Name of sector: MAMI

Dates of deployment: 23 July – 23 September 2020

Reason for request:

A recent analysis of SMART survey data from Afghanistan has shown that 15.3% of infants under 6 months (u6m) are wasted (WHZ<-2.0), 6.2% of which are severely wasted.[1] Poor maternal malnutrition, with 1 in 5 PLWs underweight, is likely a contributing factor.  However, the findings show that the highest prevalence of wasting is observed in infants 5 months of age, and therefore there are likely other factors at play such as poor IYCF practices. Although exclusive breastfeeding was found to be 73.5% at 0 months, this decreased to 45.4% by 5 months.

A high proportion of inpatient admissions to Stablisation Centers are infants u6m, highlighting again, a significant burden of malnutrition in this age group in Afghanistan. In reality, this number is likely underestimated considering the lack of links between sexual and reproductive health (SRH) services and nutrition programming. Outpatient care for infants u6m with acute malnutrition with no complications was included in the IMAM National Guidelines revision of 2018. However, there is a lack of capacity and expertise within country to implement these guidelines effectively. The MAMI Tool[2] was designed partly in response to the same challenge with the updates to the WHO Management of Acute Malnutrition in Infants and Children Guidelines 2013, which for the first time included outpatient care for infants u6m in 2013, but with no operational guidance to implement the recommendation. The MAMI Tool guides health workers in identification, assessment and management of at-risk mothers and infants u6m.

 A better understanding of the causes of malnutrition and a holistic response is required to ensure infants under 6 months are able to survive and thrive. The MAMI Approach offers a solution that covers both preventative and curative management of at-risk infants, linking the dyad to a broad spectrum of services to tackle the underlying causes and mitigate risk. The Tool requires adaptation and contextualization based on existing services and causes of malnutrition among other factors, which the scope of work detailed in this ToR aims to do.

[1] Afghanistan Nutrition cluster, Action Against Hunger and UNICEF; Wasting among infants under 6-months: A silent public health problem in Afghanistan. May 2020. Access at:

[2] Emergency Nutrition Network; C-MAMI Tool v2.0; Access at:

Key achievements:

  1. Situational Analysis for MAMI in Afghanistan
  2. Options for MAMI integration depending on existing services
  3. Action plan for testing MAMI integration in a number of selected areas


Name of sector: IYCF-E

Dates of deployment: 14 January – 22 February 2019

Reason for request:

The northwestern part of Afghanistan has been severely impacted by drought in 2018. The impact of drought on nutritional status is highly linked to reduced access to safe water, health concerns and increased likelihood of food insecurity in the months to come with the impact possibly more severe in provinces with pre-existing high prevalence of malnutrition. An estimated 125,000 acutely malnourished children under five and 32,750 pregnant and lactating women (PLW) will be in need of life saving emergency nutrition services across the 20 drought affected provinces. Of these, the nutrition cluster plans to assist 89,500 children under five and 9,745 PLW for emergency nutrition assistance.
The nutritional trend analysis shows an increase of GAM prevalence by Weight for Height Z-Score (from 7.5% to 7.8% in Kunduz, from 11.8% to 14.4% in Kunar, from 9.4% to 11.2% in Zabul and from 6.8% to 7.1% in Logar province) in most of the provinces that were assessed during the period of January to June 2018. In addition, Rapid SMART surveys in some of the hotspot locations of Badghis, Kandahar and Jawzjan provinces reported very high levels of acute malnutrition; these are areas which are severely affected by drought especially affecting displaced people as well Kochi/Nomads population. The combined GAM prevalence (WHZ <-2SD and/or MUAC <125mm and/or Oedema) shows that the level of wasting among children under five years of age exceeded the emergency threshold of 15% (Badghis-19.7%, Kandahar-22.3% and Jawzjan-27.4%). The rapid nutrition assessment in Herat province by World Vision identified 24% GAM prevalence and 4% SAM prevalence among the protracted IDP population while a staggering 25% GAM and 9% SAM among the new IDP population.

While breastfeeding is a very common norm and practice in Afghanistan, the practice of optimal IYCF practices remains a major problem. SMART Survey in Ghor province (2016) identified that 99.6% children 0-23 months are ever breastfeed and only 65.0% of children 0-5 months are exclusively breastfeed. Practice of proper complementary feeding for children 6-23 months age is even worse in Afghanistan due to several reason (i.e. poverty, drought/natural calamities, lack of diversified food availability and agriculture, poor knowledge & practice of IYCF, conflict/displacements etc.). According to SMART survey results (2016) in Ghor, the rate of introduction of solid, semi-solid or soft foods to children 6-8 months of age is only 47.0%. At national level, an average of 16% of children receive a minimum acceptable diet.
The drought response has consisted of a two-fold approach – on the one side an intensification of screening and support to health facilities delivering services and on the other, a scale up of mobile health and nutrition teams to reach children & PLWs in settlements and hard to reach locations.
Integrated Management of Acute Malnutrition (IMAM) services have been scaled up in 2016-2017, yet the increased coverage and quality of Infant and Young Child Feeding in Emergencies (IYCF-E) intervention remain a major need. Currently the national IYCF strategy is being reviewed by an international consultant. While the role of the IYCF-E Tech RRT Advisor is mostly on improving IYCF-E program delivery in the field and capacity development, the lesson learned from the field can be shared as inputs to the work of the IYCF consultant to further enrich the strategy review.

Key achievements:

  1. Report from program visits highlighting key strengths and weaknesses encountered.
  2. Workshop report and recommendations based on discussions.
  3. Training report from practical trainings undertaken at field level and the training materials used.
  4. Training report from the Master Training.
  5. Final recommendations based on the outcomes from the meetings with the IYCF TWG at national level.