Country: World Source: ODI - Humanitarian Practice Network Kate Sadler Abigail Perry Karima Al-Hada’a Tamsin Walters Rita Abi Akar Gladys Mugambi Rebecca Brown Lena Cherotich Gillian McKay Protracted crises, driven by conflict, climate shocks, displacement and economic turbulence, are expanding vulnerability and increasing the numbers of children, pregnant and breastfeeding women, and adolescent girls affected by undernutrition. Whilst there is now a broad recognition of the need for multisectoral preventive action, operationalising it – who does what, where, and how it is funded – remains elusive. As a result, humanitarian nutrition has become trapped in a treatment reflex, diverting limited resources to the treatment of wasted children, while paying insufficient attention to addressing risk factors that could prevent their deterioration. In other humanitarian sectors, we act early to reduce risk and protect dignity. For example, the water, sanitation and hygiene (WASH) sector aims to secure safe water and sanitation early to prevent outbreaks of disease. Protection integrates gender-based violence risk-mitigation from the start. Nutrition should do the same and deliver preventive action alongside treatment. A treatment-only approach is a false economy – it waits for harm, fuels recurrence of undernutrition, and leaves structural drivers untouched. Undernutrition in crisis: multiple forms, shared drivers Undernutrition takes multiple forms. Wasting is defined by low weight-for-height and/or a low mid-upper arm circumference. It is often described as ‘acute’ because it can change quickly and is associated with elevated near-term risk of death. Stunting is defined as low height-for-age and is often described as ‘chronic’, reflecting longer-term constraints related to diet, illness and care. Micronutrient deficiencies occur when diets lack essential vitamins and minerals (e.g., iron, vitamin A, iodine), weakening immunity and undermining growth, energy and learning. Although wasting is often framed as a humanitarian concern and stunting as a ‘development’ issue, crises frequently see all three forms at high levels in the same populations – and often in the same children. When deficits overlap (e.g., a child who is wasted and also stunted and/or micronutrient-deficient), the risk of illness and death rises. The underlying drivers also overlap, meaning preventive actions that protect diets, feeding and health can reduce multiple forms of undernutrition at once. Prevention and treatment: complementary, not competing Treatment addresses acute need and reduces near-term mortality by identifying and managing wasting and micronutrient deficiencies with specialised foods and clinical care. Prevention reduces the risks that cause all forms of undernutrition through joined-up programming across maternal nutrition, infant and young child feeding (IYCF), health services, WASH, food assistance/markets, and social protection. These are not interchangeable actions but concurrent ones: we must simultaneously treat wasted and micronutrient-deficient children and design delivery to lower new cases occurring. In protracted crises, this dual track is both ethical and efficient, stabilising the health of children now while steadily shrinking tomorrow’s caseload. The case for prevention Cost-effectiveness and cost-benefit Unlike treatment, the evidence on cost-effectiveness of preventive approaches is less robust. But there is strong consensus that without prevention, we will face an ever-growing treatment burden. We do have some evidence on effectiveness of preventive interventions in crisis. For example, we know that the protection, promotion and support of breastfeeding and safe IYCF in emergencies can have a large preventive effect on morbidity and mortality among young children with a low marginal cost when embedded in health service delivery. We also have evidence on the importance of ensuring nutrition is an explicit objective of food assistance. This has been demonstrated in programmes that have seen caseloads of wasting rise where they have been forced to reduce the quality of household assistance and have ignored the specific nutritional needs of women and children. Beyond the health sector, small programmatic adjustments can support prevention of undernutrition in emergencies. Social protection (cash-plus) and cash transfers when directed to households with children under 2 years old have modestly improved growth and diet diversity, especially when paired with social behaviour change and IYCF services. Livelihoods and livestock programmes that have protected household milk supply in pastoralist communities have helped buffer child nutrition during drought, and education programmes that have kept schools open and supportive of nutrition (safe water, hygiene, school feeding) have sustained diets and service linkages during protracted shocks. Prevention is also increasingly understood to be less costly per child than treatment and as a better investment than treatment of wasting, especially when integrated into existing platforms. Preventive actions to protect breastfeeding, provide small quantities of specialised foods for children under 2 in food-insecure environs, and multiple micronutrient supplements to pregnant women in antenatal care (ANC) can be delivered from health, social protection and community-based platforms already running and can deliver benefits across outcomes (survival, morbidity, development), while simultaneously addressing multiple forms of undernutrition. That broader benefit base is why prevention can show lower cost per meaningful outcome than late-stage treatment – especially when marginal costs are low because platforms already exist. This begins to strengthen the case for domestic financing: governments can prioritise prevention with their own resources where value for money is highest, and then use that domestic commitment to leverage external funders for surge response when treatment needs escalate. Simply put, a narrow focus on treating only the wasted child is a false economy. It prioritises a small, specific population while leaving everyone else sliding towards risk. Slightly different choices that adopt a nutrition lens to design and deliver food assistance, market support, maternal and child health, WASH and education service delivery and social protection, can prevent more children becoming undernourished and reduce relapse after treatment for wasting. Locally led and context-responsive Prevention works best when it is designed and driven locally – by community health workers, civil society, and local food and health systems workers that know the norms, bottlenecks and what will work in-situ. Crucially, these actors are the first and last responders: they remain when funding is reduced, when international agencies depart, and between emergencies. Investing in their preventive capacity builds an enduring base that is present no matter what – making programmes more acceptable, scalable and quick to adapt as crises evolve, while also strengthening the very platforms (primary health care, markets, social protection, etc.) needed for long-term resilience in protracted settings. When attention swings entirely to treatment, these community-driven solutions are sidelined and the capacity to address impacts of the next crisis erodes. Equity, sustainability and intergenerational impact Prevention often acts at system or community levels (policies, services, protections) so it reaches whole populations, not only those individuals who have contact with a community health worker or clinic. This narrows inequities by design. For example, enforcing the code for marketing of breast milk substitutes across all programmes and supply chains; setting minimum nutrition specifications for household food assistance and transfers and deliberately leveraging local markets – sourcing locally, shaping cash and vouchers to improve access to nutritious foods, and supporting small vendors to stock them – all helps to improve diet quality, reduce incidence and relapse of wasting, and stabilise child nutrition. By targeting structural determinants (poverty, fragile food systems, WASH gaps, protection of breastfeeding, women’s agency), preventive action can deliver gains that are more durable and less donor-dependent. Crucially, investing in maternal and early-life nutrition reduces risk across the life course and into the next generation – improving health, learning and earnings, thus compounding returns over time. Approaches for prevention: the need for more high-quality evidence Emerging multisectoral initiatives are starting to show how prevention of undernutrition can be operationalised in crises. The AHEAd evidence synthesis and decision tool, alongside many country-level multisectoral nutrition action plans and programme models such as Nawiri in Kenya’s arid and semi-arid lands and the Community Resilience to Acute Malnutrition programme in Chad, illustrate how nutrition-specific and nutrition-sensitive actions can be layered across health, food assistance and markets, as well as WASH, livelihoods and social protection platforms in humanitarian settings. Early learning suggests these approaches can be feasible, acceptable and impactful, but high-quality impact and cost-effectiveness data remains limited – especially on what intensity, timing and combinations of actions work best in different contexts. Continued investment is therefore needed not only for support and delivery of preventive packages, but also for embedded implementation research and routine data systems, so that humanitarian actors can move from promising models to a robust menu of proven, scalable options. Targeting and data to support prevention Prevention only works if we identify risk early and prioritise scarce support in crisis. Strategic investment in essential, timely data can ensure efficient use of funds, by pinpointing need and precipitating early action. Lean, actionable indicators (e.g., measures of infant feeding practices, nutrition status of children under 5, recent food ration cuts, water access, market prices, etc.) are sometimes available through existing platforms and data collection mechanisms to help target and design packages. For effective prevention we also need trend data – signals that show direction, not just snapshots. Existing systems can do this: routine screening and admissions data from wasting treatment, simple sentinel site checks, and price/market trackers. None is perfect, but together they flag when risks are rising so preventive action can start early before undernutrition surges. In most settings, risk isn’t flat across the year. Increases in numbers of wasted children happen annually during the lean season, the malaria/diarrhoea peaks and harvest time. This knowledge can be used to time preventive actions around predictable gaps in food access and care – for example, providing blanket nutrition support to young children during lean-season months has been shown as an effective approach to preventing wasting in some humanitarian contexts. In the data-scarce settings common in humanitarian crisis, mixed methods that blend what exists with light, rapid collection – pairing secondary data with short surveys, key-informant interviews and quick focus groups – can help fill information gaps. Working with local authorities, community leaders, including diverse perspectives of men, women and youth, marginalised communities and civil society, to ensure that insights reflect reality and have local ownership, can help steer relevant intervention design for prevention quickly. By tracking simple trends, building on local solutions and acting before the curve, context-relevant support can be timed to the calendar, not the crisis. Conclusion A humanitarian response that waits until children are already undernourished is neither inevitable nor efficient. We must protect wasting treatment while shifting practice and financing so prevention is expected rather than optional: resourcing analysis, targeting and monitoring, and building an evidence base that is practical using routine data, implementation learning and real-world costs. Crucially, prevention of undernutrition does not require new standalone lines of programming; the levers exist in what we already do – food assistance, ANC, IYCF in emergencies, cash/vouchers and social assistance, health and WASH programming and market support – provided these platforms are designed with a nutrition lens and aligned across sectors. In this form, prevention can be highly efficient, offers stronger value for money when integrated, and can be anchored in domestic systems to complement external support for shock response. The choice is not prevention or treatment – it is a balanced portfolio that reduces risk earlier and lowers caseloads over time to shrink tomorrow’s caseload today. Kate Sadler is a public nutritionist with over 25 years’ experience of designing, managing, evaluating and researching nutrition programmes across Africa and Asia. She is a technical associate with NutritionWorks. Abigail Perry is the Global Program Lead for Nutrition at the World Bank. She has more than 20 years’ experience working in humanitarian and development nutrition spanning policy, operational and research roles. Karima Al-Hada’a is Planning and Liaison Specialist at Scaling-Up Nutrition Secretariat, and the Assistant National Food Systems Convenor at the Ministry of Planning & International Cooperation, YEMEN. Tamsin Walters is a public health nutritionist with 25 years’ experience in nutrition policy and strategy development, technical guidance and evaluation. She is a partner at NutritionWorks. Rita Abi Akar is a public health nutritionist with over 10 years’ experience, currently researching the links between nutrition and climate change and the importance of shifting power to local actors. She is a technical associate with NutritionWorks. Gladys Mugambi is a Kenyan public health and nutrition leader working with Ministry of Health, an advocate for multisectoral food security and nutrition priorities. She supports policy, coordination and implementation with partners at national and county level. Rebecca Brown is a public health nutritionist and a partner at NutritionWorks. She has over 25 years of experience of providing technical support to multisectoral nutrition guidance, policy development and programming. Lena Cherotich is an independent public health consultant with over 16 years of experience in East Africa, specialising in systems change, adaptive learning, and advancing equity, inclusion and locally led approaches. Gillian McKay is a senior humanitarian health technical leader at Elrha, with over 15 years’ experience as a humanitarian health practitioner, researcher, and funder working to strengthen nutrition and health outcomes in crisis settings.

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