Nutrition in Emergencies

Collaborative Effort on Monitoring Relief Assistance

Anne Ralte

During the last few years, donors have come under pressure to report on results of programmes. USAID and State Department's Bureau of Population, Refugees, and Migration (State/PRM), the two US government agencies responsible for providing relief overseas, discussed for some time the need to coordinate on performance indicators. Implementing partners encouraged this coordination effort and the adoption of commonly shared indicators to facilitate data collection and reporting to several donors. In consultation with technical agencies, a small set of indicators was selected in 1999 that could be used to measure overall progress in relief situations. The indicators are Crude Mortality Rate (CMR) and nutritional status of children under five.

Crude death or mortality rates (CDR or CMR) are the most critical indicators of a population's health status and the category of data to which donors and relief agencies most readily respond. A CMR not only indicates the current health state of a population, but also provides a baseline against which the effectiveness of relief programmes can be followed¹. CMR is relevant to USAID and State/PRM in respect to their programmes that address critical, physical needs of populations in crisis.

In addition to CMR, USAID adopted nutritional status of children under five. Acute malnutrition in children under five is closely associated with risk of death. If CMR and nutritional status are improving, probably most of the humanitarian assistance support systems are working. These two indicators help track the cumulative effect of the relief effort on the most vulnerable populations.

Review of Progress

Nutritional status of children under five has been used as a performance indicator by USAID's Office of Food for Peace since 1997 when this was included as one of its Strategic Objective indicators for Title II emergency food aid. The Office of Food for Peace invested considerable time in the consultative process with its implementing partners to select indicators jointly. Other selected indicators reflected values and core principles important to the Private Volunteer Organization (PVO) community, that is, the "do no harm" approach to implementing emergency food aid programmes.

Crude death or mortality rates (CDR or CMR) are the most critical indicators of a population's improving or deteriorating health status and the category of data to which donors and relief agencies most readily respond

Since CMR data collection was new to its implementing partners, the Office of Food for Peace supported field-testing of a methodology that combined CMR data collection with existing nutrition survey protocol. The pilot test, undertaken by World Vision/Sudan in 1999, demonstrated that the methodology was feasible and doable by PVOs. Implementing partners requested technical assistance and training to be able to adopt the methodology. Since then, efforts have been made to coordinate on establishing methodologies and to provide technical support.

As a joint US government policy advocacy effort, USAID and State/PRM consulted donors and international organizations on the adoption of nutritional status and CMR as commonly shared indicators. The Canadian International Development Agency (CIDA) and other organizations² support this effort. There was broad consensus that an investment is needed to ensure that programmes have the capacity to carry out, analyze, interpret and report on survey findings. This requires training and the provision of technical support to PVOs/NGOs and other implementing partners. There was also consensus on the need to standardize survey methodologies among organizations conducting nutrition surveys. All organizations expressed interest in participating in a training workshop. Some organizations expressed the view that food security, vulnerability and livelihoods analysis should be integrated as part of nutrition data analysis and interpretation.

A recent positive development of the several years of advocacy effort is the willingness of implementing organizations, technical agencies and donors to work together to resolve technical problems in collecting reliable data in emergencies, standardize methodologies, and strengthen the technical capacity of all partners.

Proposed Plans

To standardize methodologies and ensure that reliable survey data is being reported, USAID is organizing a workshop July 23-25, 2002 in Washington DC in collaboration with CIDA and State/PRM. The workshop is coordinated by the Food Aid Management (FAM) and the Food and Nutrition Technical Assistance Project (FANTA). This initiative is a collaborative effort of many partners including UNICEF, WHO, CDC, PVOs and the SCN's Refugee Nutrition Information System (RNIS). The training workshop is part of a broader technical assistance support system being established for implementing partners that draws on experts from technical agencies and independent experts on emergency nutrition. Ongoing USAID-funded projects, such as CERTI, FANTA, Linkages, are also part of this effort. For example, the CERTI Project (Tulane University) is leading the effort to develop information management tools for field reporting, a web-based forum for posting survey results, and a listserve for field practitioners to have direct, immediate access to the pool of experts.

Standardized survey methodologies will be field tested in about three countries where data will be collected and analyzed as a joint effort, and appropriate interventions will be introduced. Follow-up surveys will be undertaken in each site every six months so trends can be monitored. The pilot test will demonstrate whether these indicators are the most critical ones for measuring overall progress in relief situations. It will also review other indicators that should be included without a burden to implementing partners, for example, the feasibility of integrating food security and vulnerability analysis. It will also demonstrate the feasibility of a collaborative approach to gathering data in emergencies with representative sites selected by participating organizations. For policy and decision makers, this will provide an improved understanding of humanitarian assistance needs and emergencies that require attention, including those that are less visible, based on real time information that is reliable. This effort will facilitate decision-making and the provision of timely, appropriate assistance to the most vulnerable groups.

Notes:

1. Noji E (1998) Monitoring and Evaluation in Complex Humanitarian Emergencies, Emergency and Humanitarian Action. WHO: Geneva.

2. Rome: WFP, FAO. Geneva: UNHCR, IFRC, ICRC, WHO, RNIS (SCN), The Sphere Project. Brussels: European Union, Medecins sans Frontiers, Medecins du Monde, Centre for Research on the Epidemiology of Disasters (CRED).

Contact: Anne Ralte aralte@usaid.gov

Humanitarian Needs of Refugees Versus the Chronic, Although Similar, Needs of Host Population:

The case of Western Tanzania Refugee Camps

Angelina Ballart

Presented to the SCN 29th Session in Berlin 12 March 2002

Refugee Camps of Western Tanzania

Wide spread insecurity resulting from political and military conflicts in the Great Lakes region of Africa continues to cause refugees to flee into Tanzania. Further, the continued and political unrest in Burundi in 1993, and Democratic Republic of Congo (DRC) in 1996, continues to cause a new influx of refugees. Although efforts are being made through the Arusha peace process for Burundi and through Lusaka negotiations for DRC, such initiatives have not yet resulted in sufficient progress to allow refugees to be safely repatriated to their countries of origin.

The refugee operation in Tanzania aims at providing protection, care and maintenance assistance to about 500,000 refugees hosted in 13 camps and at the same time facilitating voluntary repatriation. To achieve this, various humanitarian services have been provided in the refugee camps, these include, shelter, water and sanitation, food, health and nutrition.

Following various interventions in the refugee camps, the health and nutrition situation has been stable. Health and nutrition services provided include:

· maternal and child heath services (growth monitoring, antenatal clinic, family planning, immunization)

· control of malaria

· Parasite control for children and pregnant women

· integrated management of childhood illnesses (IMCI)

· prevention of HIV/AIDS

· prevention of mother to child transmission of HIV

· selective feeding programme (therapeutic feeding and supplementary feeding programmes)

· micronutrient/multiple micronutrient supplementation

· infant feeding in emergencies

· prevention of low birthweight, and

· support to nutrition surveys.

The Government of Tanzania expressed interest in furthering the international efforts to support neighboring countries affected by conflict and civil strife to democratize and respect human rights so as to end the refugee crisis. It has outlined the sacrifice made by local communities to host refugees at the expense of other risks such as insecurity, disease, poor nutritional status, scarce resources, environmental damage and land degradation that cannot be quantified in monetary terms.

To date, it is estimated that about one million local inhabitants live in the refugee-affected areas. They are comprised of subsistence farmers with very low income and relatively high malnutrition, morbidity and mortality rates. Poor farming practices are a major constraint to food production, coupled with poor road infrastructure, and inadequate marketing systems. The proximity to refugee camps has influenced the prices of the local foodstuff, deteriorating security and destruction of natural environment of the host villages.

Donors continue to provide support for the refugee operation. However, the Government of Tanzania bears the responsibility of hosting 500,000 refugees and the burden of poverty and heavy international debts to be serviced.

Health and nutrition situation

The health and nutrition situation in the refugee-affected areas, unlike in the refugee camps, is a significant public health problem. Malaria, pneumonia and diarrhea are the major leading causes of mortality and morbidity. Support provided include:

· capacity building of health and nutrition staff
· special feeding programme
· food and medicines and supplies to some of the health facilities and prisons
· water and sanitation projects, and
· technical and financial support to health, nutrition and education.

Dilemmas affecting the host community

A number of constraints and dilemmas affect Tanzania’s ability to respond to the refugee situation, including:

· Tanzania is among the least developed countries

· inadequate resources to support asylum seekers

· increased insecurity and tension between the local population and refugees

· acute emergencies becoming long term programmes

· donor support is directed to refugees while development support to refugee affected areas is given lower priority

· cross infections from countries of origin to host population

· abrupt reduction of donor support which interferes with provision of basic services creating insecurity to host population

· increased donor/media attention on refugees while local population deteriorates, and

· inadequate allocation of donor support either caused by media bias, political priorities or geo-economic interests.

Situation/Activities/Services	Refugees	Host population
Population	500,000	1,000,000
Under-five mortality/1000/live births	54	137
Infant mortality/1000/live births	32	88
Neonatal mortality/1000/live births	11	32
Maternal mortality/100,000/live births	56	529
Child wasting, % <2SD	3.2	9.2
Special feeding program	available	not available
Micronutrient supplementation	available	available
Infant feeding in emergencies	· assessment done	· not done
	· capacity building and community sensitization	· both done
Prevention of LBW program	available	not available
Nutrition survey	conducted yearly	rarely conducted
Control of malaria	Indoor spraying twice a year, community sensitization	Only community sensitization on use of insecticide treated nets
MCH Services	· growth monitoring	· growth monitoring
	· pregnant women receiving supplementary feeding and de-worming	· no supplementary feeding, no de-worming
Parasite control for children	program available	no program
Water and sanitation	· water treated, safe and clean	· not treated, not safe
	· program for sanitation	· no program
	· latrine coverage >90%	· coverage 30 - 40%
IMCI capacity building	> 80% of target	30 - 40% of target
HIV/AIDS program	included in school health and youths programs	included in youth's program only

Contact: Angelina Ballart aballart@unicef.org

Sphere Project: Handbook Revision (2002 - 2003)

The Sphere Project is an initiative managed by four NGO networks: Steering Committee for Humanitarian Response, InterAction, VOICE and ICVA. Since the launching of the first edition of the Sphere handbook in 2000, over 25,000 volumes have been sold and the handbook has been translated into 15 languages (eight spontaneously). This worldwide interest on behalf of national and international NGOs, the Red Cross/Red Crescent movement, governments, academics and UN agencies demands that the Sphere handbook be made as effective as possible. A revised edition of the handbook will be published in late 2003.

The UN Inter-Agency Standing Committee has endorsed the book as an important tool for anyone working with populations affected by disaster and called on all IASC members (UN and NGO) to promote the use of the Humanitarian Charter and Minimum Standards in Disaster Response within their organizations, particularly in their field operations.

Handbook feedback forms, the text of the first edition and additional information can be found at www. sphereproject.org.

In Spring 2003, a draft of the revised text will available on the website.

Sphere Handbook Review Process

The revision's purposes are: to strengthen the link between the Humanitarian Charter and the Minimum Standards; to update the qualitative and quantitative indicators and guidance notes as needed; to address cross-cuttings issues such as children, women, the elderly, disabled, HIV-AIDS, and the environment; to enhance linkages between sectors; to iron out inconsistencies, faults and important omissions from the first edition; and to eliminate repetitive text. In addition, as per an earlier commitment by the Sphere Management Committee, Minimum Standards relating to Food Security will be developed as part of this process.

Six Focal Points and the Sphere project office will undertake this work over one year. Each Focal Point will work in their own particular way based on their sector-specific needs. All Focal Points are committed to a broad-based consultative process with feedback and input from field-based users paramount and with an emphasis on consultation with the agencies that are regularly using the handbook in disaster response. Comments are encouraged from national and international NGOs, UN agencies, donor governments, governments where disaster response frequently takes place and academic institutions. Individuals from NGO and UN HQs as well as those from academic institutions will participate as reviewers to the revision.

To make sure that agencies' experience, insights and technical expertise inform the Sphere handbook revision, a handbook feedback form is available. It should be submitted to the project office or relevant Focal Point.

Who to Contact

The six Focal Points listed below come from NGO agencies and one academic institution. In addition to their regular work with their respective agencies, these staff are responsible for managing the revision process. Names, contacts, suggestions, recommendations or comments may be sent to the Focal points:

· Water and Sanitation: Andy Bastable, Oxfam GB (abastable@oxfam.uk.org)
· Nutrition: Anna Taylor, Save the Children UK (a. taylor@scfuk.org.uk)
· Food Aid: John Solomon, CARE USA (Jsolomon@care.org)
· Shelter & Site: Graham Saunders, Catholic Relief Services (graham.saunders@crsbh.ba)
· Health Services: Rick Brennan, International Rescue Committee (brennan@theirc.org)
· Food Security: Helen Young, Tufts University (Helen.young@tufts.edu).

The Sphere Project
PO Box 372
1211 Geneva 19
Switzerland
sphere@ifrc.org