC last week, Dr Steve Collins presented the results of a large-scale randomised controlled research study, demonstrating that an innovative new RUTF product made exclusively from ingredients grown in developing countries, is more effective than the currently available UN gold standard product, and around 20% lower in cost. He asked why, given the potential to treat almost an additional 1 million severely malnourished children within existing budgets, and the sustainable benefits that local manufacture of this recipe will have on developing countries’ agriculture, has the UN acceptance process so far made no progress in allowing this innovative life-saving product to be made available to those who need it? Would this scandalous waste of resources be tolerated in other sectors?