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News result, a 1-day emergency simulation exercise was developed in consultation with a range of NIE experts. The simulation was reviewed and revised following each course. Field-based exercises relating to the management of acute malnutrition and nutrition surveys were adapted from the HTP and tested during the course in Uganda. Evaluation Modules were delivered by experienced facilitators and feedback was obtained using a variety of evaluation approaches. All materials were piloted at least twice and reviewed and revised from one course to the next based on comments from course participants, our partners and course facilitators. Module-specific and end-of-course evaluation forms were administered to participants. Feedback from each partner organisation and the course facilitators was obtained verbally and via email. Follow-up of course participants was done approximately 3 months after each course ended. Assessment A multiple-choice questionnaire was developed and tested to assess the progress of participants. Each of the 40 questions was designed to correspond to one of the three levels of learning, based on a modified version of Bloom’s taxonomy (knowledge, combined comprehension and application, and problem solving) 9 . The MCQ was pilot tested before being administered to course participants. The test was given at the start and end of the course and scores were reviewed and analysed by participant and topic. Results Course uptake Overall, 131 applications were received for the three courses run during the pilot phase. The first course (held in Lebanon) was restricted to practitioners from the Middle East and only 19 applications were submitted. Fifty-six applications were received for each of the two other courses (held in Uganda and Thailand). A total of 67 people attended the courses. The majority of participants worked either for an international non-governmetnal organisation (INGO) (28%) or a UN agency (34%). The rest worked for government ministries (9%), academic institutions (8%), local NGOs (6%), donor organszations (6%) or were self-employed (9%). Sixty-six per cent of participants worked in nutrition, 15% in health, 9% in general emergency programme management and 8% in food security. One participant worked in logistics. One third (33%) of participants were working in Western Asia (including Middle Eastern countries), 18% in Northern Africa (predominately Sudan), 13% in Eastern Africa, 12% in Southern Asia, and 6% each in Western Africa, South-east Asia and Australia. The rest had a regional/global remit. Overall, 73% of participants were national staff (i.e. working in the country where they are from). Simulation exercise: Inter-agency coordination, Thailand course A Perry/NIETN, Uganda, 2011 Table 1: Overview of the NIERTI courses run to date Location Lebanon Uganda Thailand Partner American University of Beirut University of Makerere Asian Disaster Preparedness Centre Duration 6 days 12 days 10 days Number of participants Modules covered 17 (+2 students) 20 28 Introduction to NIE Introduction to NIE Introduction to NIE Causes of malnutrition Causes of malnutrition Causes of malnutrition Humanitarian system Humanitarian system Humanitarian system Humanitarian standards and M&E Humanitarian standards and M&E Humanitarian standards and M&E Rapid assessments Rapid assessments Rapid assessments Nutrition surveys Nutrition surveys Nutrition surveys - Surveillance and early warning Surveillance and early warning - Food security and livelihoods Food security and livelihoods Food assistance Food assistance Food assistance Micronutrient interventions Micronutrient interventions Micronutrient interventions - Advocacy Advocacy Management of severe acute malnutrition Management of moderate acute malnutrition An overview of each of the courses run during the pilot phase of the NIERTI is given in Table 1. Cost The first of the three courses (held in Lebanon) was subsidised since it was the first ‘pilot’ course. The fee was US$500 for 6 days (excluding accommodation) and the cost of course facilitators was covered by the project funding. This course has not been included in the following analyses because it is not representative of the actual costs of running NIE training. The next two courses had a fee of US$ 2,500 including meals and accommodation. The course in Uganda was 12 days and the Thailand course lasted 10 days. This equates to US$208 per person per day for Uganda and US$250 per person per day for Thailand. As a comparison, the 5-day course in NIE run by the University of Westminster (London, UK) costs the equivalent of US$ 1,100 (based on current exchange rates), excluding accommodation and meals other than lunch. This equates to US$ 220 per day or US$ 2,640 for 12 days. Of the 48 people who attended the full-price courses in Uganda and Thailand, 83.3% were funded by their employer, 10.4% were sponsored by another organisation and 6.3% were self funded. Feedback from participants indicated that the course was viewed as good value for money. Of the 222 enquires that had been received about the initiative by the end of August 2011, 23 were requests for funding support. None of these individuals subsequently Management of severe acute malnutrition Management of moderate acute malnutrition Management of severe acute malnutrition Management of moderate acute malnutrition Infant feeding in emergencies Infant feeding in emergencies Infant feeding in emergencies Emergency preparedness Emergency preparedness Emergency preparedness Emergency simulation Emergency simulation Emergency simulation Professional development Professional development Professional development - Pre-/post-test MCQ Pre-/post-test MCQ - Field training (nutrition surveys) - - Field training (management of - SAM) - Field training (management of MAM) - attended a course. Sixteen people who were offered a place on a course reported that they were unable to attend because of a lack of funding. The most expensive components of the courses were the facilitators followed by accommodation/meals for participants. Expenditure on facilitators was US$ 1,227 per participant in Uganda and US$ 661 per participant in Thailand. In both cases this does not include a fee for the lead facilitator or for an additional facilitator who taught several modules, both of whom work for UCL CIHD. The cost per participant in Thailand was lower because we had more participants and were able to secure facilitators who were based locally and who were not in a position to accept a fee (which cannot always be guaranteed). Even so, the course in Thailand only just covered all costs using fees and in Uganda we incurred a loss that was buffered using project funding. The cost of accommodation, meals and the training venue was $72 per participant per day in Uganda and $110 per participant per day in Thailand. Evaluation The response to each course was positive. Overall, 56% of participants strongly agreed and 42% agreed that the course they attended met the goal to prepare them to respond to the nutritional needs of people affected by emergencies. The improvement in 9 Anderson LW et al. (eds.) (2001). A Taxonomy for Learning, Teaching, and Assessing: A Revision of Bloom's Taxonomy of Educational Objectives. New York: Longman. 51
News performance and ability of participants is difficult to quantify; however there were some signs that the courses had a positive impact. The average score for the MCQ increased from 52.0% at the start of the course in Uganda to 63.5% at the end. In Thailand the average score increased from 52.5% to 65.5%. Only 29 of the 67 participants responded to the follow-up email. Among these 29, there were numerous examples of positive actions resulting from attendance on the courses. The majority of responders had provided training to their own staff or to others. A group from Lebanon had developed a country-specific emergency preparedness plan for nutrition. Others had been identifying ways to strengthen the management of moderate acute malnutrition as part of CMAM. Based on feedback from the course evaluations, an 11-day ‘standard’ NIE course has now been developed and this will be the model that will be implemented by each of the training partners. This course includes the emergency simulation exercise but the field-based training is designed as an optional add-on to the standard course, depending on the opportunities available and the logistic feasibility at each training site. Discussion On one level, the overall goal of the NIERTI to increase the availability of high quality training in NIE has been met. There are also indications that the training model will be sustained by our partner organisations. The courses have gained a positive reputation among the NIE community and, at the time of writing, all three institutions have taken steps to implement their next course. Each institution has started to investigate ways to strengthen their own capacity and to institutionalise the training. This includes engaging regional practitioners to develop a network of known NIE facilitators and incorporating the course (or elements of the course) into post-graduate training. There also appears to be a reasonably steady market for the courses. Despite increased focus on the development of NIE capacity, we are only aware of one other specific course in NIE that is run on a regular basis. Other training initiatives that have emerged over the past few years are still predominately ad-hoc or one-off events hosted by international agencies. In light of the extent of the capacity gap in nutrition and the high turnover of staff within the humanitarian sector, investment in occasional training, while being very useful, will not be sufficient. The process of setting up the NIERTI has highlighted a number of issues that will need to be considered if we are to make further progress in addressing the lack of capacity in the sector. These have been grouped into three major themes: the cost of capacity development, providing practical training in NIE and standardisation of training. facilities in Thailand were excellent value for money and it is difficult to achieve similar at a lower cost. The other main contributor to the cost of the courses is also challenging to solve. The main reason why NIE training is expensive is because of the reliance on relatively few NIE practitioners who need to be flown in to teach on courses. We were not able to run the NIE courses using only staff from the partner organizations. None of the available facilitators had experience of working in emergency contexts and all felt that practical experience was an essential prerequisite. As such, external facilitators had to be employed. Significant effort went in to identifying experienced facilitators based in each region. However, the NIE community is still relatively small, the work commitments of potential facilitators are unpredictable, experienced staff are in high demand and expect to be paid a fee that is commensurate with their experience, and relatively few NIE practitioners have sufficient teaching experience. The latter point is particularly important; although course participants appreciated the extensive experience of the facilitators while the ability to transmit information and to manage teaching sessions effectively was also valued highly. The most obvious solution to this is to build the capacity of national practitioners and academic staff. This approach would reduce costs and could promote sustainability. Development of the capacity of academic staff will require exposure to emergency nutrition programmes. A recent piece of research looking at pre-service training in NIE found that academic staff can be isolated from the work of NGOs and UN agencies 10 . This gap needs to be bridged in order to enable academics to gain hands-on experience. Training in the sector is still more commonly undertaken by agencies rather than higher education institutions. Although this approach can improve capacity within the humanitarian sector, it has the potential to further weaken the academic system that could provide a sustainable approach to strengthening capacity in the longer term (8). The other constraint to strengthening national academic capacity is the continuing issue of low salaries, high staff attrition and conflicting demands among academic staff in developing countries 11 . In order to establish academic institutions as providers of high quality nutrition training, this problem will need to be addressed. This might also help to attract experienced NIE practitioners in to the academic sector. One solution to this is to include classroombased teaching as part of an integrated work-based training programme that includes field exposure. In 2010, the Consortium of British Humanitarian Agencies (CBHA) launched a competency-based training programme for humanitarian staff, which includes field placements. More recently, Save the Children UK and Concern Worldwide initiated 1 and 2-year emergency nutrition internships, which include placements at head quarters as well as at field sites. Another option would be to develop partnerships between academic institutions that can provide theory training and humanitarian agencies operating in relevant countries. Practitioners could attend training and then opt for a shorter and more affordable work placement in their country of origin. This arrangement would also help to bridge the gap between the academic and operational agencies in these countries. For practitioners already working within the humanitarian system, a relevant work placement could be one of the pre-requisites for attending the theory training. The cost of capacity development The NIERTI course fee is undoubtedly prohibitively high for some individuals and agencies. professional competencies Standardisation of training and the need for However, the fees provide an indication, and A recurrent issue that emerged during the Providing practical training in NIE perhaps an under-estimation of the real cost of development of the NIERTI was the lack of Two key themes emerged from the evaluations running a course of this nature in the current common understanding of the competencies and course participant follow-up. First, participants emphasised the importance of the climate. The cost of accommodation/meals required by NIE staff. Although experienced seems quite high but in fact it is extremely difficult to find alternatives at a lower cost in practitioners have a reasonable sense of what problem-solving course exercises, field-based training and the emergency simulation for 10 Uganda, other than in hostel-type settings. The NutritionWorks (2011). In-service and pre-service training enabling them to put into practice the theory A Perry/NIETN, Beirut, 2010 covered. Second, participants felt that postcourse internships, work placements and mentoring would have enabled them to consolidate their learning further. The role of practical training in NIE was emphasized in the 2007 capacity review by Gostelow. The field-based training included in the course held in Uganda was well received but this is a difficult activity to maintain. Running field training in an emergency programme can be disruptive and the nature of emergency response does mean that from one year to the next it is difficult to guarantee that relevant programmes exist or are accessible in the country/region where training is being held. Field training also lengthens the duration of courses, which increases both the time and financial commitment for participants. Training session on infant and young child feeding in emergencies, Beirut, 2010 in NIE. http://www.ennonline.net/meetings/servicetraining 52
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