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Veronique Priem, Niger, 2002DakoroStabilisationCentreScaling up the treatment of acute childhoodmalnutrition in NigerBy Isabelle Defourny,Emmanuel Drouhin,Mego Terzian,Mercedes Tatay,Johanne Sekkenes andMilton TectonidisMilton TectonidisEmmanuel Drouhin is the Niger Desk Officer, Isabelle Defourney thedeputy Desk Officer for Niger and Mego Terzian is the Emergency DeskOfficer, all based in Paris with MSF France. Johanne Sekkenes is theHead of Mission of MSF Niger and Milton Tectonidis the NutritionConsultant in the Medical Department of MSF France.Field ArticleThis article presents a strong case from Niger thatmanaging severe malnutrition on a large scalethrough outpatient treatment is a real possibility.For a short period during the summerof 2005, Niger – a country whose peopleare amongst the poorest in theworld - had the dubious privilege ofhitting prime time on international television,as officials and advisors attempted to explainwhy so many children were starving and whynothing had been done to help them. Despitea prevalence of wasting constantly hoveringaround or above 15% and the third highestunder-5 mortality rate in the world (259 per1000 live births 1 ), health authorities and theirbilateral, multilateral and international partnerspresent in the country were almostexclusively focused on development programmesaddressing ‘underlying causes’.Food security early warning systems in Nigerwere essentially limited to rainfall data andagricultural production estimates. Theabsence of any sustained attempt to monitor,let alone treat, acute malnutrition, combinedwith a fatalistic complacency towards high‘structural’ rates of wasting, led to unacceptabledelays and errors in the response to theepidemic of malnutrition that affected Nigerin 2005.The development of solid equivalents oftherapeutic milks in the last five years isinspiring a major change in the treatment ofacute malnutrition 2,3,4 . These nutrient-denseReady to Use Therapeutic Foods (RUTF) haveled to the development of an outpatientapproach to treatment based on simplifiedmedical and nutritional protocols for all butthe most complicated cases. In rural settings,multiplication and decentralisation of programmeentry points leads to rapid and thoroughdiagnosis of wasted cases in the community.Effects on programme capacity andcoverage are dramatic and costs per patienttreated reduced. Programme indicators suchas cure, mortality and default rates have, tothe surprise of many, consistently outperformedthose obtained with the classicapproach advocating predominant or exclusiveinpatient management 5,6 .Applying this new strategy to the crisis inNiger in 2005, Médecins Sans Frontières(MSF) expanded operations well beyond theprogramme established in Maradi region in2001, going on to admit over 63,000 severelymalnourished children in therapeutic feedingprogrammes during the year, by far thelargest nutritional intervention in the organisation’shistory. Even outside periods of acutecrisis, home consumption of RUTF has the, asyet, unexploited potential of making theeffective management of acute malnutritionfar more accessible in resource poor countriescharacterised by high malnutrition rates andnumbers of wasted.MSF in Niger and the response to the2005 crisisThe outpatient treatment programme forsevere malnutrition in Maradi was opened inJuly 2001 after a measles epidemic sweptthrough the region. The continuing largenumbers admitted (4,443 in five months)exceeded expectations and led MSF to maintainthe project. The number of admissionsrose every year reaching 9,524 in 2004, bywhich time direct admissions into outpatientcare had increased to over 50% of all admissions.Reluctance amongst clinicians to dischargestabilised patients quickly from theinpatient centre had been overcome, curerates had reached 83.5% and overall mortalityrates had fallen to 6%.In the first few weeks of 2005, the MSFteam in Maradi noticed a distinct change inthe pattern of admissions compared to previousyears. By early February 2005, weeklyadmission rates were triple what they hadbeen in 2004, without any additional deploymenton the part of the existing programme.By mid March 2005, MSF launched evaluationsin Maradi and Tahoua that confirmedhigh rates of acute malnutrition - months earlierthan the usual hunger gap - and began toexpand and extend activities in both regions.Weekly family food rations and a large dischargeration were added to the therapeuticpackage of RUTF and medical care offered toall admitted children. By early July 2005, 45international staff and 660 national staff wererunning 27 outpatient centres (OC) and fivestabilisation centres (SC) for severely wastedchildren. From August 2005 onwards, activitiesin Tahoua and the northern parts ofMaradi were handed over to other internationalagencies, and subsequent MSF effortswere concentrated on the most affected areasof Maradi and Zinder, where the majority ofadmissions for severe malnutrition werebeing recorded. In late September 2005, thefeeding programme in Maradi admitted 2,043new patients and was monitoring 8,727 malnourishedpatients a week, 934 of them in the1Unicef. State of the world’s children 2006: Excluded andinvisible. NY: Unicef 2005.2Briend A, Lacsala R, Prudhon C, Mounier B, Grellety Y,Golden MH. Ready-to-use therapeutic food for treatment ofmarasmus. Lancet 1999; 353: 1767-1768.3Collins S. Changing the way we address severe malnutritionduring famine. Lancet 2001; 358: 498-501.4Community Based Therapeutic Care (Khara T. Collins, S.ed). ENN Special Supplement Series, No. 2, EmergencyNutrition Network, November 2004.5Collins S, Sadler K. Outpatient care for severely malnourishedchildren in emergency relief programmes: a retrospectivecohort study. Lancet 2002; 360: 1824–1830.6Ciliberto MA, Sandige H, Ndekha MJ, Ashorn P, Briend A,Ciliberto HM, and Manary, MJ. Comparison of home-basedtherapy with ready-to-use therapeutic food with standardtherapy in the treatment of malnourished Malawian children:a controlled, clinical effectiveness trial. Am J ClinNutr 2005; 81: 864 –870.2

MadarounfaOutpatientCentreAnne Yzebe, Niger, 2005four inpatient facilities and the rest in outpatientcare. In the three southernmost departmentsof Maradi, two decentralised paediatricunits were also opened and medicines wereprovided to a dozen government health centres,to facilitate free outpatient and referral healthcare for all under 5 children. Between July andOctober 2005, MSF distributed over 4,000 tons(129,487 rations) of blended, enriched flour andcooking oil to families of 53,031 at risk or moderatelymalnourished children aged less than 5years old. In Zinder region, MSF would go on toadmit over 21,000 severely malnourished childrenin the last five months of the year, usingthe same simplified outpatient system as inMaradi.Programme designChildren between 65 and 110 cm of height wereadmitted on the basis of mid-upper arm circumference(MUAC) < 110 mm, weight-forheight(W/H) < -3 Z scores (ZS) of the NCHSstandard or the presence of bilateral oedema.Children in the same height range with aweight for height between –2 and –3 ZS accompaniedby severe pathology were also admitted.Children between 60 to 65 cm height and above6 months of age were admitted on the basis ofweight-for-height or oedema criteria only.All admissions received systematic amoxicillinfor 5 days, single doses of albendazole,folic acid and vitamin A according to weight,and measles immunisation. Those identified aspositive for falciparum malaria by rapid bloodtest received artemesin-based combinationtherapy (ACT). Specific treatments were givenfor respiratory, gastrointestinal or cutaneousdiseases according to standardised protocols.All complicated cases presenting with anorexia,severe pathology or moderate to severe bilateraloedema were immediately referred to a SC.Uncomplicated cases were consulted andweighed weekly and sent home with furtherspecific treatments, 1000 kcal/day of a RUTF(two 92g packages of Plumpy’nut daily) and asof March 2005, a family protection ration of 5 kgof blended, enriched flour (Unimix) and 1 litreof cooking oil. Returning outpatients withanorexia, severe pathology, appearance of moderateto severe oedema, abrupt or progressiveweight loss or failure to gain weight after 4weeks in the programme, were referred to a SC.Children reaching exit criteria (W/H > -2 ZS for2 consecutive weeks, mid upper arm circumference> 110 mm, no oedema and absence ofongoing infection) were sent home with a dischargeration of 50 kg of millet, 25 kg of cowFigure 1 Weekly admissions to Maradi programme during 2005Weekly addmissions Maradi Region 2005Médecins Sans Frontiéres, NigerMaradi SC + 7 OCopened 2001-2004Dakoro SC + 6 OCopened weeks 16-17Aguié SC + 3 OCopened weeks 25-26peas and 10 litres of cooking oil.All six SCs had planned capacities of up to250 children, with actual patient counts reachingover 300/day in some centres during thepeak part of the year when 100 patients/daywere being admitted. Along with standardfeeding centre facilities, SCs had well staffedintensive care units of up to 50 beds to handlecritical cases referred from outpatient care.These units were equipped with oxygen, a miniblood bank, broad spectrum parenteral and oralantibiotics and the ability to monitor a largenumber of children receiving tube feeding (F-100 milk) or rehydration (Resomal solution).Stabilised patients were referred back to outpatientcare unless they had already reached dischargecriteria (W/H > -2 ZS for 3 consecutivedays, mid upper arm circumference > 110 mm,no oedema and absence of ongoing infection) inwhich case they were discharged directly homewith a one-month discharge ration.ResultsMSF admitted 43,529 malnourished childreninto its programmes in Maradi and Tahouaregion between January 1st and December 31st2005 (see figure 1). Almost 20,000 were admittedin a ten week period (weeks 30 to 40) inAugust and September 2005. As in previousyears, 95% of admitted children were under 85cm in height. Moderately malnourished childrenbetween –2 and –3 ZS with severe pathologyrepresented 6.4% of admissions, and kwashiorkoronly 2.8%. These results are typical forcountries in the Sahel, with chronic high rates ofwasting striking weaning age children less than24 months old, reaching dramatic levels duringhunger gap periods and epidemic proportionsduring bad years.Detailed results are given here for all 37,483patients treated and discharged from programmesin Maradi region, including the SCs inMaradi, Aguié, Tiberi and Dakoro and 18 associatedOCs in the six rural departments(Madarounfa, Guidan Roumdji, Aguié,Tessaoua, Mayahi and Dakoro) opened for atleast part of the year (see table 1). Results from2005 are compared with results for the sameregion between the years 2001-2004 when therewas one SC in Maradi and seven outpatientcentres in the three heavily populated, agriculturaldepartments of southern Maradi, whichalso accounted for 75% of the admissions in2005 (see figure 2). Geographical expansion wasnot the determining factor explaining the dramaticincrease in the number of admissions toMSF programmes in Maradi over previousyears.Out of the 39,353 admissions in Maradiregion in 2005, only 0.8% was readmissions(relapse within 3 months of previous discharge).A total of 25,688 (65.3%) were admitteddirectly into outpatient care and of these, 1,996(7.8%) were subsequently referred to a SC atsome point during the course of treatment. OCsTiberi SC + 2 OCopened week 36OC= Outpatient centreDakora SC closedAguié SC to SCF10 OC to SCF & ACFweek 48SC= Stabilisation centre3

Field Articleaccounted for 31,246 (83.4%) of 37,483 total discharges(see table 2). Overall programme curerate was 91.4%, mortality rate 3.2%, default rate4.7% and 0.7% were transferred out of MSF programmes.These results are superior to those obtainedin 2004 when cure rates were 83.5%, defaultrates 10.3% and mortality rates 6.0%.Readmission rates also dropped from 1.6% in2004 to 0.8% in 2005. The better results in 2005,despite much larger patient numbers, wasprobably due to early diagnosis and greaterparticipation in the programme, encouraged bythe introduction of protection and dischargerations in March 2005 amidst widespreadhousehold food insecurity. Although childrendischarged from outpatient care have longerdurations of stay and lower daily weight gainsthan those treated as inpatients, they still spendless than a month (29.1 days) in the programmeand their daily weight gain (10.5 g/kg/d) iswell above recognised benchmarks. It could beargued that spreading the total weight gainover a longer period of time within the patient’susual family environment may be a factorexplaining the low rate of relapse (0.8%) followingcure.DiscussionNiger faced an epidemic of acute malnutritionin 2005 primarily affecting young children lessthan 24 months of age in the southern areas ofMaradi and Zinder provinces during thehunger gap period between June and October.This epidemic occurred on top of chronicallyhigh rates of wasting and mortality amongstyoung children.In Niger, most rural families are highlydependent on market food purchases for a largepart of their dietary intake . In 2005, milletprices in Maradi reached up to 28,000 CFA for a100 kg bag in July compared to 8,000 CFAreceived by farmers at the time of the previousharvest in 2004. There is a striking correlationbetween the market price of millet in Maradi in2005 and the number of admissions of wastedchildren into MSF programmes five weeks later(see figure 3).MSF’s experience in Niger has importantimplications for medical practice in countrieswith high endemic rates of childhood malnutritionand large numbers of children requiringtreatment.• The results of MSF’s outpatient programmedescribed here, combined with results froman increasing number of similar programmes elsewhere, suggests that the vastmajority of severely wasted children can becured with simplified weekly surveillanceand ready to use therapeutic foods forhome consumption.• In Niger since 2001, tens of thousands ofmothers and fathers have been makingsustained efforts to bring their wastedchildren to MSF feeding programmeswhere, in over whelming numbers, theypersist in attending each week until completecure of their child has been achieved.All reason and evidence suggests that facedwith an effective, accessible and easy to useremedy, parents are willing to go to greatlengths to save the lives of their children.• The new paradigm of outpatient care usingnutrient dense therapeutic foods makesnonsense of the argument that the treatmentof malnutrition is a desirable but impossibleobjective for resource poor countries.Therapeutic foods can be produced andmade widely available where the need isgreatest. Acute childhood malnutrition,highly prevalent and frequently lethal, isalso eminently treatable.For further information, contact MiltonTectonidis,email: milton.tectonidis@paris.msf.org orIsabelle Defourny,email: isabelle.defourny@paris.msf.orgTable 1 Programme indicators for Maradi programme, 2005Weeks SC openAdmissions OC (n)Admissions SC (n)Total admissions (n)Proportion directadmissions to OC (%)Maradi Aguié Tibiri Dakoro Total MaradiregionWeeks 01-527,92613,61221,538Weeks 25-48 Weeks 36-52 Weeks 16-481,9824,2776,2592,2564,2396,4951,5013,5605,06113,66525,68839,35363.2% 68.3% 65.3% 70.3% 65.3%Figure 2100%90%80%70%60%50%40%30%20%34,86,853,3Discharges by Category (%) Maradi2001 – 200529,36,663,916,87,475,810,3 4,73,26,083,591,4% Defaulted% Died% CuredCuredn(%)15,968(90.8%)6,340(90.7%)7,139(91.7%)4,800(93.6%)34,247(91.4%)10%0%2001 2002 2003 2004 2005DiedDefaultedTransferredn(%)n(%)n(%)Total Discharges (n)707(4%)875(5%)37(0.2%)17,587190(2.7%)279(4%)180(2.6%)6,989140(1.8%)494(6.3%)8(0.1%)7,781181(3.5%)114(2.2%)31(0.6%)5,126Deaths in SC (n) 627 144 82 127 980Discharges from SC (n)Movements fromSC to OC (n)In hospital mortality (%)Movements OC to SC (n)3,3794,9577.5%6251,175 7339501,4575.5%2,302 1,0832.7%6.2%645 3643621,218(3.2%)1,762(4.7%)256(0.7%)37,4836,2379,7996.1%1,996Table 22002200320042005Figure 3Discharge profile per year for MaradiregionTotal discharge from SCand OCn5,3076,3559,52437,483Discharge from OC only3,871Comparison between the evolution ofweekly millet market prices in Maradi(FEWS/SIMA) and weekly admissions ofmalnourished children in Maradi (MSF)n3,5577,10431,246Direct admissions toOC (n)13,6124,2774,239 3,560 25,68830002500OC to SC/Directadmission OC (%)Average length of stayOC (days)Average length of staySC (days)Average weight gainOC (g/kg/d)Average weight gain SC(g/kg/d)4.6% 15.1% 8.6% 10.2% 7.8%29.113SC=Stabilisation centre OC=Outpatient centre31.9 28.526.511.729.116.4 16.1 13.910.6 10.4 10.2 10.410.518.9 19.1 14.3 14.217.3Weekly price100kg (CFA)2500200015001000500Price of milletin Maradi(francs CFA)MSF Maradi FeedingProgramme WeeklyAdmissions0W1 W15 W30 W452000150010005000weekly admissions4

Research5Early initiation of breastfeedingreduces neonatal mortalitySummary of published research 1 A womanworking in oneof the villagehouseholds inA recently published study assessed the contributionof the timing of initiation of breastfeedtalperiod (median age 14 days for establishedand 2.1% partially breastfed during the neona-Burkino Fasoing to neonatal death. The study also set out to breastfeeding pattern).Experiencebasedmeasureassess whether the different types of breastfeeding(exclusive, predominant, and partialThere was a marked dose response ofincreasing risk of neonatal mortality withbreastfeeding) were associated with substantiallydifferent risks of neonatal death.of householdincreasing delay in initiation of breastfeedingfrom 1 hour to day 7. Overall, late initiationMethod(after day 1) was associated with a 2.4-fold food insecurityThis study took advantage of the 4-weekly surveillancesystem from a large ongoing maternalvitamin A supplementation trial (ObaapaVitA)in rural Ghana involving all women of childbearingage and their infants. During thecourse of routine four-weekly field visits, whena birth was reported, the trained village fieldworkersincrease in the risk of neonatal mortality. Thesize of this effect was similar (Adjusted OddsRation (aOR): 2.44; 95% CI:1.60 to 3.74; P

Five cross-sectional surveys were conductedin refugee camps in north and eastAfrica between 2000-2002 to assess thelevel of iron deficiency anaemia and vitaminA deficiency in populations dependenton long-term international food aidand humanitarian assistance. Althoughthere has been much information onmicronutrient deficiency outbreaks likescurvy, pellagra and beri-beri amongstrefugees, there has been very little informationpublished on the prevalence of themore widely prevalent deficiencies ofiron, vitamin A and iodine.Although there were various methodologicalissues around interpretation ofthe findings, e.g. issues of age recall mayaffect estimates of age-specific anaemiawhile recall bias may have affected estimatesof vitamin A capsule coverage, theoverall findings give enormous cause forconcern.Study findingsThe prevalence of anaemia in children[haemoglobin (Hb) 60% affected in 3 of five camps. Irondeficiency [serum transferring receptor(sTfR) >8.5 mg/L] was also high, rangingfrom 23 to 75% (this measure is used toassess iron deficiency because it is relativelyunaffected by the acute phaseresponse associated with inflammationand infection). There was also a strongecological correlation between the prevalenceof iron deficiency and anaemiaamong different camps. Although childrenwere more affected, anaemia wasalso a public health problem in adolescentsand women. While the prevalence ofanaemia in the worst affected camps compareswith findings from other refugeestudies, i.e. in Burmese and Somalirefugee children, the levels constitute aserious public health issue.Mean serum retinol in children, afteradjustment for infection status, rangedfrom 0.72 to 0.88 +/- 0.2 µmol/L in thefour camps assessed and vitamin A deficiency(

ResearchMarket-based contractsprotect against pricerises in MalawiSummary of research 1Commodity options contracts are typically usedto hedge against price volatility. They operate ina similar way to insurance. Payment of a premiumis exchanged for the right, but not the obligation,to either buy or sell a commodity at apredetermined price for a particular period oftime into the future. The premium cost is determinedby the difference between the currentmarket price and the price protected, the lengthof time that the price protection is needed andthe volatility of the market. There are two typesof options contracts. ‘Put’ options are options tosell at a specified price in the future, and aretypically used by producers or exporters to protectagainst falling prices. ‘Call’ options areoptions to buy at a specified price in the futureand are typically used by importers to protectagainst rising prices. According to a recent articlein Humanitarian Exchange, when combinedwith a physical delivery contract, options contractscan help importers manage costs, andmitigate the risk that prices will increase dramaticallywhen there is a shortage in the market.In September 2005, the Malawian governmentsigned an options contract with StandardBank of South Africa. The contract allowed forthe purchase of a maximum of 60,000 tonnes ofmaize at a cost of approximately $18m – enoughto meet the food gap if donor and private sectorcommercial imports did not reach anticipatedlevels. The Department for InternationalDevelopment-UK (DFID) provided the financeto pay the options premium up front and theWorld Bank provided technical support. Theoptions contract provided the government witha mechanism to trigger additional imports atshort notice, put a price cap on the cost of maizefrom South Africa and provided protectionagainst the risk that prices would move higher.Agreeing an ‘over the counter’ contract meantthat the cost, included delivery to Malawi,reduced uncertainty over transport prices.In response to continued evidence of shortagesin the market and concern about risinglocal prices, the government exercised the firsttranche of the options contract on 7th ofOctober, buying 30,000 tonnes of maize. It exercisedthe second tranche on 15th of November,when it bought the remaining 30,000 tonnes.Malawi’s early experience with options contractswas largely positive. The majority of thepurchased maize was used to meet humanitarianneeds and did not reach the commercial market.The maize helped to avoid severe shortfallsin the humanitarian pipeline. Additionally, bythe time of delivery in December 2005/January2006, prices had risen by between $50-$90 atonne above the ceiling price of the contractwhile transport costs had also increased.Getting water in thedrought affectedlandscape in MalawiOne of the key challenges that the private sectorfaces in Malawi is uncertainty about whenthe government will intervene in the maize market.To address this problem, the options agreementwas made public via a government pressrelease. Private sector traders in Malawi and inthe region are supportive of this approach, andlook forward to an opportunity to be involvedcommercially.In the future, the government (or donors)could resell maize purchased through theoptions contract to local traders, who wouldthen manage distribution and commercial sales.In this way, the government or donor role is limitedto risk management (a critical need inMalawi, where local traders capacity to manageimports is weak). Over time, and as the capacityof local traders and the commercial marketstrengthens, this risk management functionwould naturally fall back to the private sector.Implications for humanitarian agenciesOptions contracts have the potential to enable aproactive, risk-management approach to the procurementof food by humanitarian agencies.They offer potential cost savings by allowingagencies to buy protection at lower market priceswhen these are available. They potentially speedup response mechanisms since triggering prearrangedoption contracts can be quicker thantendering for supply contracts. Local and regionaltrade are also supported through options contracts.Enabling agencies, like the World FoodProgramme, to work with option contracts will,however, require some significant transformationsin the way that funds are accessed andbudgets managed. These contracts require longtermprocurement plans if they are to be costeffective.For those agencies that have significantcore funding, this may not be a problem.However, where the procurement of fooddepends on contributions by donors to emergencyappeals, the opportunities to agree at anearly stage what food requirements will be in thefuture, and to ensure an early response, havebeen limited. Option contracts are a solution tothis problem since they allow for contingentimport contracting. As an example, donor agenciescan begin purchasing options contracts atthe first sign of a problem, then exercise or ‘call’for deliveries only if needs become apparent.Budgeting process within agencies may alsohave implications for the use of option contracts.In many agencies, significantly lessmoney is budgeted for disaster preparednessand prevention than is allocated to disasterresponse. Spending money on options contractsmay mean that there is less money to spendlater on emergency aid, if the option does notenable a crisis to be averted. Most importantly,humanitarian agencies receive much less creditfor their roles in preventing emergencies thanthey do for responding effectively when anemergency arises.1Slater R and Dana J (2006). Tackling vulnerability tohunger in Malawi through market-based options contracts:implications for humanitarian agencies. HumanitarianExchange, no 33, pp 13-17, March 2006J Dana, Malawi/Critical gapsin droughtresponse inGreater Hornof AfricaSummary of published research 1The drought currently affecting an estimated11 million people in the Greater Horn ofAfrica is said to be the worst in more than adecade, with the impact being most severe inpastoral areas on the Ethiopia-Kenya-Somaliaborder. Many humanitarian actors haveexpressed frustration that in spite of excellentearly warning, most agencies, donors andnational governments proved unable toaddress the crisis effectively in its earlystages. A recent HPG briefing paper reviewsthe extent of emergency livelihoods responsesin the region, drawing on secondary data andinterviews with national and internationalactors in affected areas.The review argues that the quality andcredibility of early warning systems have notbeen called into question in this case. The progressivedeterioration of pastoral livelihoodsin the region was well documented. However,while aid actors with a long-term presence indrought-affected areas moved quickly tomodify and scale up their interventions inresponse to the crisis, it was not until the situationwas extremely acute that it attractedmeaningful attention.National and international actors withinfrastructure and programmes in affectedareas were flexible in rapidly adapting andexpanding pre-existing livelihoods interventionsin response to the crisis, e.g. waterdevelopment and rehabilitation activities,herd survival actions, human and animalhealth assistance and cash interventions werepossible right from the start of the emergency.Opportunities were not, however, taken tobuild on longer-term work by heavily frontloadingthe emergency response with livelihoodsinterventions. Food requirements constituted85% of total needs identified underthe Kenyan Flash appeal while 83% of therevised Somali Consolidated appeal processwas for food assistance.The review asks why was there such a disconnectbetween long-term programmingand the emergency response. Three mainareas are identified as problematic: inadequatepreparedness, capacity imbalancesbetween food and livelihoods programmingand funding constraints.Inadequate preparednessDespite the cyclical pattern of droughts in thisarea, there are no national preparedness plansin Somalia or Ethiopia. Kenya is moreadvanced and has community and districtlevel drought preparedness plans. The mainconstraint appears to have been the absence7

Researchof national and sufficiently large local contingencyfunds to implement these plans rapidlyon a large scale. The lack of effective coordinationbetween district and national levelsmeant that these contingency plans did notform the basis of wider national and internationalresponses. As a result, internationalactors largely bypassed national structures ineach country. Since international actors alsolacked pre-existing emergency plans for collectivework, there was little consensus onthe balance to be struck in the emergencyresponse between preventive livelihoodsinterventions and food assistance.Capacity imbalances between foodand livelihoods programmingA key weakness was the lack of capacity forassessing, designing and implementing livelihoodsinterventions. Assessments were generallylacking the hard data that food assessmentswere able to provide to demonstratepotential life-saving impact. In addition, thereappear to have been significant delays inplanning for large-scale livestock relatedlivelihoods interventions. Many donors, especiallyin Kenya, felt that plans for de-stockingwere being submitted at a time when it wasno longer appropriate to intervene to acceleratelivestock off-take. Some agencies, particularlyinternational relief organisations, alsomentioned a lack of capacity to implementthese programmes. Both implementing agenciesand donors reported a dearth of innovativeapproaches: many claimed that the crisiswas so severe that less established programming,such as cash transfers, were too risky.However, well-designed and timely livelihoodsinterventions were possible whereagencies had longer-term programmes andan intimate understanding of the local context.Funding constraintsFunding for livelihoods interventions wasmuch lower than for food assistance. The difficultyof attracting donor funding for livelihoodsprojects was widely reported byhumanitarian agencies, with donors in returnindicating a lack of receptivity at headquartersto such interventions. This was reportedlydue to an overload of requests for non-foodresources globally, as well as a lack of contingencyfunding. Although the ConsolidatedAppeal for the Horn of Africa focused primarilyon non-food interventions, it was notlaunched until April 2006 and was, in anycase, critically under-funded.ConclusionEffective early warning does not ensure anadequate and timely response in slow onsetdisasters. Where agencies had a long-termpresence and were flexible in redeployingfunds earmarked for long-term activities,livelihoods interventions were implementedin a timely manner. It is essential that relevantnational preparedness plans are in place incontexts where vulnerability is chronic andwhere acute crises are likely to develop. Inorder for these plans to be effectively put intooperation, there must be investment innational capacity to implement emergencylivelihoods programming on a large scale.USAID in publicprivateallianceinitiativeSummary of published research 1The United States Agency for InternationalDevelopment (USAID) established the publicprivatealliance initiative - the GlobalDevelopment Alliance (GDA) - approximatelyfour years ago. The initiative reflected the factthat over the past 30 years, resource flows fromthe United States (US) to the developing worldhad shifted from being predominantly government-led,to a situation where now 85% ofresources come from fixed capital investment,remittances and various forms of private funding.According to a recent article in OECDObserver, there are many examples of how theGDA has successfully forged partnershipsbetween the public and private sector.Under the GDA in Malawi, a non-governmentalorganisation (NGO) called ProjectPeanut Butter (PPB) teamed up with Nutriset toestablish a production facility for Ready to UseTherapeutic Food (RUTF). Nutriset donatedfinancing and shared its intellectual property,i.e. the recipe. USAID gave $130,000 to PPB tofinance the production facility and training ofMalawian staff. PPB and Nutriset providedcumulative funding and in-kind resourcesworth $450,000. Nutriset did not make a profit.The production facility uses local raw materialsand will soon have its capacity expanded. Otherexamples of successful partnership cited in thearticle include work with the Dutch company‘Royal Ahold’, which is one of the largest buyersof food in the world. As well as bringing itsknowledge of agricultural quality to the table,Royal Ahold co-funds projects with NGOs onthe ground in Ghana. The company has foundopportunities to encourage new businesses,such as cosmetic product lines from shea butter.USAID has contributed more than $2 million tothe alliance, which Royal Ahold has more thanmatched through cash contributions and technicalexpertise.There is also the Sustainable Forest ProductsGlobal Alliance with the Swedish firm Ikea,Home Depot and other large buyers of forestproducts to which USAID has contributed over$7.5 million since 2002. Alliance partners haveA malnourished childhelps herself to locallyprodued RUTF in Malawimore than matched this amount to the tune ofover $27.5 million in funding.GDA is, however, not the only governmentagency building alliances. In recent years, otherOECD countries have also become involved,e.g. GTZ, DFID and CIDA. In spite of the manysuccesses, the article highlights the fact thatthere are important lessons to learn from thisway of working.First, grant mechanisms rather than budgetsupport work best. Typically, USAID and privatepartners fund the implementing organisation,usually NGOs. Second, partnerships canboost aid effectiveness in some sectors. In agriculture,productivity appears to have beenenhanced by bringing market disciplines andexpertise about cultivation and quality standardsto bear.There are also lessons of warning. Partnersshare risk but do not make that risk disappear.Good projects have been known to comeunstuck late in the process because of suddenshortage of business funds. Also, there are lobbiesagainst partnerships seeing them as effortsto standardise global markets thereby creatinglosers, e.g. local farmers that do not make thecut. Partners, therefore, need to think abouthow farmers who do not meet productivityrequirements in particular markets can diversifyinto other agribusinesses, such as food processingand packaging, or even switch to otherareas such as tourism.1Runde. D (2006). How to make development partnershipswork. OECD Observer, No 255, May 2006, pp 35-37Mothers feeding theirchildren local RUTF,produced throughProject Peanut ButterM Manary, Malawi, 2003M Manary, Malawi, 20031Saving lives through livelihoods: critical gaps in theresponse to the drought in the Greater Horn of Africa. HPGbriefing note. May 20068

ResearchField ArticleRevisiting ‘new variant famine’in southern AfricaSummary of published research 1S Roughneen, Dafur, 2006The ‘New Variant Famine’ hypothesis was firstpublished in 2003. It postulated four factorscontributing to worsening food shortages insouthern Africa and limiting recovery;i) household level labour shortages due toadult morbidity and mortality, and therelated increase in numbers of dependantsii) loss of assets and skills due to adultmortalityiii) the burden of care for sick adults andchildren orphaned by AIDS, andiv) the vicious interactions between malnutrition and HIV.A paper just published in HumanitarianExchange draws on recent published researchand two recent studies in Malawi andSwaziland to reassess the new variant faminehypothesis.Both Malawi and Swaziland are predominantlyagricultural, poor and vulnerable andare suffering high prevalence epidemics ofAIDS. In both countries, farming is labourintensive,reliant primarily on hoe-cultivatedmaize in a single farming season and food crisis,including chronic malnutrition and recurrentfamine, is common to many parts ofMalawi and Swaziland. Both countries also facea severe HIV/AIDS epidemic. Adult prevalenceof HIV/AIDS among ante-natal clinic(ANC) attendees in Swaziland – 42.6% - is thehighest in the world. In Malawi, prevalenceamong ANC attendees is 14.4%. Mortality inSwaziland has almost tripled over the past tenyears, from about eight deaths per 1,000 in 1994to about 23/1,000 in 2004. Adult mortality hasalso risen sharply in Malawi. In both countries,these increases are almost entirely due to AIDS.HIV/AIDS and loss of household labour,assets and skillsResults of household studies in both countriesduring the 2002-3 crisis clearly show thatHIV/AIDS was one cause of declining agriculturalproduction. Evidence from Swazilandfound a reduction in maize production of 54.2%in households with an AIDS-related death. InMalawi, households without an ‘active adult’suffered a 26% drop in tuber production, a 53%fall in cereal production and a 51% reduction incash crop income compared to households withat least one ‘active adult’. There is also animportant gender dimension to this impact. InMalawi, in households with a recent adult maledeath, the area planted is 32% lower than inhouseholds with a recent adult female death.HIV/AIDS and rural livelihood copingstrategiesA survey of HIV affected households in Malawifound that three quarters of householdschanged their usual crop mix towards lesslabour-intensive crops in response to labourshortages and lack of resources. In contrast, inSwaziland decreasing the area under cultivationwas a common response. According to onestudy, the area under cultivation decreased byan average of 51% in households with an AIDSrelateddeath, compared with 15.8% for householdswith a death that was not AIDS-related.In Malawi, one household study found thatsome 40% of those affected by chronic illnesssold a portion of their assets to buy food or topay medical or funeral expenses. In Swaziland,households with an AIDS death experienced a29.6% reduction in the number of cattle theyowned.HIV/AIDS and changing dependencypatternsIn 2003, UNAIDS estimated that about 500,000children (about 50% of the total number oforphans) in Malawi and 65,000 children (65% oftotal orphans) in Swaziland below 17 years ofage had lost one or both parents to AIDS.Caring for an increasingly large number oforphans is placing a tremendous burden onextended families and community networks. Atthe same time, kinship networks have provenresilient in providing at least a minimum levelof care and socialisation for children orphanedby AIDS.HIV/AIDS and malnutritionOverviews of nutritional surveys during the2002-3 drought found clear signs that doubleorphans have a much higher prevalence of malnutritioncompared with children with one orboth parents living. It also found that, althoughchild malnutrition rates were higher in ruralareas (which tended to have lower HIV prevalence),the decline in nutritional status wasmost marked closer to towns (which have higherprevalence of HIV/AIDS than rural areas).There is also preliminary evidence that therebound in nutritional status after the end ofthe drought in 2003 was less robust than expected.Other aspects of the relationship betweenmalnutrition and the HIV/AIDS epidemicremain speculative and under-researched.Little is known about the indirect impacts of theHIV/AIDS epidemic on the spread of childhoodinfectious diseases, and studies of adultnutrition and HIV infectivity and virulence arecomplex, contradictory and/or inconclusive.In conclusion, the authors state that recentresearch supports the view that AIDS is challengingrural livelihoods, underminingresilience to other shocks and stresses and creatingnew patterns of malnutrition. It is alsoargued that in many areas of southern and easternAfrica, each turn of the cultivating seasonsis seeing a small, significant and usually negativechange in rural livelihoods. While communitiesare resourceful and inventive in respondingto the stresses they face, a significant proportionof the rural population is being grounddown into chronic destitution. According to theauthors, this is preventable but it is not beingstopped and until it is, we face the prospect ofmajor, ongoing interventions to support socialwelfare in affected communities.Runde. D (2006). How to make development partnershipswork. OECD Observer, No 255, May 2006, pp 35-37View of Fata Borno IDP camp, North Darfur,temporary home to 18,000 IDPs.DeliveringSupplementaryand TherapeuticFeeding inDarfur:Coping withInsecurityBy Gwyneth HogleyCotes, GOALGwyneth joined GOAL in November, 2005as the Nutrition Coordinator for Darfur,Sudan. She has a BA in InternationalStudies and Master of Public Health (MPH)degree focusing on child health and survival.Her work experience includesresearching the barriers to therapeuticfeeding centre attendance in Eritrea in2001 and training Ministry of Health staffin Ghana in improved disease control andimmunisation information managementtechniques.GOALs Simon Roughneen assisted in conceptualising,framing and editing this article.This article would not be possiblewithout the professionalism and bravery ofGOALs nutrition workers and the rest ofthe Darfur field team.9

Field ArticleThis article describes the ongoing challenges thatinsecurity poses to the GOAL nutrition programmein Dafur and the strategies they have respondedwith.In February 2003, fighting erupted betweenSudanese government forces and theSudanese Liberation Army (SLA), a rebelmovement seeking to achieve greaterautonomy for the Darfur region and its people.Later the SLA was joined by the Justice andEquality Movement (JEM), a pan-Sudaneseopposition group. The conflict made headlinesaround the world when government-armed‘Janjaweed’ Arab militias conducted widespreadattacks and looting in Darfur villages,resulting in an estimated 200,000 deaths and thedisplacement of some 2 million residents.The fighting and displacement has slowedits pace somewhat since the start of the conflictbut, in late 2005 and into 2006, areas of westernand northern Darfur have seen renewed violence,resulting in new displacement. Currently,there are approximately 1.75 million Darfuriansliving in internally displaced persons (IDP)camps or host communities throughout Darfur,with another 200,000 refugees in Chad. Thehumanitarian situation has been further compromisedby the spread of the conflict acrossthe border into Chad. At the time of writing, aninternationally mediated peace agreement wassigned between the Sudanese government andone faction of the SLA. However, a second SLAfaction and the JEM party refused to sign, causingtension throughout the Darfur region andraising concerns that the split could cause aresurgence of fighting.As a result of the conflict, most residents ofDarfur have seen a complete disruption of theirlives and livelihoods, with access to land, markets,and services restricted by violence andfear. Productive assets have been depleted,either looted by warring factions, or sold as ameans to get food and shelter.Humanitarian situationDespite the influx of aid in 2004, the humanitariansituation has remained precarious. As aresult of widespread food aid and supplementaryfeeding, global acute malnutrition (GAM)rates have dropped from the critically highrates that were found at the height of the conflict,but are still alarming, ranging from 10-20%throughout Darfur. Even before the conflict,large portions of Darfur were characterised as‘chronically-destitute’ with wasting levels of20%, criteria that would have justified emergencyintervention long before the fightingstarted 1 . However, after three years of intensehumanitarian activity, international assistanceis beginning to wane. Starting in May 2006, theWorld Food Programme (WFP) will be forced tohalve its food aid to nearly 3 million residents ofDarfur, because of a shortage of donor funding.GOAL’s work in DarfurAfter the conflict began, GOAL set up twoemergency assistance programmes in Darfur.The first was started in February 2004, in theKutum region of North Darfur, an arid areasubject to food insecurity even before the conflict.The war in Darfur had further exacerbatedthe health and nutrition problems in the area,and rates of malnutrition were typically higherthan in other parts of Darfur. GOAL had a historyof involvement in the region, and wasalready monitoring the humanitarian situationbefore the conflict began.Approximately 45-50,000 IDPs are currentlyliving in host communities and in camps nearthe primary town of Kutum. GOAL currentlyprovides primary health care and water/sanitationservices throughout the region and incamps. GOAL’s nutritional services are providedusing the Community-based TherapeuticCare (CTC) approach, including supplementaryfeeding (SFP), outpatient therapeutic feeding(OTP), and inpatient care for complicated casesof severe malnutrition.In March 2004, GOAL began operating inJebel Mara, a contested area in a fertile mountainregion that once provided much of theregion’s food. After the war began, much of theland was abandoned following attacks on villages,and the food security and health of thepopulation declined rapidly. At that time,GOAL was the only agency working in the area.The programme distributed non-food reliefitems to IDPs and provided supplementaryfeeding, therapeutic feeding (TFP), primaryhealth care (PHC), and water/sanitation services.Due to a significant deterioration in the securitysituation, this programme was closed inJanuary 2006.The impact of insecurity on the provisionof nutritional servicesDifficulty providing servicesGOAL’s services are spread out over a widearea of North and West Darfur. Because populationmovements are restricted by insecurity,GOAL must travel to field sites on a daily basisto bring services to populations in need. As aneutral agency, GOAL provides nutrition servicesin both government and rebel-held areas ofDarfur.This presents logistical constraints in termsof transportation and communication, as GOALhas to coordinate all activities with all the variouspolitical factions before travel can be authorised.Access to programme sites is carefullyregulated, and authorities on all sides must benotified in advance of all programme staff andpatients who are to be transported across militaryboundaries.Table 1The purpose of advance notification and communicationprocedures is to determine if fightingor suspicious movements are occurring inthe travel areas. However it does not provide aguarantee of staff safety. Non-governmentalorganisations (NGOs) risk having their carshijacked or getting stranded by an outbreak ofviolence each time they enter the field. Specialcommunication equipment must be available,and all GOAL staff must adhere to very stringentsecurity procedures at all times. Every stepis taken to ensure, as much as possible, that personneland assets are not exposed to unnecessaryrisk.Rigid security protocols make it difficult tovisit local communities outside of the clinicareas. Thus assessments, screening, follow-upvisits, and community sensitisation cannotalways take place as planned. In rural areas,nutrition services are generally provided inconjunction with clinic services, and screeningis conducted among clinic attendees; activecase-finding is nearly impossible given thesecurity constraints. The coverage attainedusing this method is very low, and additionalmethods have to be developed in order to reachlocal communities.Service interruptionsGOAL provides SFP and CTC services on a biweeklyschedule, as weekly distributionsresulted in large numbers of caretakers defaultingfrom the programmes. Prior to each distribution,communication with authorities andadvance notification allows GOAL to identifyareas that are unsafe for travel. When fightingor troop movements occur, programme activitieshave to be temporarily suspended, and nostaff or food aid can be transported to field sites.In most cases, there is no way to communicateto beneficiaries when services have beeninterrupted – no telephone service is availablein rural sites. Beneficiaries sometimes travellong distances to reach the SFP/CTC site, onlyto find that staff and provisions have notarrived. This results in a serious lack of confi-1Assessing the Impact of Humanitarian Assistance, A Reviewof the Methods in the Food and Nutrition Sector. JeremyShoham, HPG Background Paper.The impact of various degrees of insecurity on population movement and programmingProblem Result Impact on programmeRestrictedaccess toconflictaffectedareasOccasionalserviceinterruptionsdue tofighting orinsecurityGeneralconflictLimited screening in rural communitiesLimited ability to conduct household visits onchildren who are absent from OTP/SFP servicesLow numbers of children followed up afterdefaultLimited numbers of staff allowed into programmesitesReduced confidence in programme servicesOccasional long gaps in-between food distributionsFrequent population movementsWomen fear travelling far from homesReduced programme coverageIncreased default ratesReduced ability to assess and respond toreasons for defaultIncreased costs, as additional staff mustbe hired and trained in field locationsIncreased default ratesReduced rate of weight gainIncreased length of stay in programmeReduced cure ratesIncreased defaulter ratesNeed for increased flexibility inprogramme responseDifficulty locating defaulters, largenumbers of children lost to follow-upIncreased defaulter ratesReduced coverage10

Field ArticleS Roughneen, Dafur, 2006dence in NGO services, particularly in ruralareas. Caretakers become less willing to travelto the SFP site after a service interruption,resulting in high rates of programme default.The interruption also has a negative effect onthe growth and recovery of the child, especiallyduring periods of ongoing insecurity, whenthey may not receive supplementary food forsix weeks or more.GOAL nutrition worker Hawaida Tijaniexplains TFC rations for under-5s tomothersNutrition programmes are affected by interruptionsof other services as well. Medical serviceclosures can reduce the number of beneficiariesavailable for screening, lowering the programme’scoverage. Suspensions or delays ingeneral food distributions cause food to beshared among other family members, loweringcure rates.Reduced programme effectivenessMost agencies providing SFP and CTC servicesin Darfur report low levels of attainment ofinternational standards for feeding programmes.In the current context, achieving the acceptablecure rates of more than 70% and default rates ofless than 15% is extremely difficult.Although much of the conflict-affected populationis concentrated in IDP camps, mostlysituated near major towns, hundreds of thousandsof conflict-affected people are still livingin rural communities. It is these populationsthat are most difficult to reach with nutritionalservices (see table 1). Even under more stableconditions, nutrition programmes often haveproblems with caretakers defaulting due tolong distances between homes and services,poor understanding of the importance and purposeof feeding programmes, and seasonalmigration. In Darfur, all those problems exist aswell, but are compounded by the problem ofcaretakers who are often afraid to walk to SFPor CTC sites because of the threat of physicalviolence or harassment. In some areas ofDarfur, African Union (AU) peacekeepingforces escort people twice a week from localcommunities to the market, or guard women asthey collect firewood because the danger ofrape or physical attack is so high. Caretakersmay also have little confidence in the programmebecause the agency has previouslybeen absent. In short, the costs of attendingnutritional services often outweigh the perceivedbenefits.Risk of sudden programme closureOne of the biggest problems with providingnutritional services in insecure areas is the possibilityof a complete evacuation and abandonmentof services in the event of a large-scaleoutbreak of fighting. The agency will not onlylose capital assets, such as vehicles, computers,and office facilities, but less tangible resourcesas well, such as programme information andthe training that has been invested in local staff.The community being served will suddenly becut off from needed aid, and may be angry orresentful at the agency for pulling out, makingre-entry into an area more difficult if the securitysituation improves sufficiently to allow for it.Even smaller programme suspensions canpresent serious challenges to nutrition programmes.In December 2005, an attack on oneof GOAL’s key focal areas in West Darfurcaused a shutdown of services in the vicinity.Numerous local field-based staff fled with theirfamilies to distant villages, including nutritionoutreach workers. The food store located in thetown was abandoned, all supplies and foodcommodities lost. Approximately 10,000Darfurians were displaced to villages scatteredthroughout the area, including nearly 600 malnourishedchildren who were enrolled inGOAL’s SFP.A rapid response was essential to ensure thata nutritional crisis did not emerge. GOAL conductedsecurity assessments to determine thelocation of the majority of the new IDPs, andconducted rapid nutrition assessments withintwo weeks of the attack to determine where SFPservices could be moved in order to reach thegreatest number of displaced beneficiaries.An additional problem was locating missingstaff. In each village visited, sheikhs were askedto locate any displaced GOAL staff that hadrelocated to the area. The sheikhs were giventhe date and location of GOAL’s next visit sothat staff could receive pay and be returned towork in a new site if they so wished.Although SFP supplies and staff were availablein the area, the conflict was so disruptivethat providing health or nutrition services wasimpossible. However, in another scenario, itmay have been possible for SFP services to continuein this location, as all the required inputs– staff, food, and facilities – were already positionedin the field. Based on the lessons learnedfrom this experience, GOAL is planning to testthe option of self-sufficient field-based locationsin its programme in North Darfur so thatservices can be continued for a short time, evenif the location gets cut off from the programmebase by fighting.Strategies for dealing with insecurityDecentralising servicesDecentralising nutrition services allows for betteraccess into local communities, and, if suppliesand staffing are sufficient, can allow SFPand CTC services to continue even in the eventof a suspension of travel to the field.GOAL’s nutrition programme in Jebel Maraoperated out of one central hub, with four primaryprogramme centres. In each, a food storewas built to hold SFP supplies and food.Enough food was stored to cover at least twodistributions, or one month, of food. From eachof the programme hubs, two or three SFP siteswere served. Every two weeks, nutrition workerstravelled by car from the primary town inthe region. They stayed in secure overnightlocations, set up with bedding and shelters ineach of the four programme hubs, which werethen used as a base to provide SFP services tothe surrounding sites.Each programme hub was used as a base toserve 2-3 nearby SFP sites, and all sites wereserved during 3-4 day overnight visits. Thisstrategy increased the amount of time availableat each SFP distribution, allowing womenenough time to walk from their homes to theproject site. However, additional logistical andsecurity planning was required to ensure thatcommunication systems were in place and thatsupplies were pre-positioned and sufficient forthe whole stay.Overnight visits also increased the risk thatstaff could be stranded in a field location iffighting erupted between the field site and theprogramme base. This happened in January2006, when the base town of Golo was attacked,and staff working in the field had to be evacuatedby airlift. This underscored the importanceof good communication systems, clearlydefinedevacuation plans, and advance preparation– for example, one way to prepare forthis scenario is to identify potential helicopterlanding sites in all programme locations, andcollect GPS data for each site.Although it carries risks, the strategy ofdecentralising services could be taken one stepfurther, by hiring local nutrition staff, who arethen fully trained in providing SFP or CTCservices. In the case of Jebel Mara, field-basednutrition staff had already been identified, andSelma Abdullah of GOAL distributingTFC rations at Fata Borno Clinic/IDPCamp, north Darfurthe storage capacity for food commodities andsupplies was adequate. Caretakers kept theirregistration cards with them so record-keepingwas also decentralised.With additional training,the field-based nutrition staff could havecontinued SFP services even if the headquartersstaff were unable to reach the location.S Roughneen, Dafur, 200611

Field ArticleT Keegan, Dafur, 2006GOAL staff meet local sheiks to discussaccess and programme activities inKutum town and IDP campsDeveloping strong communication with communities,local leaders, and authoritiesGood communication systems are crucial for anumber of reasons. First, because of the threatof insecurity and the restrictions placed on NGOmovement, agencies often have very limiteddirect access to local communities, making screening and community sensitisation impossible fortown-based staff. Instead, community volunteers, locally-based staff, and local leaders mustbe enlisted to bring messages to communities.In GOAL’s Jebel Mara programme, between4 and 8 outreach nutrition workers operatedout of each programme hub. On distributiondays, the outreach workers helped provide SFPservices. During the rest of the two-week cycle,they visited the homes of children who hadbeen absent at the distribution to reducedefaulters, and conducted screening and communitysensitisation. Outreach workers wereselected from local communities; although theywere still subject to some danger while travellingin rural areas, they had better knowledgeof the local security situation, and were betterable to access rural communities.In GOAL’s North Darfur programme, locally-basedCommunity Health Promoters (CHPs)conduct house visits to follow up on childrenabsent from SFP or CTC services, to conductscreening and education, and to raise awarenessamong the community. In rural areas,where distances are great, CHPs are providedwith donkeys in order to travel between villages.In areas where no CHPs are present, localsheikhs are asked to inform community membersabout nutrition services to encourage themto bring thin children for screening.In October 2005, GOAL carried out a householdnutrition survey, covering the entire catchmentpopulation of its North Darfur programme.To enter rural villages, a number ofsteps had to be taken:• Discussions were held with local authoritiesto gain approval to carry out the survey.• Advance approval was sought from authorities,listing all locations selected for the survey,and the dates that villages would bevisited.• Letters were carried by clinic staff to thesheikhs in the selected villages to informRecording theMUAC valuethem of the purpose of the survey, and thedates on which the communities would bevisited.Without effective channels of communication,the survey would not have been possible.Regular communication enhances the acceptabilityof the organisation within the communityand reduces the threats to staff, who cansometimes be regarded with suspicion by militaryand political groups. It is important tomaintain visibility and transparency of programmeactivities, so that communities areaware of who is providing key services, andhow those services are organised. This reducesthe risk to staff by increasing the perceivedvalue of the organisation – there will be less interferencein programme activities if soldiers orcommunity members perceive that the organisationis providing valuable services, and can trustthat the organisation will do what it says it will.Health and Community EducationOne of the most important factors in successfullyproviding nutrition services in insecure areasis community awareness and education.Because agencies are limited in their directaccess to communities, following up on beneficiariesis much more difficult. Instead, nutritionworkers must stress at each distribution theimportance of returning every two weeks forservices. In order to increase the perceived benefitsof the programme, mothers are encouragedto think of Corn Soy Blend (CSB) as treatmentfor a sick child, rather than as food. At each distribution,caretakers have to be reminded of theimportance of not sharing CSB.In both of GOAL’s Darfur programmes, SFPservices are provided in conjunction with clinicservices, located on or near the grounds of alocal health centre. This encourages the idea ofSFP as a treatment, and also allows easy referralbetween health and nutrition services.Planning for the futureAs in most emergency situations, there was alarge influx of funding and agency support afterthe early, critical stages of the Darfur conflict,resulting in a quick improvement in health andnutritional status among children in the region.Funding for food aid and nutritional serviceshas slowly waned since the initial crisis passed.However, hundreds of thousands of householdsare still dependent on food aid as their primaryfood source, and still lack access to livelihoods,productive land and alternative sources of foodbecause of ongoing insecurity.A number of challenges have emerged in2006. The WFP recently announced that food aidrations in Darfur will be cut in half because of ashortage of funds. This will directly reduce theeffectiveness of SFPs, as food rations are sharedamong other family members. Donor supportfor SFPs and TFPs has declined as a result oflowered admissions following the early nutritionalcrisis. The majority of agencies providingsupplementary and therapeutic feeding inDarfur have demonstrated poor performance incomparison with internationally accepted standardsfor cure and default rates, resulting in furtherquestions about the effectiveness of feedingprogrammes given the context of insecurity anddifficult access.It is difficult to get a true sense of the nutritioncontext in the region because of the constraintsin carrying out surveys and rapidassessments. Surveys can only be conductedamong accessible populations, such as in IDPDrug distribution during an SFP atGOAL clinic, Kassab IDP camp, northDarfurcamps, towns, and more stable rural areas. Themost vulnerable children are often missed bythese surveys. However, several recent assessments,including one carried out by GOAL inOctober 2005, have found that GAM rates arestill above emergency thresholds in many areas,and increasing admissions in feeding programmesindicate that the situation is worsening.Food security has been further compromisedby the conflict, especially for the manyvulnerable populations still living in camp settings.Faced with a reduction in internationalassistance, many agencies are having to adoptnew strategies to sustain the gains that havebeen made since 2003.Given the precarious state of donor funding,the dependence of two million Darfurians onfood aid, and the inability to predict the effectthe Abuja peace deal will have on the securitysituation on the ground, it is clear that effectiveprovision of nutrition services in Darfur is contingenton a number of external factors. On theone hand, reduced general food rations willcompromise the effectiveness of the SFPs andTFCs, where implemented. On the other,renewed fighting between opposing factions –currently divided over the recent peace agreement– will undermine the ability of agencies toprovide SFPs and TFPs.Providing nutritional services in conflict settingsis particularly challenging, but can beeffective with planning, flexibility, and goodcommunication. While high rates of malnutritionpersist, populations in Darfur will continueto require emergency feeding services over thecoming months. However, it is clear that shorttermnutrition solutions, such as emergencyfeeding programmes, are at risk of being discontinuedgiven the constraints that have developedover the last few months. In order to sustainthe improvements that have been seen innutrition over the last 3 years, greater attemptswill need to be made to build the capacity ofexisting community and health structures toaddress malnutrition in the long-term.For further information, contact: GwynethHogley Cotes, Nutrition Coordinatoremail: ghogley@gmail.com, and Dennis Curry,Field Coordinator – Kutum, Darfuremail: dcurry@goalsudan.com12T Keegan, Dafur, 2006

J Spector, Valid Int, EthiopiaJ Spector, Valid Int, EthiopiaNewsWHO meetingreport oncommunitybasedmanagementof severemalnutritionMinistry of Health staff workingin outpatient therapeutic carein a clinic in EthiopiaA meeting of experts was organised by theDepartment of Child and Adolescent Healthand Development and the Department ofNutrition for Health and Development of theWHO, by UNICEF and by the UN Standingcommittee on Nutrition in Geneva on 21-23November 2005, to review recent developmentsin community-based management of severemalnutrition and to formulate recommendations.In preparation for this meeting, five backgroundpapers were prepared:• A review of methods to detect cases ofseverely malnourished children in the communityfor their admission into communitybasedtherapeutic care programmes. MyattM, Khara T, Collins S.• Efficacy and effectiveness of communitybasedtreatment of severe malnutrition.Ashworth A.• Key issues in the success of communitybasedmanagement of severe malnutrition.Collins S, Sadler K, Dent N, Khara T,Guerrero S, Myatt M, Saboya M, Walsh A.• Local production and provision of ready-tousetherapeutic food for the treatment ofsevere childhood malnutrition. Manary M.• The sustainability of Community-basedTherapeutic Care (CTC) in non-acute emergencycontexts. Gatchell V, Forsythe V,Thomas PR.These, along with the meeting report, are allavailable athttp://www.who.int/child-adolescent-health/publications/NUTRITION/CBSM.htmTaking MUAC measurement of a child in EthiopiaRevised Operational Guidanceon IFEAn updated version of the OperationalGuidance for Emergency Relief Staff andProgramme Managers on Infant and YoungChild Feeding in Emergencies is now availablefrom the ENN. First developed by theInteragency Working Group on IFE in 2001, ithas been revised by the IFE Core Group(UNICEF, UNHCR, WHO, WFP, IBFAN-GIFA,CARE USA, Fondation Terre des hommes,and ENN) co-ordinated by the ENN.The aim of this short document is to provideconcise, practical (but non technical)guidance on how to ensure appropriate infantand young child feeding in emergencies. Anumber of elements are also applicable innon-emergency settings.The Operational Guidance focuses especiallyon infants and young children under 2years of age and their caregivers, recognisingtheir particular vulnerability in emergencies.It is intended for emergency relief staff andprogramme managers of all agencies workingin emergency programmes. It applies to emergencysituations in all countries.Beginning with a summary of key points,this 24 page document is organised into sixpractical steps:1 Endorse or Develop Policies2 Train Staff3 Coordinate Operations4 Assess and Monitor5 Protect, Promote and Support IFE throughIntegrated Multi-Sectoral Interventions6 Minimise the Risks of Any ArtificialFeeding.Key definitions are included at the end andsupporting information on how to implementthe guidance is referenced throughout.The revised Operational Guidance is currentlyavailable in English and Bahasa (Indonesia)and translation into other languages is underway.Agency support and feedbackThe 2001 OperationalGuidance was supportedby 30 INGOs/NGOs/UN agencies.The IFE Core Groupwish to define andestablish agency supportfor this revisededition with futureprints listing supportingagencies.If you or youragency would liketo engage in thisprocess, would like to receive printcopes, or have any feedback or comments youwish to share, contact the IFE Core Group c/oEmergency Nutrition Network, 32, LeopoldStreet, Oxford, OX4 1TW, UK.Tel: +44 (0)1865 324996, fax: +44 (0)1865 324997,email: ife@ennonline.netThe Operational Guidance can also be downloadedfrom http://www.enonnline.net inpdf or html formatInternational Food and NutritionSecurity Course 2007An international training programme on foodand nutrition security is planned to take placebetween 12 February – 27 April, 2007, atWageningen International, The Netherlands.It aims to provide the course participants withknowledge, skills and motivation to identify,plan and implement effective action on foodand nutrition security at various levels, rangingfrom (national) policy level to regional,community, household and individual levelprogrammes.The training programme can be followed as acomplete 11 weeks' programme, which leadsto a diploma at postgraduate level or can befollowed as 'stand alone' certificate courses.Course content1. Distance Learning Programme: KeyConcepts in Food and Nutrition2. Key Concepts and Current Issues inNutrition3. Food and Nutrition Security in theContext of HIV/AIDS4. Seminar on Rights Based Approaches forFood5. Monitoring and Evaluation of Impact onFood and Nutrition Security6. Nutrition Communication and Promotion;a NewApproach to Nutrition EducationA limited number of fellowships to covercosts are available from the NetherlandsFellowship Programme (NFP). Candidatesshould first apply to WageningenInternational for admission to the coursebefore 1st September, 2006. Acceptable candidatesthen apply for a NFP fellowshipthrough the Netherlands Embassy in theirown country (deadline: 1st October 2006). Theapplication deadline for non-fellowship candidatesis 30th January 2007.Apply to Wageningen International online atwww.wi.wur.nl or email: training.wi@wur.nlor contact Wageningen International, P.O. Box88 6700 AB Wageningen, The Netherlands,Tel +31 317 495 495 Fax: +31 317 495 395For further information on the content of thecourse, email: fannie.deboer@wur.nl or wijnand.klaver@wur.nl13

Improved formula for WHO oralrehydration saltsA new improved Oral Rehydration Salts (ORS)formula has been developed by the WorldHealth Organisation (WHO) and UNICEF. Itcontains less glucose and sodium than the standardformula (245 mOsm/l compared with theprevious 311 mOsm/l), which allows for quickerabsorption of fluids. This reduces the needfor intravenous fluids and makes it easier totreat children with acute non-cholera diarrhoeawithout hospitalisation. Because of theimproved effectiveness of reduced osmolarityORS solution, WHO and UNICEF now recommendthat countries use and manufacture, fordiarrhoea of all aetiologies and in all agegroups, the new formulation.Detailed recommendations concerning theprovision and production of ORS are providedin a revised joint WHO/UNICEF publication,'Oral Rehydration Salts: Production of the NewProfile of new ORS formulaNew ORS g/l % mmol/lSodiumchlorideGlucose,anhydrousPotassiumchlorideTrisodiumcitrate,dihydrate2.613.51.512.683 Sodium 7565.854 Chloride 657.317Glucose,anhydrousOrientation workshop on IFEThe IFE Core Group 1 is planning an orientationworkshop on infant and young childfeedingin emergencies (IFE) scheduled for 1-2 November 2006 in Oxford. Organised bythe ENN and funded by UNICEF, IBFAN-GIFA and CARE USA, the overall aims of themeeting are:• to orientate participants on IFE, the workof the IFE Core Group and the IFEresources that have been developed.• to identify and practically address the keyconstraints facing staff in implementingIFE related policies and strategies inemergency settings.• to network technical HQ and regional staffof UN agencies and NGOs with donors,professional bodies and academics.The workshop agenda has been informed bya recent evaluation of the use of Module 2(see summary in this issue) and by field experiencesshared with the IFE Core Group relatingto emergency responses in Pakistan andIndonesia post earthquake and post tsunami.This workshop is not limited to infant feedingspecialists but will include NGO and UNHQ and regional staff, donors, professionalbodies, academics and media representatives.The meeting will:• Facilitate exchange of experiences on sup-752.9 14.146 Potassium 2020.5 100 Citrate 10Osmolarity 245ORS' that is available on the WHO website,along with the revised monograph of the formulaat http://www.who.int/medicines/publications/pharmacopoeia/Oralrehydrationsalts.pdf/ Detailed technical information can befound on the UNICEF site: http://www.supply.unicef.dk/catalogue/bulletin9.htmAdditional information on diarrhoea can befound on UNICEF's Facts for Life websitehttp://www.unicef.org/ffl/07/ and on theWHO Child and Adolescent Health web sitehttp://www.who.int/child-adolescenthealth/New_Publications/CHILD_HEALTH/Acute_Diarrhoea.pdfFor more information contact: DanielaBagozzi, Communications Officer, WHOTelephone: +41 22 791 4544,Mobile phone: +41 79 475 5490,E-mail: bagozzid@who.int or Claire Hajaj,Media Officer, UNICEF New York,Telephone: +1 212 326 7566E-mail: chajaj@unicef.org©UNICEF/SD02-025/Yvonne ThobyThe new ORS packagingporting IFE at a regional and nationallevel, with focus on Asia in particular.• Explore the use of policy guidance inrecent emergency responses to identifystrengths, weaknesses, and constraints toimplementation.• Highlight the recently updatedOperational Guidance on Infant andYoung Child Feeding in Emergencies(2006) and establish criteria that defineagency support.• Demonstrate the use of the trainingmaterials.• Identify training needs and resourcesneeded to support training activities.The IFE Core Group members will meet for athird day to formulate a strategy for movingforward.Anyone who is interested in attending, orwould like to recommend a participant,should contact the IFE Core Group c/o MarieMcGrath, ENN, tel: +44 (0)1865 324996,email: ife@ennonline.net,1Since 1999, an interagency collaboration (IFE CoreGroup) has been committed to developing training materialsand policy guidance on infant feeding in emergencies.The IFE Core Group currently comprises UNICEF, UNHCR,WFP, WHO, ENN, IBFAN-GIFA, Fondation Tdh, and CAREUSA, co-ordinated (since 2004) by the ENN.NewsNew ClassificationTool IntegratingFood Security andHumanitarianActionA new tool has been developed at the FoodSecurity Analysis Unit ( FSAU) to harmoniseand improve the rigour of classifying andproviding early warning of various stages offood security and humanitarian situations.Developed in-situ in Somalia, the TechnicalManual for the Integrated Food Security andHumanitarian Phase Classification (IPC)draws on internationally accepted standardsand so is applicable in a wide array of livelihoodcontexts and crisis types.The IPC is not an assessment method anddoes not replace existing food security informationsystems or methodologies. Rather, itis a complementary classification system thatintegrates multiple data sources, methods,and analyses to provide a ‘common currency’for food security and humanitarian crises,explicitly linking analysis to action.Key aspects of the tool include:• Situation Analysis: where fundamentalaspects of a situation (e.g. severity, cause)are identified.• Classification of food security andhumanitarian situations into one of fivephases based on outcomes on lives andlivelihoods – (1) Generally Food Secure,(2) Chronically Food Insecure, (3) AcuteFood and Livelihood Crisis, (4)Humanitarian Emergency, and (5)Famine/Humanitarian Catastrophe.Using key information, Early WarningLevels (EWL) are used to communicatethe risk of a worsening phase: (1) Alert,(2) Moderate Risk, (3) High Risk.• A Strategic Response Framework isprovided for each phase with a view tomitigating immediate negative outcomes,supporting livelihoods, and addressingunderlying/structural causes.Organised into four components, the IPCcomprises a core Reference Table (coveringphases and EWL), Analysis Templates (tohelp organise key information),Cartographic Protocols (mapping and communicationtools to visualise situationalanalysis on one map), and PopulationTables (to aid effective communication ofpopulation estimates).The manual is available from the FoodSecurity Analysis Unit – Somalia, KalsonTowers, Parklands, Box 1230 Village Market,Nairobi, KenyaPh: 254-20-3745734 Fax: 254-20-3745098Email: fsauinfo@fsau.or.keOr online at http://www.fsausomali.orgIdeas for future improvements are welcomeand should be directed to the FSAU.Ref: FAO/FSAU 2006. Integrated FoodSecurity and Humanitarian Phase Classification: Technical Manual Version 1. Nairobi,FAO/FSAU Technical Series IV.1114

NewsNew WHO growthstandardsThis New WHO Growth Standards for infants and childrenup to 60 months of age, highlighted in Field Exchange 27, arenow available. The standards were developed using data collectedin the Multi Centre Growth Reference (MGRS) study.They describe normal child growth from birth to 5 yearsunder optimal environmental conditions and can be appliedto all children everywhere, regardless of ethnicity, socio-economicstatus and type of feeding.The new standards differ from any existing growth charts ina number of ways:• The new standards are prescriptive and describe howchildren should grow. This differs to the descriptive referencesthat have only been available until now.• Breastfeeding is the biological norm and the breastfedinfant is established as the normative growth model. Theprevious growth reference was based on the growth ofartificially fed children.• The pooled sample from the six participating countrieshas allowed the development of a truly internationalstandard (in contrast to the previous international referencethat was based on children from a single country).Child populations grow similarly across the world’smajor regions when their needs for health and care aremet.• These standards include new growth indicators beyondheight and weight, such as skinfold thickness.• The study’s longitudinal nature allows the developmentof growth velocity standards. This should enable the earlyidentification of children in the process of becomingunder or over nourished, rather than waiting for childrento cross a growth threshold.• Six key motor development milestones are included thatprovide a link between physical growth and motor development.The WHO continues to recommend the use of theNCHS/WHO international growth reference for childrenolder than 5 years. The new standards do not affect anthropometricmeasures, indicators, cut-offs, etc, for adolescents,adults, pregnant adults, and the elderly.The new growth standards will have implications foremergency nutrition programming, especially for screening,prevalence estimation and monitoring/evaluation.A paperby WHO comparing growth patterns and estimates of malnutritionbased on the WHO Child Growth Standards and theNCHS/WHO reference is currently in press 1 . This analysishighlights important differences between the WHO standardsand the NCHS reference that vary by age group,growth indicator, specific percentile or z-score curve, and thenutritional status of index populations. Particularly relevantfor emergency contexts, the analysis identifies increasedprevalence of wasting and severe wasting using the newgrowth standards, in infancy (2.5 – 3.5 times the estimatesbased on the NCHS references) and also throughout childhood(1.5 to 2 times the NCHS based estimate). The operationalimplications for emergency nutrition programming arenot explored in this paper but are highlighted in a detailedletter submitted to Field Exchange (see this page).The standards and associated software are available on theWHO website www.who.int/childgrowth.Training and sensitisation will be taking place in variousparts of the world during this year.For further information, contact: Dr Mercedes de Onis,World Health Organization, Department of Nutrition, 1211Geneva 27 Switzerland. Telephone: 41-22-791 3320.Fax: 41-22-791 4156. E-mail: deonism@who.int1de Onis M, Onyango A, Borghi E, Garza C, and Yang H. Comparison of theWHO Child Growth Standards and the NCHS growth reference: implications forchild health programmes. Public Health Nutrition, 2006 (in press).LettersThis new 2006 WHO Growth standards:What will they mean for emergencynutrition programmes?Dear EditorWhilst welcoming the principleswhich have driven the developmentof the new 2006 WHO growth standards(see news piece this page), wewish to draw attention to importantpractical implications for emergencynutrition programmes. We think it isimportant that these are exploredand discussed in detail before thenew standards are implemented inoperational settings.The need for new growth standardsAn internationally valid, ‘gold standard’range against which childgrowth can be assessed has longbeen needed. There are several reasonswhy the previous NCHS(National Centre for HealthStatistics)/ WHO Reference data fellshort of this ideal:i) It was constructed on a cohortof North American children,from a single community and asingle ethnic group of Europeanancestry.ii) Data was gathered from 1929-1975, a long period duringwhich nutrition varied greatly.The main issue of concern wasthat infants were pre-dominantlybottle-fed rather than breastfed,as is considered ideal today.iii) Statistical methods haveadvancedsignificantly since the originalNCHS/WHO growth curveswere constructed in the 1970’s.Applying better statistical techniquesto the same dataset waswhat led to the CDC 2000growth references.Age/Monthsiv) Increasing numbers of studiesin both developed and developingcountry settings found thatapparently healthy, breastfedchildren were being labelled asabnormal according to theNCHS/WHO References.MGRS (Multi-centre GrowthReference Study)The MGRS 1 ran from 1997-2003 andwas explicitly designed to generatea growth standard to show howchildren should grow, rather thanjust a reference that allows comparison.Following extensive screeningto select only those children free ofhealth or environmental (socio-economic/nutritional)constraints togrowth, a total of 8,440 childrenwere observed at six internationalsites (Brazil, Ghana, India, Oman,Norway, USA). The study had twocomponents: longitudinal work followedchildren from birth to 24months; a cross-sectional studyobserved children from 18-71months. State-of-the-art statisticaltechniques were chosen to constructgrowth curves from this data. Keyoutcomes from the MGRS are:i) The strongest evidence yet thata single international childgrowth standard is valid. Freeof environmental and nutritionalconstraints, children of very differentethnic groups all grew thesame: only 3% of length variancewas due to inter-site differences.ii) New z-score and percentile references charts/tables for weightforage,length/height-for-age,and weight-for-length/height.iii) Additional standards not presentin NCHS/WHO Reference:Body Mass Index (BMI); Midupper arm circumference1www.who.int/childgrowth/en/Figure 1 – Comparison of weight for age percentiles for boys aged 0-36 months15

(MUAC); skin-fold thickness;and motor developmental milestones.iv) A devoted website with extensiveliterature relating to MGRS and thenew standards.v) Free downloadable software whichmay, in the future, enable both individualand population anthropometricstatus to be calculated using eitherNCHS/WHO Reference or WHOStandard data.Differences between the old and newgrowth curvesThere are important differences betweenthe old references and the new standards.There is however no easy or consistentway of transforming anthropometricmeasures between the two: the growthlines do not run in parallel with simpleshifts up or down. Factors affecting themagnitude and direction of differencesbetween old and new cut-offs include: achild’s age; a child’s length/height; whichmeasure (i.e. WHZ; WAZ or HAZ) is beingconsidered; whether the child under considerationis above or below median; andwhether the z-score or % of median isbeing considered. As an example, shownbelow are the weight-for-age percentilelines (P) for boys between 0 and 36months. The curves cross, sometimes morethan once, illustrating that the magnitudeand direction of the difference between theNCHS/WHO Reference and the WHOStandards is dependent on the age of thechildren and his location on the distribution.In short, the net effect of the new standardson the measurement and diagnosisof growth and malnutrition is complex!Implications for emergency nutritionassessments and feeding programmes1. Comparability and interpretation ofnutrition dataInterpreting trends in nutritional statusand setting agreed thresholds for actionare important for emergency nutrition programmes.With the adoption of the newWHO standards the ability to easily comparethe results of current surveys withprevious data will be lost, and this willmake new data more difficult to interpret.This problem could be overcome byallowing for a period of dual-analysis ofsurvey data. If results from surveys areanalysed using both the new WHOStandards and the currently usedNCHS/WHO Reference, then sufficientdata and experience may be built up withthe new system whilst assuring ‘backwardscompatibility’. Though potentiallycomplex and confusing for non-specialistpolicy-makers, this approach would eventuallyenable trend and risk models to berecalibrated and appropriate new actionthresholds set. However, a note of cautionmust be added. Although software is availablefrom the WHO web site that can beused to analyse surveys (WHO Anthro2005), at the moment it does not deal withcases of oedema in the standard way, makingcalculation of the correct estimates ofGlobal Acute Malnutrition (GAM) andSevere Acute Malnutrition (SAM) difficult.2. Prevalence assessments using z-scoresWeight-for-length/height is a key anthropometricmeasure for emergency feeding,widely used in malnutrition prevalencesurveys to assess the need for, or effect of,a nutrition programme. It is thereforeimportant to know what are the expectedeffects of the WHO Standards on the measuredprevalence of GAM and SAM.• Effect on SAM ~ a marked increaseOverall, the new WHO standards willincrease the measured prevalence of SAMthrough increasing the value of the weightfor height

A Fundi, ACF-USA, S Sudan, 2004Waiting to be weighed in the HT programmeField ArticleHome treatment forsevere malnutritionin South SudanBy Josephine Querubin, ACF-USAJosephine Querubin is a medical doctor who has been working in humanitarianwork for the past 12 years. Beginning in her home country, thePhilippines, she moved to international work with the EU, MSF-CH, andthen ACF-USA. She began working with ACF-USA in South Sudan inAugust 2003 becoming Medical and Nutrition Coordinator, and finished inMarch 2006.The author would like to acknowledge the work of the local staff and ACF team in SouthSudan reflected here. In particular, the author would like to mention Mark Wamalwa,Veronica Natesiro, Edna, and Samson Ekale who have displayed immense dedication andhard work in running the programmes in south Sudan, caring for the children in more waysthan drugs and food alone ever could. The author would also like to acknowledge the supportof Marie Sophie Simon, HQ nutritionist with ACF-USA, who has been with the teamthroughout and taught us how to do things right, yet enjoy at the same time.This article details the largely positive experiencesof ACF-USA in using home treatment as an integralpart of their programme to manage severemalnutrition in South Sudan.Many parts of South Sudan, especiallyin Upper Nile and Bahr-elGhazal regions, experienced aprolonged pre-harvest hungerperiod in 2005 following the delayed rainsthat had adversely affected crop productionin the previous year. Given the poor access towater and health services in the area, in conjunctionwith a large influx of returnees, thenutritional situation became even more precariousthan usual. ACF-USA had a strongpresence in Upper Nile since 2001 and wastherefore able to extend programming inBahr-el Ghazal in response to the emergingnutritional emergency in Twic and Gogrialcounties in 2005.Both Twic and Gogrial counties are situatedin Warab State in the northern section ofthe Upper Nile region, North East of SouthSudan. Warab State lies in the flood plainsagro-ecological zone and receives extensiveseasonal flooding from the tributaries of theRiver Nile. With a vast land area, the villagesand homesteads are scattered and far apart.The population is predominantly from theDinka tribe, which comprise approximately5% of southern Sudan’s estimated populationof about 8.9 million. Crops and livestock productionare the main sources of livelihood.17Background to treatment for severemalnutritionIt is common practice among the communitiesof the south for women to tend to everymember in the family, as well as performmost of the household and farm labour. Atthe same time, mothers are the principal caretakersof any severely malnourished childadmitted to a treatment centre. ConventionalTherapeutic Feeding Centres (TFCs), especiallyin open settings with widely dispersedpopulations and where the beneficiary andcaretaker must stay in for 24 hours for anaverage of one month, have always beenfaced with low coverage or a high defaultrate or both. Following various studies toimprove the management of the severelymalnourished and increase the impact oftherapeutic feeding programmes, ActionContre le Faim (ACF) has, in recent years,employed the Home Treatment (HT)approach. In this approach, once medicalcomplications have been controlled, the childcontinues nutritional rehabilitation withReady-to-Use Therapeutic Food (RUTF) athome and comes for scheduled follow-up atthe centre until the desired weight is reached.Piloted by ACF-USA in Upper Nile in 2004,the HT protocol was subsequently implementedin Gogrial county last year.TFC-HT programmeThe programme was designed to cover atleast four Payams in the county (WestGogrial). One Therapeutic Feeding CentrebasedHome Treatment Programme (TFC-HT) was established in Alek, with the capacityto treat 200 severely malnourished, alongwith one Supplementary Feeding Programme(SFP), designed for a capacity of 800 moderatelymalnourished children. HealthEducation and Gardening programmes werealso implemented alongside. These programmesran over a six-month period.Initial activities of the team focused onlinking with the SRRC (Sudan Relief andRehabilitation Commission) counterparts,local authorities, and other agencies on theground, on community orientation andmobilisation, and on preparing for both thelogistics and technical requirements of theprogramme. ACF-USA designed and implementedthis phase within a three-week period.During this period, Sudanese national staffreceived training that covered general subjectslike the organisation’s charter and Staff Rulesand Regulations, as well as technical topicslike nutrition/malnutrition, and the objectivesand functioning of the TFC-HT and SFP. Inaddition, each category of staff received specifictraining following a standard moduleand according to their duties and responsibilitiesas detailed in their job descriptions.From experience and analysis of the context,ACF-USA consider the minimum standardacceptable in south Sudan for feedingprogrammes coverage is 50% of the acutelymalnourished children as estimated from abaseline nutritional survey in the targetedarea. For its programmes in Alek, GogrialWest in 2005, ACF-USA targeted coverage of

Field Article60%, hence, 200 severely and 800 moderatelymalnourished were expected at the TFC-HTand SFPs, respectively. At the end of its sixmonth programme life, the TFC-HT exceededthe expected beneficiary case load, havingadmitted 259 children under five years of ageand three adults. This is equivalent to programmecoverage of 78% of all severely malnourishedchildren based upon the Decembernutritional survey and the February rapidassessment.ACF South Sudan TFC-HT protocolACF-USA’s protocol for the treatment of severelymalnourished individuals is divided into differentphases: Phase I or the Intensive CarePhase, Transition Phase, and Phase II or theRapid Weight Gain/Rehabilitation Phase.Admission criteria are as follows:• For children 6-59 months, a weight for heightratio of less than 70% and/or bilateral oedema(kwashiorkor) and/or MUAC (Mid-Upper Arm Circumference) less than 11.0 cmfor children with height above 75 cm.• Children or adolescents from 5 years to 18years, a weight for height less than 70% ofthe median and/or bilateral oedema.• Adults with body mass index less than 16and/or bilateral oedemaPhase I (Intensive Care) is carried out in theTFC where the patients receive systematic medicaltreatment, and daily medical follow-up,with specific treatment if indicated. Nutritionaltreatment is based on a F75 therapeutic milkdiet that provided 135 ml/kg per kg bodyweight per day. The average stay is 4 to 7 days.Patients move to the Transition Phase when:• they are recovering their appetite• in kwashiorkor cases, when the oedema hasbegun to disappear• they are no longer fed by naso-gastric tube(if this was necessary during phase I)• they are no longer seriously ill.In the transition phase, the energy intake isincreased and the proportion of energy-providingnutrients modified, allowing the patient toadapt progressively to a diet expresslydesigned to produce a rapid gain in weight.Hence, F100 milk is introduced at 100ml/kg toprovide the same energy value as phase I, i.e.100 kcal/day. This phase lasts 2-4 days and isalso carried out in the TFC.Following the transition phase, the patientwithout problems is transferred to Phase II(Rapid Weight Gain) of treatment (for patientswith kwashiorkor, complete disappearance ofoedema signals this transfer). The treatment consistsof medical check-up every two days andfull F100 diet (i.e. 200 kcal/kg/day plus porridge)to obtain optimal increase in weight. Theaverage stay is 2 to 4 weeks. This phase is carriedout either at the TFC or as Home Treatment.The Home Treatment option is offered to caretakerswhose children fit the following criteria:• Older than 12 months• Acute medical complication/illness havebeen controlled and no need for further medicaltreatment• Absence of nutritional oedema on admission• The child has successfully passed throughphase 1, transition phase and spent 2 days inrehabilitation phase within the TFC itself• The mother/caretaker fully understands thefeeding protocols• The patient/caretaker lives in the catchments areas delimited for Home Treatment.The patients on Home Treatment are not consideredas cured, and medical and nutritionalfollow up continues through weekly attendanceat the identified HT Centre/s and through regularmonitoring by home visitors. In case oftreatment failure or relapse (loss of weight,medical complication (such as primary complextuberculosis (PTB)), the beneficiary is readmittedand continues treatment in the centre. Thosewho do not fit the HT eligibility criteria completePhase II of treatment at the TFC.The discharge criteria for the TFP are:• an ascendant weight gain curve and no diseasepresent, and• reached target weight for height of 80% ofmedian and MUAC > or = 12 cm for twoconsecutive measurements, and• for kwashiorkor cases, at least 15 days sincethe disappearance of oedema.All severely malnourished patients admitted tothe therapeutic programme are discharged tothe SFP for the Consolidation Phase. Patientsare reviewed during the scheduled distributionsof the SFP to receive follow-up care (medicalmonitoring and supplemental feeding) toavoid relapse.ResultsBased on all programme records, the cure ratein the TFC-HT programme was high at 81%(this compares well with the SPHERE minimumstandard of 75%). The mean length of stayfor the children who recovered was 48 days,averaging a weight gain of 9 g/kg/day. Seventytwo percent of those children that recoveredunderwent home treatment, while 28%remained at the centre throughout. Of the 28%who were managed in the TFC, 10% did so dueto persistent medical complication or becausethey were aged under 11 months. The remaining18% were actually eligible for home treatmentbut opted to stay at the centre, eitherbecause of distance from their homes or due toflooding that would have impeded follow-up.A Fundi, ACF-USA, S Sudan, 2004Weight gainDuring the second phase of treatment whererapid weight gain is meant to occur, children atthe TFC spent an average of 22 days gaining16g/kg per day to reach the desired weight. Athome, it took about 18 days longer to reach targetweights with a slower weight gain of7g/kg/day. Ninety two percent of the childrenon HT completed the treatment until full recovery,while only 82% did so at the TFC. The childrenwho recovered on the HT regime spent 4-5 days in phase 1 and 4 days in transition at thestabilisation centre where they adapted to theuse of RUTF (Plumpy’nut).Medical assessment as partof the TFC-HT programmeLength of staySome of the children had medical complicationsthat could not be controlled or reversed at theTFC. Four and a half percent were thereforereferred to specialised clinics, although themortality rate at the TFC was still minimal at2.5%. These specialised clinics (currently tenwith another under construction) come in theform of PHCUs (Primary Health Care Units),run by Norwegian Church Aid (NCA). Theseprovide primary health services for the entirecounty of West Gogrial, and are available forthe referral of medical complication cases.DefaultingOverall, defaulter rates were low at 12%, with15% defaulting among those who stayed at theTFC and 7% amongst those on HT. Generally,the shorter stay at the centre (average of 8-9days) as well as the readiness to use RUTF athome improved receptivity to, and acceptabilityof, the HT programme among mothers andchildren. There were no cases of relapse amongHT children that compelled their return to thecentre. An ongoing study of this treatment protocoland its results across different AAH missionsis being undertaken and it is anticipatedthat the duration of stay at TFCs may be evenshorter elsewhere than found in this programme.ConstraintsAlthough largely successful, certain programmeconstraints operated. As with mostareas in south Sudan where ACF-USA operates,homesteads and villages are widely dispersedamidst difficult terrain, which frequently experienceswidespread flooding. Without internalmeans of transport in the field or the capacity tomatch the number of centres with the numberof villages, the strategy is highly reliant on anetwork of locally based ‘home visitors’. Theircritical role involves screening and referrals atthe community and household level, monitoringthe children (particularly those on hometreatment) and tracing defaulters. Given thephysical arduousness of the work and shortagesof home visitors, programme effectivenesscan easily be compromised. Given this and thegeneral economic marginalisation and growingneeds of the south Sudanese community, especiallyfollowing the peace accord with theNorth, there are many challenges still to betackled if we are to achieve full coverage andmaximum impact of HT.For further information, contact Adalbert MenaFundi, email: med@aahssd.org, or Marie-SophieSimon, ACF-USA, email: mss@aah-usa.org1A training module for National Staff in the TFC/SFP wasdeveloped by ACF-USA and was employed in Alek.18

EvaluationSC UK, Dafur, 2002Evaluation ofDafur EarlyWarning andFoodInformationSystemSummary of evaluation 1Save the Children UK (SCUK) recentlycommissioned an evaluation of theDarfur Food Information System (DFIS),which was established in North Darfurin 1993. This evaluation was carried out inNovember and December 2005 and covered thethird phase of the DFIS from 2002 to 2004. Bythat time, the system had expanded to monitorthe food security status of displaced Dinka inSouth Darfur and more recently had expandedinto West Darfur. During most of DFIS’s lifetime,its principal role has been to provide earlywarning of the impact of drought, the mainthreat to food security in Darfur. In 2003, armedconflict broke out in the three states of Darfuron an unprecedented scale and with ferociousintensity. Thus, DFIS had to adapt from being adrought-oriented early warning system (EWS)to one where conflict was the principal threat tofood insecurity, triggering the displacement ofover a million people. How DFIS performed inadapting to this very different context was oneof the key focus areas of the evaluation. Theevaluation also reviewed the DFIS’s effectivenessin providing early warning of droughtrelatedfood insecurity before 2003 and in triggeringtimely response.After the tragic death of SCUK staff, theorganisation decided to rapidly pull out of allthe Dafur States on 19th December 2004. As aresult, SCUK had to discontinue DFIS without aproper hand over to other actors. This evaluationalso considers the legacy of DFIS sinceSCUK withdrew from Darfur.Performance of DFIS prior to the conflict –2002 to early 2003Since 1996, DFIS has been based on theHousehold Economy Approach (HEA) methodology.The starting point was to divide ruralNorth Darfur into six ‘food economy zones(FEZ)’ and to carry out baseline profiles in each.North Dafur whereSCUK operated untilDecember 2004DFIS has been run entirely by national SCUKstaff during its lifetime, ensuring a strong senseof ownership of the system and of its methodologyby the SCUK Darfur team.It is unfortunate that some of the baselineprofiles that underpinned DFIS were written upbut not published up until 2004 - at least fouryears after they had all been completed - thusmissing opportunities to influence and inform.Nevertheless, the baseline profiles provide veryvaluable information on livelihoods in NorthDarfur and were essential to the annual villageand household survey carried out in Octobereach year. This is when HEA really came into itsown, producing a clear plan for food aid needsin each FEZ, as well as recommendations forother non-food emergency interventions. Thereis every indication that this annual assessmentwas carried out effectively, professionally andin a timely manner during the pre-conflict period.The collaboration between internationalnon-governmental organisations (INGOs), theWorld Food Programme (WFP) and governmentin the process was exemplary, under theauspices of the Food and Water EmergencyCommittee of North Darfur. In 2003, SCUKplanned a nutrition survey encompassingcausal analysis of one of the FEZs, but the fieldwork was hampered by insecurity.Market monitoring was done weeklythroughout the year as an ongoing indicator offood security status. Nutrition surveys usefullycomplemented the regular food security monitoringby confirming the existence (or otherwise)of a food crisis in a FEZ of particular concern.However, the underlying causes of malnutritionare still poorly understood for someFEZs in North Darfur.The publication of periodic DFIS bulletinsthroughout the year was the main means ofcommunicating EW messages between annualassessments. These bulletins brought togetheranalysis of all the different indicators and wereparticularly useful for trend analysis. However,presentation of the bulletins was not very compelling.Recommendations in earlier evaluationsto improve the bulletins do not seem tohave been effectively implemented.SCUK’s early warnings of annual food aidneeds in North Darfur were rarely heeded anddid not trigger a timely response from donorgovernments. A very small proportion of estimatedneeds were delivered by June/July – thecritical months – in 2001, 2002 and 2003. Thepolitical environment was simply not conduciveto a timely response.Between 2001 and 2003, DFIS’s close relationshipwith state government really paid offin terms of how the authorities, and the Wali inparticular, could use the DFIS analysis for theirown lobbying and advocacy purposes with federalgovernment and with international donors.Collaboration with federal government at atechnical level was also strong. DFIS was seento provide accurate and realistic estimates ofneed partly because of its methodology. Butfederal government’s overall willingness torespond to food crises and food insecurity inDarfur was limited.The negative impact of a consistently lateresponse to food crises in Darfur included distressmigration, high malnutrition rates andreduced cultivation because of food shortagesin the early 2000s. As is typical for most EWS,DFIS’s focus was biased towards informationgathering and analysis with much less attentionpaid to communication and advocacy. Giventhe hostile political environment that DFIS wasoperating within, there needed to be a muchgreater investment in advocacy (and persuasiveoral presentations rather than written reports)than was actually the case. This would haverequired organisational commitment at all levels:in Darfur, Khartoum and London.Technical support and capacity building ofDFIS partners has been a prominent feature ofits work. As a result, SCUK has built up a cadreof individuals in North Darfur – in governmentand in INGOs – with a good understanding offood security and of HEA, and has built a senseof ownership of the DFIS approach. The challengewith government was how to buildcapacity in a sustainable way when governmentdepartments were so poorly resourced interms of basic infrastructure, such as computersand transport. Also, as government officialsbecame more skilled, many sought work withinternational agencies. The one gap in DFIS’scapacity-building work was with local communitybased organisations (CBOs) and NGOs,some of which enjoy much greater access torural areas and local communities during thecurrent conflict than government staff.Performance of DFIS once conflict becamethe principal threat to food insecurity, 2003-2005During 2003/04, SCUK’s programme in Darfurwent through a major transformation to adaptto a large-scale and highly politicised, conflictrelatedemergency. By all accounts, this was avery painful transition, ridden with tensionbetween incoming international staff and longtermnational staff, unclear management structuresand the emergence of dysfunctional parallelsystems. This seriously inhibited DFIS’s performance.19

Methodologically, it really struggled toadapt. A major gap was the lack of anyassessment of DFIS’s capacity to adapt tothis escalating conflict environment, norwas consideration given to bringing inexternal expertise, despite the limitedexpertise in-country to work in such a politicisedconflict environment. Erroneously, thefocus of the country programme was onlongterm issues of vulnerability and foodsecurity in Darfur. But fortuitously thismeant that an external consultant wasbrought in during 2004 to support DFIS toaddress underlying issues of vulnerability.Adapting to the new conflict environmentwas not part of the consultant’s terms of reference,although this soon became central toher role. This input was critical but was late.For example, not until mid-2004 did theHEA methodology adapt to doing rapidassessments. Yet these were needed frommid-2003. When rapid assessments werecarried out, the reports were strong andwell-written. Meanwhile the DFIS bulletinswere not. They tended to follow the old formatso they were neither compelling norclear in terms of their key message. A muchsharper and tighter analysis was needed. Inshort, the key early warning/monitoringrole that SCUK could have played during2004 was not fully realised.In order to respect humanitarian principleswhen conflict broke out, and to protectSCUK’s independence, DFIS needed toadapt institutionally to this changed andhighly politicised environment. Mostnotably it needed to distance itself from government,one of the key actors in the conflict.Unfortunately this took a long time to happen,dangerously affecting perceptions ofSCUK. Such an adjustment in institutionalrelationships would never have been easyand could only have been managed by anexpatriate presence. It was too much to haveasked of national staff who had spent yearsbuilding those relationships.Despite these shortcomings, there is evidencethat DFIS played a valuable role earlyon in the conflict, briefing incoming agenciesand providing time-series data (e.g.market price data) on demand. Althoughslow to be written up, its database on livelihoodsbefore the conflict is invaluable forcomparative purposes to understand howlivelihoods have been affected by the conflict,and is being used as such by a smallnumber of international agencies.SCUK’s withdrawal from Darfur waslamented, without exception, by all agenciesinterviewed during this evaluation. It hasleft a gap in information collection andanalysis at state-level that has not yet beenfilled, as most agencies focus on informationcollection in their own particular geographicarea of coverage. Unfortunately the waythat SCUK withdrew did not help to bridgethis gap. Withdrawal appears to havebecome a logistics exercise in which strategicdecisions about handover to other agenciesand even protection of the SCUKresource base, were overlooked. In short,SCUK has not left behind a functioninginformation system in Darfur.1The Darfur Early Warning and Food InformationSystem. Final Evaluation of Phase 111. By MargieBuchanan-SmithEvaluation of use of IFEtraining materialsBy Chloe AngoodAn evaluation was recently conductedof two training modules (Module 1and 2) on Infant Feeding inEmergencies (IFE) developed by theIFE Core Group (UNICEF, WHO, WFP,UNHCR, IBFAN-GIFA, CARE USA, FondationTerre des hommes and ENN) and produced bythe ENN 1 . The purpose of the training modulesis to prepare emergency relief staff to safeguardmaternal and child health in emergencies byensuring appropriate infant feeding. Module 1is aimed at emergency relief staff while Module2 is more specifically designed for health andnutrition workers directly involved with caregiversand infants. Both modules are availablein print, online and on CD.MethodThe evaluation was conducted betweenFebruary and May 2006 and covered the periodApril 2005 – April 2006. It involved an analysisof ENN’s distribution database, downloadsfrom the ENN website, and an email surveytargeting 100 recipients. Thirty-four recipientsresponded to this email (one third of all recipients).Answers were clarified through furtheremails and telephone calls.Main findingsEvaluationChloe has a Bachelors degree and a Masters degree in Development Studies, withan emphasis on HIV/AIDS, nutrition and agriculture. Following 3 years as a programmeco-ordinator for the NGO, Viva Network, in Zimbabwe, she worked forthe HQ offices of Viva Network (programme management and training) and forMango (recruitment). She is currently studying for a MSc in Public HealthNutrition at the University of Southampton and working part-time for the ENN.Figure 1 Use of materials by respondents2520151050None Own interest On file/in libraryPassed to otherorganisationsDistribution of training materialsThe print materials and CDs were distributedon request by the ENN. A discretionary subsidisedcharge was applied, although the materialswere available free to individuals or agencieswho could not afford to pay for them.Overall, 169 copies of Module 1 and 826 ofModule 2 and 47 CDs were distributed to 28organisations (including UN organisations,local and international NGOs, training andresearch institutions) and 13 individuals in 46different countries. In addition, 1755 itemswere downloaded from ENN’s websitebetween December 2005 and April 2006. Therelatively small number of CDs requested maybe due to lack of marketing as the CDs hadbeen developed and produced by the ENN inhouseon a ‘shoe-string’ budget, with no fundingfor larger scale production and distribution.The majority of the materials (90%) were distributedto IFE Core Group members, mainlyUNICEF, UNHCR, IBFAN-GIFA and CAREUSA. The materials were mostly used internallyby these organisations, in regional and fieldcentres, or were distributed to partners. In someinstances, the materials were shared withdonors to highlight the work of the IFE CoreGroup and in one case cited, to successfullyfundraise for continued agency participation inthe IFE Core Group.Only 10% of the print materials were disseminateddirectly to recipients outside of the IFECore Group. Donor agencies did not feature onthe print distribution list but were targeted bysome IFE Core Group members and at thelaunch of the materials at the UN SCN meetingin 2005.Downloading Module 2 from ENN’s websitemay well be a more practical means of access foragencies – web access was identified as a significantaccess point in a previous evaluation ofModule 1. However, even allowing for that, amore proactive targeting of field level operationsis needed.Uses of materialsThe materials have been used in a variety ofways (See figure 1) in different contexts. Theseinclude:• Training field practitioners. For example,UNHCR in Ethiopia used Module 2 to trainfield personnel in seven refugee camps,including doctors, nurses, midwives,community health agents and traditionalbirth attendants.• Producing other training courses and materials.For example, IBFAN-Asia Pacific usedModules 1 and 2 to develop guidelines fortheir partners in how to survey calamitystruck areas following the Asian tsunami.• As an advocacy tool for policy change(see box 1).1See Modules 1 and 2 online at www.ennonline.net and contactdetails at the end for print copies.Advocacy/awarenessraisingTrainingothersCreating othermaterialsno. respondents20

EvaluationThe materials have been used more broadly thanintended – half of respondents used the materialsin non-emergency contexts. Only one quarterused them to train practitioners – this may reflectalternative uses, the need for more specific targetingof the materials, or a lack of training skillsamongst the users.Content of materialsThe survey confirmed that the materials providepreviously unavailable technical information tofield practitioners. A number of respondentsdescribed some of the content as ‘unique’ and fillinga gap in information. However, there was acall to further simplify the text. A number ofrespondents also raised the appropriateness ofthe materials (particularly pictorial representation)in places where cultural taboos aroundbreastfeeding exist.Respondents highlighted gaps in informationnot covered by the materials. Infant feeding inthe context of HIV and AIDS, and complementaryfeeding were considered priority areas. Othersuggestions included:• Practical advice on how to handle organisationshanding out infant formula/baby milk• Include a section ‘20 frequently askedquestions’ on infant feeding in emergencies• Community preparedness for emergenciesin terms of infant feeding (considered particularly relevant for Latin America)• Related human rights and humanitaria laws.Accessibility of materialsThe survey revealed the need to make the materialsaccessible to a wider audience. There wasclear demand for the modules to be translatedinto other languages (including French, Spanishand Italian). Other formats that may be more easilydistributed were suggested, e.g. as a powerpoint presentation and as a book. Although CDformat could improve access considerably, it hasbeen under utilised as a means of distribution 1 .Respondents also suggested holding trainingworkshops.Planning, Monitoring and EvaluationAnalysis of the project as a whole revealed a lackof clearly defined targets and indicators. The distributionof materials was adequately monitoredby ENN, however the system to monitor webdownloads needs improving. There is also nosystem to track dissemination by IFE Core Groupmembers other than ENN. It is still early days butsubsequent evaluations may reveal more aboutthe long term impact of the training modules.RecommendationsSpecific recommendations from the evaluationinclude:• Marketing the materials to a wider range oforganisations, including international NGOsand donors, technical and nontechnical staff.Box 1“At the end of 2005 I was informed that a churchorganisation had written a letter to the Ministry ofHealth (MOH) offering to provide free infant formulato distribute to all artificially fed infants incountry starting from 9 months of age. I spoke onthe phone to the head of the MOH departmentand reminded her of the previous experience inour country when breastfeeding rates decreased3 times because of the free formula supply, and Ialso reminded her of the provisions of theInternational Code. She suggested that I write astatement to this effect to the MOH, so that theycould use it when answering the letter, which of• Revision of the materials on the basis of newevidence in priority areas, such as infant feedingin the context of HIV and AIDS and themanagement of severely malnourished infants.• Future updates should consider the adaptedmaterials developed by users in future versionsof the modules, refine the text, anddevelop versions applicable where culturaltaboos may exist.• Highlight resource gaps that do not fall withinthe remit of the IFE Core Group to otherpartners and organisations that might be willingto produce them.• Consider developing new materials on priorityareas, such as complementary feeding inemergencies. Engage in a deeper process ofconsultation with stake-holders to decide onpriority areas.• Translation of the materials into other languages, develop and market the CD formatmore widely, and consider producing futuredrafts of the modules in a more cost-effectiveformat.• Hold regional workshops to orientate userson applying the modules.• Define plans, including targets, objectives,outputs and indicators for the next stage ofthe project.• Set up systems to monitor downloads fromthe ENN website and to track the secondarydissemination of materials through IFE CoreGroup members.Follow-upSince the evaluation, the ENN has begun toaddress a number of the recommendations,including developing a better system to monitordownloads from the ENN’s website, and direct‘marketing’ of the materials to NGOs and donors.A number of the issues highlighted in the evaluation,such as developing training materials oncomplementary feeding in emergencies, updatingthe materials to reflect developing areas likeinfant feeding in the context of HIV and AIDS,and translation of the materials, have long beenidentified as priority work areas by the IFE CoreGroup. A perquisite to seeing these recommendationsthrough is the identification of resources tosupport IFE activities. This will be one of themain outcomes sought at of the IFE orientationworkshop scheduled in November 2006 (seenews section in this issue).A full copy of the evaluation is available from theENN. For further information on the trainingmodules or the November meeting, (see newspiece, p14) contact the IFE Core Group c/o MarieMcGrath, ENN, email: ife@ennonline.net1Large sections of Modules 1 and 2 have been included on therecently completed TALC CD on community nutrition. Fordetails, see www.talc.orgcourse I did. I referred to Module 1, section 2.4'Donations of infant formula in emergencies canbe dangerous’, Section 3.1 'The InternationalCode of Marketing of Breastmilk Substitutes(BMS)' and Annex 1 'The International Code ofMarketing of BMS – summary of portions relevantto emergencies'. I was told informally that my letterwas shown to the deputy minister and wasused while answering the letter of the churchorganisation. Their answer was negative. Thechurch organisation also intends to change itspractices and in future support breastfeeding. Soyou can see that the materials were quite useful.”T Krumbein, Uganda, 2005LocallyproducedRUTF in ahospitalsetting inUgandaBy Tina Krumbein,Veronika Scherbaum,and Hans Konrad BiesalskiA mother spoonfeedsher baby in the NUTina Krumbein is a graduatenutritionist. Thisarticle forms part of herdiploma thesis submittedto the Departmentof Biological Chemistyand Nutrition, Universityof Hohenheim, Germany.Veronika Scherbaumholds a MSc degree inMother and Child HealthNutrition. Since 1998,she has been a lecturerin Nutrition inDeveloping Countries atUniversity of Hohenheim, Germany. Inthe 1980s she worked for several yearsin Ethiopia as a nutritionist. More recently,she has been involved in consultancies(mainly for evaluation of SFPs, TFPs andbreastfeeding promotion) in Afghanistan,Iraq, Zimbabwe and Darfur.Hans K Biesalski is director of theDepartment of Biological Chemistry andNutrition. He is actively involved inresearch on vitamin A metabolism and issupervisor of studies in InternationalNutrition. He is a member of IVACG andchair of a couple of studies dealing withVitamin A Deficiency Disorders (VAD).This pilot study was financially supportedby the Eiselen Foundation, Ulm and theGerman Medical Missionary Team.T Krumbein, Uganda, 2005Food storage roomin the Nutrition UnitField respondent to evaluation, 2006.21

Field ArticleThis article describes some of the preliminary findingsof a recent study that introduced locally producedReady to Use Therapeutic Food (RUTF) 1 intoa hospital setting in Uganda, comparing its use toF100 during the rehabilitation phase. This articlefocuses particularly on the experiences producinglocal RUTF in a hospital setting, including costcomparisons with the routinely used F100.Kumi Hospital (formerly KumiLeprosy Centre) is located in Kumidistrict, about 8 km east of KumiTown in Eastern Uganda. Establishedas a general hospital in1997, most of the servicesand programmes of Kumi Hospital are donorfunded. In 1996/97, a poor regional harvest ledthe Medical Superintendent of Kumi Hospitalto request a nutritionist from the GermanMedical Missionary Team (GMMT) to help withthe construction of a Nutrition Unit (NU). TheNU was subsequently established inSeptember/October 1998.Development of the Nutrition Unit (NU)Initially the NU treated severely malnourishedchildren in the rehabilitation phase, with stabilisationand initial care offered in the paediatricward of the hospital. The NU also providedfood (NU diet, see box 1) for malnourished childrenwho were admitted to other wards orcould stay near the hospital. At this stage, otherward staff provided medical care to the children.To improve the care and monitoring of thechildren, especially at night, and to avoidabsence of the mothers/patients on some days,a 16-bed extension to the NU was opened inMarch 2001, where the children could beaccommodated with their caretaker. In May2004, the NU became a ward with its ownemployed nursing staff and a dedicated doctorfor daily supervision. Severe clinical cases (e.g.those who required naso-gastric feeding) continuedto be first admitted to the paediatricward, with transfer to the NU once stabilised.Malnourished children without obvious medicalcomplications were directly admitted to theNU ward.All children admitted to the NU are treatedaccording to WHO’s 10-step-guidelines (1999).F75 (during the initial phase) and F100 (for therehabilitation phase) are produced from freshcow’s milk, oil, sugar, and vitamin-mineralBox 1complex (CMV therapeutic). The majority ofchildren are weighed daily and weightgain/kg/day was calculated.As well as treating severe malnutrition, the NUis also actively involved in:• Identification of malnourished children inthe area through home visits or immunisationoutreach work.• Teaching caretakers about basics of nutrition,hygiene and primary health care.Caretakers also worked in the garden of theNU growing some of the food for the programmelike groundnuts, vegetables andfruits.• Counselling of the caretakers in the NU andduring home visits, by a trained socialworker.• On the job training and supervision of NUstaff.Since the NU began in 1998, almost 1000 patientshave been admitted. Additionally the NU hastaken care of outpatients enrolled in the feedingprogramme but not admitted to the NU.Study objectivesThe main objectives of the study were:• To compare weight gain, duration of stayand other parameters of two groups of children,one group receiving locally producedF-100 and the other locally produced RUTF,during the rehabilitation phase.• To develop a suitable procedure for smallscale local production of RUTF.• To develop recommendations for use in theNU on how to produce and administer RUTF.• To assess and compare prices of F-100 andRUTF (both locally produced)The study was carried out in the NU betweenSeptember and December 2005.Study outline and preliminary findingsDuring the first weeks of the study, childrenentering the rehabilitation phase (after theirappetite returned) were randomly divided intotwo groups, one group receiving F-100 and theother local RUTF. However, some children didnot like the taste or could not manage 2 RUTFduring this early stage of rehabilitation and sorandom allocation was abandoned. Instead,children whose appetite had improved andwho liked the taste of the RUTF were managedusing RUTF with small amounts of the NU-diet 3 . These children (n=10) were compared tothose who had selected to receive either F-100exclusively for several days first or immediatelya combination of F-100 with small amountsof the NU diet (n=5). All three children whowere suffering from oedematous forms of malnutritionon admission received F-75 during theinitial phase. At the beginning of the rehabilitationphase, two kwashiorkor cases chose the F-100 group and one opted into the RUTF group.Thus self-selection determined the majority ofassignments to the F100 or RUTF group, basedon the appetite and food preference of the malnourishedchild.Weight gainWeight gain averaged 9.7g/kg/d in the F-100group and 7.3 g/kg/d in the RUTF group. Themean duration of stay was 32.6 days in the F-100 group and 28.5 days in the RUTF group. Onadmission, all children in the F-100 group wereseverely wasted (W/H z-score

Field ArticleInitially the sugar was not ground whichmade the product very crumbly and difficult toeat. The sugar was subsequently ground beforemixing with the milk powder, which made theproduct smoother and more palatable. It wasfeasible to grind all the sugar because therewere only small amounts for each productioncycle (140 g sugar for 500g RUTF).In the beginning, an electric mixer, whichwas brought from Germany, was used to stirthe ingredients. Subsequently, mixing wasachieved through using a spoon and mashingand shaking ingredients in a closed containeruntil the mixture was a paste.This proved to be as effective as the electricmixer and was independent of electricity – animportant consideration in an area wherepower cuts are common.Training staffAfter learning about RUTF production, the NUstaff members had a chance to ask questionsabout the product and the production. A sheetwith basic information about the product andquantities required for children was includedwith other recipes in the NU kitchen.Advising mothersThe paste was given out to the children in cupswith a lid. The mothers were told to feed thechild with a spoon out of the cup and to offersufficient amounts of drinking water.Cost comparisonThe cost of producing local F-100, using bothfresh cows milk and full cream milk powder(FCM), and for locally produced RUTF werecalculated and compared, based on quantitiesof each that contain 1000 kcal (see table 1). Onelitre (1000ml) of F-100 based on fresh cow’smilk costed 698 USh (32 cent) 7 which is cheaperthan the local RUTF produced in this study((920 USh (42 cent)/1000kcal where groundnutsdid not need to be purchased, and remainscheaper if groundnuts had to be bought (1004USh (46 cent)/1000kcal). The high cost of milkpowder is the main reason for the higher priceof RUTF, which also accounts for the high costof FCM based F100 - over double the price offresh milk based F100.ConclusionsDifferent degrees of malnutrition require differentfeeding options. For severely malnourishedchildren with/or without complications, duringthe initial stage of rehabilitation it is appropriateto offer small amounts of RUTF in additionto F-100 and to observe which type of therapeuticfood a child prefers.Appetite does not always remain consistentduring the early stages of recovery. Some childrenwho re-developed signs of fever or diarrhoeatemporarily lost their appetite again. Insuch situations, it is important to have access toalternative types of therapeutic food.Locally produced RUTF was well acceptedby the majority of less severely malnourishedchildren in the NU. The duration of stay wasalso shorter in these children. This suggests thatearlier discharge combined with a weeklycheck-up and distribution of RUTF (i.e. homebasedtherapeutic feeding until full recovery) isa realistic option for certain children and theircaretakers, especially for those who live close by.Local production of RUTF in the NU inKumi hospital is feasible. The means for production(spoon, cups, boxes, a fridge) werealready available in the NU, and practicalities,like grinding sugar or manual mixing, werepossible since only small amounts were beingprepared. However, local production did relyon imported vitamin-mineral mix, which in thisinstance was already being supplied. This maybe a constraint where a supply and a budget arenot in place. Only small amounts were produced,therefore the caster sugar, which wasused instead of icing sugar, could be groundeasily before use. This could become more difficultwhen larger amounts of RUTF have to beproduced locally (e.g. during the rainy seasonwhen there are typically higher admission rates).RecommendationsDifferent types of locally prepared RUTF (e.g.with milk powder in supervised feeding settingsand without milk powder for locally preparedtake home rations) should be explored toincrease the variety and safety of therapeuticfood and to support the local economy.In an institutional setting (hospital/NU) theright time to offer RUTF to (severely) malnourishedchildren with complications needs to befurther investigated. There needs to be access todifferent types of therapeutic food for childrenat various stages of malnutrition.Children who are discharged early (beforefull recovery) should receive a take-home rationof RUTF and be followed-up on a weekly basis.The right time for discharge needs to be negotiatedbetween the caretaker and hospital/NUstaff members.For further information, contact: Dr. VeronikaScherbaum, email:scherbau@uni-hohenheim.de6To prevent aflatoxin contamination mothers were told toexclude all peanuts that showed any discoloration or otherirregular appearance.7F-100 prepared with full cream milk would cost 1558 USh(71 cent) (see table 1)Table 1Box 2Cost-comparison of 1000kcal equivalents of F-100 (using fresh cow milk or full creammilk powder) and local RUTFFresh cows milk Full cream milk powder (FCM) Local RUTFAmountCost Amount Cost Amount880 ml fresh cows milk 440 Ush 110g FCM 1320 Ush 57g FCM75g sugar 113 Ush 50g sugar 75 Ush 53g sugar20g veg oil 35 Ush 30g veg oil 53 Ush 29 ml veg oilHalf a msp* CMV 110 Ush Half a msp CMV 110 Ush 3g CMVPeanuts (or groundnuts) are very common in Kumiand are grown in the NU-garden. For the study,they were taken from this year’s harvest. Afterharvesting, the mothers dried, peeled 6 , roastedwithout salt and milled them using a wooden mortar.The paste was stored in a tin. Before makingthe RUTF, the quality of the paste was checked bychecking the colour, smell and taste.For the study, 7.5kg of full cream milk powder(enriched with Vitamins A and D) was bought in inKampala and Mbale supermarkets at a cost of30,000-35,000 USh (13.50-16 euro) per 2.5kg tin.Before using the powder, the use-by date, appearance,colour (white to yellow, creamy), taste andthe smell (milky, bit sweet) were all checked.Sugar and oil were already regularly bought bystaff of the NU for the preparation of F-75 and F-100. Sugar was purchased in Kumi town in 50 kgbags,which cost 75,000 Ush (34 euro) per bag(the price of 1 kg of sugar is 1,500 USh). It was48 g peanut pasteCost784 Ush80 Ush29 ml veg oil 46 USh106 Ush83 Ush **Cost per litre: 698 (32 cent) Cost per litre: 1558 (71 cent) Cost per 190g:*** 1004 Ush (46 cent)Costings calculated in Ugandan Shillings (Ush) and euro (cents).*Measuring spoon included with CMV therapeutic** When bought at the local market*** Costing calculated from weights and prices to produce 500g RUTF (2625 kcal): where cost/500g divided by 2.63 toproduce cost/190g RUTF (1000 kcal)impossible to stop ants getting into the bags so,before using the sugar, impurities were removedand quality was checked.Vegetable oil was regularly bought in cans of20 litres. The price of one can was 35,000-40,000Ush (16-18 euro). The cost of 1 litre was 1,750-2,000 USh. Quality was checked before use.Vitamin-mineral-premix (CMV therapeutic) wasalready available in the NU since used in thepreparation of F-75 and F-100. It is regularlyordered from Nutriset in France. The costs were asfollows:1 kg of CMV: 15.69 euro1 carton of 6 tins of 800 g each (4.8 kg): 75.31euroTransport to Kumi from France: 62 euro/cartonTotal price per carton (6 tins; 4.8 kg):302,080 Ush(137.31 euro)/carton (3 cents/g) CMV was storedin 800 g tins in the kitchen. Before use, the usebydate and quality were checked.A recoveringchild feedshimself porridgein the NUBox 31. First the vegetable oil is warmed through.Then the amount of peanut paste andthe amount of (cooled) oil are weighedwith a digital weighing scale to thenearest 0.1 g and both are mixed with aspoon until the mixture becomeshomogenous (this takes about 5 minutes).2. The sugar is then weighed and groundwith a pestle and mortar to a finer powder.The required amount of milk powderand CMV are weighed and mixed with thesugar in a container. Mixing takes about4-5 minutes.3. The peanut-oil-mixture is then pouredinto the powder-mixture and again mixedwith a spoon until it becomes a kind ofpaste. It is not only stirred but alsopressed/mashed against the container.T Krumbein, Uganda, 200523

Agency ProfileLutheran Development Services (LDS)ENN, 2006L to R: Bjorn Brandberg, Meketane Mazibuko, Euni Motsa,and Nhlanhla Motsa (picture taken in complete darkness!)Name ....................... Lutheran DevelopmentServices (LDS)Address ................... P. O. Box 388, Mbabane,SwazilandTel ........................... +268 404-5262/404-3122fax ........................... +268 404-3870Email ....................... lds@realnet.co.szFormed .................... 1994Director ................... Bjorn BrandbergNumber of staff ....... 42Main office ............... Ka Schiele, Mbabane,Swaziland, with a fieldoffic in NdzevaneAnnual Turnover ...... 4.5 million Emalangeni(approx 750,000 US dollars)By Marie McGrath, ENNA n ENN trip to Swaziland offeredthe opportunity to profile one of the localNGOs, Lutheran Development Services (LDS),working there. Thanks to a very accommodatingteam who gathered together at only anhour’s notice, I spent a couple of hours talkingwith four of the organisations’ key staff. TheDirector of LDS, Bjorn Brandberg, joined theorganisation in 2004, replacing the retiringdirector, Pamela Magitt. As an architect and aSanitation Advisor, he first began working inAfrica in 1976. Many years were spent doingconsultancy work in the region with the WorldBank/UNDP/UN Habitat. The desire to workwith his own team was one of the reasons forjoining LDS. Meketane Mazibuko, Gender andAdvocacy Co-ordinator, and Euni Motsa, HIV& AIDS Coordinator, joined LDS as food distributionpersonnel in 1995. Halfway through theinterview we were joined by Nhlanhla Motsa,the LDS Emergencies Project Manager, whobegan working with LDS in 1995. While I wasimpressed with how each had worked theirway up the organisation into key roles, I wasparticularly taken with Euni’s openness in sharinghow 2002 was a particularly challenging yearfor her, where her appointment as HIV/AIDSCo-ordinator coincided with her learning of herown HIV positive status. While it has not beeneasy, the support and “gentle nudges” of herLDS colleagues has meant that she now headsup the HIV/AIDS section and is an inspirationalexample of positive living with HIV/AIDS.Bjorn began by explaining how LDSemerged from a trend within the LutheranWorld Federation (LWF) to shift from LWFowned NGOs to localised NGOs. LDS is thedevelopment arm of the Evangelical LutheranChurch in Southern Africa Eastern Diocese. It isan autonomous NGO governed by a Board ofDirectors whose chairperson is the bishop. LDSwas formed in 1994 and is one of the firstlocalised NGOs that is church owned.Geographically it covers Swaziland and part ofMpumalanga Province, South Africa. In practice,activities are concentrated in the droughtpronelowveld region of Swaziland, the areawhere there is the greatest need.Given the high prevalence of HIV inSwaziland (42.6% at antenatal clinic screening),I asked Bjorn how significantly HIV/AIDSinfluenced their work. He responded thatHIV/AIDS infiltrates, “even dominates” prettymuch every aspect of their programming. Oneway or another, most of their activities are motivated,are influenced or viewed from aHIV/AIDS standpoint. This is helped througha LDS team that is dedicated to HIV/AIDS programming.While now an integrated projectwithin LDS, this was not always the case. “WhenI first started with LDS”, says Bjorn, “HIV/AIDSwas a separate sector, actually located in a separateoffice to the rest of the LDS team. In anattempt to pull HIV activities of the churchtogether, the HIV/AIDS team had been locatedin one unit”. Meketane and Euni add how,despite the original good intentions, this hadactually marginalised the group so integrationwas not very obvious, though they themselvescouldn’t see this. “So I had to take them by theear, and drag them in”, smiles Bjorn.“Literally”, laughs Meketane, “every day hewould come in and ask, ‘when are you joiningus in the LDS main offices?’ and finally one dayhe came and said, ‘you are moving in now,today’ and so we did. It was only when wemoved in that we realised how segregated wehad been. Since then, the HIV/AIDS team havefelt very much part of the LDS family.”“The next step is to drag the Lutheranchurch in as well”, says Bjorn. “We have a commonvision and goal and are doing everythingbut work together”. He explains how the LDSnetwork is much smaller than that of the churchand, if they were to join forces, would form thebiggest most powerful network. Extendingtheir activities equally to all areas would reallystretch their resources and dilute their efforts –something that working with the church networkwould help overcome. Recent developmentshave been encouraging. Fuelled by somelobbying by LDS – described as “ putting thecat amongst the pigeons”, by Bjorn – greaterinstitutional pressure is now coming from theHQ of the LWF in Geneva and from the Nordiccountries (who are the big funders for church-es) to work with organisations like themselves.So while this collaboration is not as good asthey’d like, Bjorn feels the “wind is now blowingin the right direction”.Three quarters of LDS’s work is emergencies-relatedprogramming, with sustainabilityand community involvement at the core ofwhat they do. “Our mission statement says itall”, says Bjorn, “in that we work so that ‘thepoorest of the poor develop quality of lifethrough acquisition of knowledge and skills forself-reliance and sustainability in enhancingtheir livelihoods’”. But he adds that “preachingthis is one thing, practising is quite another - wehave high ideas about helping people to takecharge of their own futures, but these can be tootough to implement on the ground”. The teamgo on to detail some of the income generatingactivities (IGAs) they have been involved in,such as a beadwork project for people livingwith HIV/AIDS (PLWHA) in a day care centrein Bethal whose products are sold within SouthAfrica. Other IGAs involve agriculture, poultryfarming, and they are developing plans forsome gardening projects. The hope is that withminimal input, IGAs can develop and reducedependency on aid. Bjorn reaffirms that thechallenge is to achieve this in areas of acuteneed where people have very limited capacityto help themselves, like in the lowveld region.Despite their origins and links with theLutheran church, LDS sources no funding fromthe local church community. “While we preachself sustainability, we then live as beggars ourselves”says Bjorn as he describes their fundingsources. LDS gets most of its funding throughthe LWF and their core donors are Bread for theWorld, Church of Sweden mission, Finn ChurchAid and Action by Churches Together (ACT).They also get funding from WFP, UNICEF, theNational Disaster Task Force (NDTF) andUNAIDS as implementing partners. At thesame time, they are trying generate fundsthrough income generating projects that offerthe freedom to use the proceeds and profits asthey see fit. One initiative underway involvessetting up a medical psychologist in a clinic in24

Agency ProfileMbabane where he will run his own facility,charging those who can afford to pay,and in doing so generate income to supportservices for those in need and fill the hugegap in psychosocial services for those livingwith HIV/AIDS in Swaziland. Eunidescribes how, despite her positiveapproach and the support of her workteam,living with HIV/AIDS can still feellike a “disaster waiting to happen.” Thisisn’t helped by a lack of high profile rolemodels in Swaziland living withHIV/AIDS and the considerable stigmastill attached to the diagnosis. Bjorn goeson to elaborate on another plan in progress,to build a Conference Centre on the landsurrounding their office which is owned bythe church and which is the most economicuse of the land. With his background inarchitecture, he was involved in drawingup the detailed plans a number of yearsago. The process of approval has been long,but with the arrival of a new bishop for thediocese who is very supportive Bjorn feelsthat this project is coming much closer tofruition.The arrival of Nhlanhla marks a goodpoint to elaborate on LDS’s emergencyactivities. LDS implements general fooddistributions under both WFP and theNDTF. School feeding programmes, mainlyconcentrated in the lowveld areas, providechildren with a snack of Corn Soya Blend(CSB) and a cooked lunch. Through clinicfeeding programmes, pregnant and lactatingwomen and malnourished childrenunder five years receive a take home rationof CSB. A newer innovation has beenNeighbourhood Care Points (NCPs) forchildren who, for a variety of reasons, arenot attending school in the drought affectedregion and are particularly vulnerable.Many come from child headed households.As well as providing a cooked meal, theNCPs offer the opportunity for informaleducation, and psychosocial support forchildren. While the NCPs started out in thelowveld region, they have spread to otherareas. Food For Work (FFW) is being developedfor those currently volunteering tosupport the NCPs, which is one of the waysLDS feels will help to transit between foodaid and recovery.Targeting is another challenge facing theemergencies programming. Nhlanhladescribes how the Relief Committees areresponsible for targeting food, mainly composedof women and a few men. Whilethey have carried out training with committeesand traditional leaders, there arealways the few with vested interests whowould like to wield their influence.“Sometimes those who are relatively welloff still want to claim food”, says Nhlanhla,“ as they feel they are entitled since theycome from a drought affected area”.Targeting is particularly challenging whenit comes to support for PLWHAs. Nhlanhladescribes that there is still a lot of stigmaassociated with positive HIV status andpeople will travel out of their area to gettested where they are unknown. This initiallymade targeting very difficult andpeople were slow to come forward andreveal their status within their community.Nhlanhla continued that this has improvedwhen it became policy that those who weretargeted through HIV/AIDS were guaranteedtheir full food ration when stocks wererunning low and where distributed rationswould need to be reduced. This provedenough of an incentive for those to comeforward.LDS have also been cooperating withLUSIP on a small holder project, SWADP(Swaziland Water and AgriculturalDevelopment Project). The lowveld regionhas very fertile soil and bringing in waterto irrigate can increase productivity up totwentyfold. Sugar cane is the most profitablecrop and can also be used for fuelproduction. “We wanted to make sure thatthis developed in the right way”, saidBjorn, “we were worried that turningsmallholders into shareholders mightmean losing their identity, or the challengeof managing a monetary economy wouldprove too much.” The project is in it’s firstphase, “trying to keep people as landownerswith technical input and support forirrigation”. As with all of their programming,they are taking a holistic approach,and will add on to the programme as needsemerge.Suddenly, we are thrown into darknessdue to a (typical) power failure and theteam leap into action using the light of severalmobile phones to finish the meeting.Bjorn feels that one of the biggest programmingchallenge for LDS is “figuring outhow we can have the best impact”. Lots ofresources are taken up with orphan care,with food aid, and with increasing numbersor people becoming infected andbecoming ill. “We want to be proactive,avoid children being orphaned, keep a productiveforce and keep people alive ontreatment”. The team feel that the roll outof anti-retroviral treatment (ART) is far tooslow with very few clinics offering this.Transport distances means that it is oftentoo difficult to travel to a clinic, queue,attend and then return in the one day. Oneof their organisational challenges comesfrom those churches that still describeHIV/AIDS as the ‘curse’. Dealing withorphans is one of the big emerging challengesin Swaziland. “Even with the developmentof NCPs”, says Bjorn, “these childrenare growing up without parents, theyare streetwise but have little education, nopsychological support and no one is passingon life skills”. The team feel that therecent ‘orphan farmer schools’ being pilotedby the WFP/FAO/Ministry ofAgriculture in Swaziland is a significantmove in the right direction, equippingcommunity-identified vulnerable childrenwith practical agricultural and life skillsthat they would not otherwise acquire.After all the difficulties portrayed by theteam they were keen to emphasise thatthey are by no means discouraged. Thiswas very obvious from the enthusiasm,comradeship and openness that theydemonstrated throughout the interview. Inthe NGO sector, negative assumptionsabout church-based NGOs often surface,i.e. having an evangelical agenda.However, with LDS it seems their onlyagenda is helping the ‘poorest of the poor’to help themselves as best they can.S Sharif, T Shah (Eycon Solution), Pakistan, 2005S Sharif, T Shah (Eycon Solution), Pakistan, 2005The PakistanEarthquakeSurvey:MethodologicalLessonsLearnedBy Leah Richardson, Moazzem Hossainand Kevin SullivanAcknowledgements go out to the survey teamsas well as to those responsible for the close partnershipbetween UNICEF, WFP, WHO and theMinistry of Health. Additionally, warm thanks toRafah Aziz (UNICEF- Geneva), Mona Shaikh(WFP Pakistan), Shadoul Ahmed (WHOPakistan), Rifat Anis (NIH, Pakistan), Zahid Larik(DDG, Nutrition Wing, MoH, Pakistan), TehzeebAli (PHC Consultant, Pakistan), Fakhra Naheed(PO Nutrition Wing, MoH, Pakistan) and ShafatSharif (Data Analyst, Eycon Solution, Pakistan)for all their hard work throughout the process.A man sets up his food stallamongst the earthquake ruins25

Field ArticleA mother prepares foodin a makeshift tent.Leah Richardson works as aPublic Health Nutritionist inthe Nutrition Service of theWorld Food Programme (WFP)headquarters. Her currentinterests are survey methods,nutrition in emergencies, andmeasuring mortality.Moazzem Hossain is anAdvisor at UNICEF NYHQ,Nutrition Section. He wascoordinating NutritionAssessment and responses inthe earthquake affected areasof Pakistan during October2005 – January 2006. He hasvast experience in conductingNutrition Assessment in differentemergencies likedrought, floods, conflicts andnow the recent earthquake.Kevin Sullivan is an AssociateProfessor in the Departmentof Epidemiology, EmoryUniversity, Atlanta. His areasof expertise include epidemiologicmethods, micronutrientdeficiencies, anthropometry,and survey methods.On October 8, 2005 a strong earthquake- said to be the most powerfulin the region in 500 years -hit the northeastern part ofPakistan. The result was massive destructionand catastrophic mortality, primarily inthe upper Northwest Frontier Province(NWFP) and in Azad Jammu Kashmir(AJK). Emergency relief was initiated withindays of the earthquake to deal with themost immediate needs and within weeks ofthe event, a Rapid Food Security andNutrition Needs Assessment was conductedby WFP and UNICEF (with support fromOXFAM). The results indicated that amongthe affected areas, most were rural. Nearly2.5 million had lost their homes and themajority of the population was living inmakeshift tents. More than half reportedloss of all grain stock and 15% reportedcomplete dependence upon charity/aid.The rice and maize harvest had been interrupted,livelihoods had been severely curtailed,and morbidity rates were high.Prior to the earthquake, acute malnutritionhad been a major public health problem(at national level 13% global acute malnutrition)and in light of the aggravating factors,the situation was expected to deteriorate.Various agencies involved in the responsewanted a more specific and accurate figureof the malnutrition prevalence along withrelevant health and vulnerability informationthat would assist in designing appropriateinterventions in affected areas.Therefore, a nutrition and health surveywas planned by UNICEF/WFP/WHO incoordination with the national Ministry ofHealth (MOH). A technical working groupof the implementing agencies was formedwith representation from all partners tooversee the survey implementation – fromdesign to data analysis through to reportwriting. In this context, the partnershipworked extremely well and was a valueaddedstep in the process. It could serve asa model for future assessments.The principal objectives of the surveywere to assess the nutritional status of children6-59 months and their mothers, to estimatethe crude mortality rates for the day ofthe earthquake as well as the pre/postearthquake rates, to determine the prevalenceof morbidity, and to investigate foodconsumption patterns and household foodsecurity. Sample sizes were calculated foreach of the survey populations using estimatesof global acute malnutrition andcrude mortality rates. Clusters were selectedusing the probability proportional to sizemethodology. Households were selectedusing systematic random sampling andhousehold lists. Data were collected in thefour surveys by six trained survey teamsbetween 21 November and 25 December2005.Methodological Lessons LearnedAssessments conducted in times of crisishave limitations and problems broughtabout by (among other things) a lack ofready information, time constraints, andharsh/dangerous working conditions. Thissurvey in Pakistan was no exception. Someof the problems encountered, mistakesmade, and solutions found are just as valuableas the results. In sharing these experiencesand lessons learned, the goal is toimprove the quality of future assessmentsand to provide a platform from which togrow.Lesson 1: At what level do you want yourresults to be representative?The first challenge the technical workinggroup faced was to create a study designthat would capture separately the conditionsof both the stable and moving populationsaffected by the earthquake. Creating apopulation sample frame was extremelydifficult considering the ongoing migrationand that those displaced (camps) weremuch more adversely affected than thosewho remained in their homes (communities).Additionally, the affected areas fellinto two major political and geographicalzones, Azad Jammu and Kashmir (AJK) andNorth West Frontier Province (NWFP) ofPakistan, which had different pre-disasterconditions and had not sustained damageproportionally. With these issues in mind,the struggle was to create a sampling framethat would translate into survey results representativeof the different populationsinvolved. Since the earthquake had affectedthe provinces unequally, and since theS Sharif, T Shah (Eycon Solution), Pakistan, 2005Scenes of destructionpost earthquake in northeastern Pakistan26

Field ArticleS Sharif, T Shah (Eycon Solution), Pakistan, 2005S Sharif, T Shah (Eycon Solution), Pakistan, 2005S Sharif, T Shah (Eycon Solution), Pakistan, 2005S Sharif, T Shah (Eycon Solution), Pakistan, 2005A surveyor records details during the nutrition and health surveySurvey team trainingSurvey teamWeighing a child in a householdaffected populations were living in both campsand in communities, four cross sectional surveyswere conducted. In the NWFP, two separatesurveys were conducted, one among thoseliving in camps and the other in communitiesof Mansehra District which was one of themost affected districts. In the AJK a similarapproach was used with one survey conductedin camps and the other in communities ofMuzaffarabad District. Findings from thesefour surveys could then be used to providespecific information of the two populationsub-groups in the two distinct areas.Furthermore, the results could be used in tandemto determine quantitatively which populationsand/or area were more in need of specificservices when compared to others, therebyillustrating the overall health, nutrition andfood security situation. Although the exercisewas relatively more expensive and time consumingthan doing only one survey, it wasfound to provide essential information at alevel of detail that would have been impossibleif only one sampling frame had been usedto provide one overall estimate.Lesson 2: How much supervision is enough?An overarching and integral factor in all surveys,including this one, is the need for consistentand meticulous supervision.Unfortunately, due to the overwhelmingnature of the emergency, staff capacity waslimited and the survey coordinating team wasnot able to designate one supervisory personfor the full data collection, analysis and reportwriting. In the absence of oversight and supervisionby one fully responsible person, especiallyduring data collection period, the surveyteams relied on their individual team supervisorsand previous experience/knowledge.Hence, some of their initiatives deviated fromthe prescribed methodology and caused somecomplications during data analysis. Thoroughtraining followed by careful supervision of theoverall process by one responsible person orteam is a pre-requisite for a smooth and highquality assessment.Lesson 3: How do you place your clusters, andmust you go to all of them?When external circumstances dictate that certaingeographical areas are not accessible, andthe accessibility will not change over thecourse of the assessment, these areas and populationsshould be excluded from your initialsampling universe. They have a zero probabilityof selection and have no purpose in thesampling universe. When accessibility is fluid(such as during times of conflict or, more contextspecific, under the threat of landslides orsnow) it is recommended to keep those areasand populations in the sampling universe incase you might be able to reach them.Automatic exclusion of these areas may introducebias into the results. Therefore, if there issubstantial reason to believe that geographicareas may be unreachable, one potential solutionis to estimate the number of clusters inthese areas that may be unreachable. Thenincrease the overall number of clusters to beselected in order to ensure that the minimumrequired sample size is achieved (for example,selecting 33 clusters when you need 30 clustersbut think that you may not be able to reachthree.) Selecting more clusters based on theassumption that some may be unreachable is areasonable approach.The caveat for this sampling methodologyis that if 33 clusters are selected with the hopeof reaching at least 30, all accessible clustersmust be included in the final sample. Forexample, if 33 clusters are selected, and onlyone of the 33 clusters is inaccessible, it isimperative that all 32 accessible clusters areincluded in the sample and that data collectiondoes not stop with the first completed 30 clusters.Since the 33 clusters are selected usingPPS, intentionally excluding clusters when 30clusters have been sampled makes it a nonprobabilitysample, and therefore may lead tonon-representative results.In Muzaffarabad community and in theAJK camps it was decided that the risk of losingclusters was great enough to warrantselecting additional ones. In the context of thissurvey where 30 clusters were required for thedesired sample size, an additional three clusterswere selected to act as a protective buffer.This means, in effect, 33 clusters were selectedfrom the sampling universe using PPS and thefinal survey design was 33 clusters of 20households. The survey team began data collectionand, in Muzaffarabad, one cluster outof 33 was inaccessible while in the AJK campsit turned out that all clusters were accessible.The methodological problem occurred whenonce 30 clusters had been included in the sample,data collection stopped and the remaining3 clusters were excluded from the survey. Thisintentional exclusion had the potential ofA survey team arrive inMuzaffarabad camp.S Sharif, T Shah (Eycon Solution), Pakistan, 200527

Field Articleinjecting bias into the results, especially if the 2or 3 excluded clusters were disproportionatelydifferent from the included clusters (harder toaccess, more affected by the earthquake, noaccess to humanitarian relief, etc).Once data analysis began the coordinatingteam realised that the data was potentiallybiased and had to apply some retrospectivemethods during the analysis to correct theproblem. The most important lesson to takefrom this is if an ‘alternative methodology’ isused in designing a survey, it is important toadhere to the accompanying methodologicalrequirements.Lesson 4: Do you calculate required samplesize? And is your sampling unit the householdor individual?Cluster sampling for nutrition surveys has historicallyoften been conducted using a standard30x30 approach (without calculating thesurvey/context specific required sample size)and using the WHO/Expanded Programmeon Immunisation (EPI) method for householdselection. Sampling methodology has beenmoving away from the standard approaches ofalways using the 30x30 design and use of thenext-nearest household quota sampling of eligibleindividuals. In this survey a few morerecent and highly regarded sampling techniqueswere applied.Firstly, sample size was calculated based onassumed prevalences, desired precision, andassumed design effect. Hence, the standard30x30 survey deviated into a smaller, fasterand cheaper 30x20 sample. Secondly, systematic,random sampling using household listswas applied in each cluster in order to selectthe households (and to move away from thepotentially biased EPI method of proximitysampling). In applying this method, it is necessaryto pre-select the exact householdsincluded in the data collection, therefore theprimary sampling unit becomes the household,instead of the child. This means that thechildren included in the sample are only to belocated in these 20 pre-selected households. Itis unlikely that there will be exactly one childper household and it is possible that there maybe less than exactly 20 children to be foundinclusive among all the selected households.This means that in some clusters, there may beless than 20 children (and in some clustersthere may be more than 20 children). The otherreason, in this survey, to have a quota ofhouseholds was for mortality estimates whichshould be based on households, regardless ofwhether or not there are children in the household.The survey teams, with experience fromother surveys, were accustomed to using thestandard proximity sampling approach wherechildren were the primary sampling unit andexactly 30 children were sampled per cluster.When using this ‘new’ sampling techniquesthey became nervous about clusters where 20households did not yield a minimum of 20children. Thinking that this would jeopardisethe survey results, and not understanding therationale behind this alternate methodology,the teams decided that a quota system for childrenmust be applied to each cluster that yieldedless than 20 children. Consequently, surveyteams selected additional households until the20 children quota was found, resulting in somecluster data containing more than 20 households.When the data were being cleaned andprimed for analysis, the coordinating teamrecognised that a modification of the methodologyhad been made in the field by the surveyteams. With the prescribed survey methodologythere was no way that there could be morethan 20 households per cluster, therefore thechange in sampling was immediately apparent.As a solution to the problem this imposed,the households exceeding the initial 20 householdrange were excluded from the analysisleaving the original methodology intact. Here,the lessons learnt worked two ways in that rigoroussupervision could avoid extra time duringdata cleaning, while rigorous data cleaninghelps in controlling manageable mistakesmade during data collection.ConclusionThe timely results of the survey played animportant role in detailing the effects of theearthquake to the outside world, to agenciesinvolved in the relief effort, and to donorsinterested in supporting the relief effort.Although there were problems encounteredduring this survey (as there is in every survey)coordinated interagency efforts ensured thatthe quality of the results were maintained.While high quality results are essential there isa high value in lessons learned – and shared.For further information, contact: LeahRichardson, email: Leah.Richardson@wfp.orgPeople in aidMark Wamalwa, one of the Kenyan nurses workingon the ACF TFC-Home Treatment programme (seefield article)ACF-USA, 2004M Lung'aho, CARE USA, 2006Training of Trainers. CARE IYCF-E/CARE Indonesia Breastfeeding Counseling course, WTimor, Feb-Mar 2006. Dr. Endang Widyastuti, CARE Indonesia Health Programme Leaderand Dr. Herti Herjati, Program Coordinator, IYCF on extreme left, 1st row.28

Field ArticleThe activities reflected here are joint projects of the CARE Infant and Young Child Feeding in Emergencies (IYCF-E) Initiative andeither CARE Kenya (the Dadaab IYCF Team is comprised of CARE Kenya, GTZ and UNHCR) or CARE Indonesia.M Lung'aho, CARE USA, 2006Kirk Dearden, Brigham Young University, atDadaab Camps, CARE IYCF-EInitiative/CARE Kenya.Kristin Helz, Columbia University and Ebla Farah, Dadaab Camps, CARE Kenya.People in aidDr. Utami Roesli & participants CARE IYCF-E/CARE IndonesiaBreastfeeding Counselling course, W Timor, Feb-Mar 2006Kirk Dearden, Brigham Young University, at Dadaab Camps,CARE IYCF-E Initiative/CARE Kenya.M Lung'aho, CARE USA, 2006M Lung'aho, CARE USA, 2006M Lung'aho, CARE USA, 2006M Lung'aho, CARE USA, 2006M Lung'aho, CARE USA, 2006Dr. Felicity Savage and dr. Utami Roesli CARE IYCF-E/CAREIndonesia Breastfeeding Counselling course, W Timor,Feb-Mar 200629An aid worker measuringMUAC during the surveyIYCF-E Team members, Dadaab Camps, Kenya: L to R: Mary Lung’aho, AnneNjuguna, Rose Ndolo, CARE IYCF-E Initiative/CARE Kenya; Irene Soi, GTZ.

CorrectionLearning about Exit Strategies in Southern Africa,Field Exchange 27The Field Exchange editorial team would like to correctthe acknowledgement on the field article on exitstrategies published in Field Exchange 27 (p31) andwritten by Kara Greenblott. In an editing slip, oneagency was selectively acknowledged which was notthe intention nor action of the author. We apologise forthe error. The author equally acknowledges all C-SAFEpartners who contributed to the project. The onlineversion of Field Exchange 27 has been corrected.Editorial teamDeirdre HandyMarie McGrathJeremy ShohamOffice SupportRupert GillDan GeorgeDesignOrna O’Reilly/Big Cheese Design.comWebsiteJon BerkeleyContributors forthis issueMoazzem HossainLeah RichardsonKevin SullivanChloe AngoodJosephine QuerubinMarie Sophie SimonIsabelle DefournyEmmanuel DrouhinMego Terzian,Mercedes TatayJohanne SekkenesMilton TectonidisTina KrumbeinVeronika ScherbaumHans Konrad BiesalskiGwyneth Hogley CotesSimon RoughneenPicturesacknowledgementMoazzem HossainTina KrumbeinVeronika ScherbaumAnne YzebeVeronique PriemS NanamaSimon RoughneenFrances MasonAndrew SealMark ManaryT KeeganMary Lung’ahoJulie DanaJ SpectorTanya KharaKarl DeeringJenny MatthewsYvonne ThobyField Exchangesupported by:The Emergency Nutrition Network (ENN)grew out of a series of interagency meetings focusing on foodand nutritional aspects of emergencies. The meetings werehosted by UNHCR and attended by a number of UN agencies,NGOs, donors and academics. The Network is the result of ashared commitment to improve knowledge, stimulate learningand provide vital support and encouragement to food andnutrition workers involved in emergencies. The ENN officiallybegan operations in November 1996 and has widespreadsupport from UN agencies, NGOs, and donor governments.The network aims to improve emergency food and nutritionprogramme effectiveness by:• providing a forum for the exchange of field levelexperiences• strengthening humanitarian agency institutionalmemory• keeping field staff up to date with current research andevaluation findings• helping to identify subjects in the emergency food andnutrition sector which need more research.The main output of the ENN is a tri-annual publication,Field Exchange, which is devoted primarily to publishing fieldlevel articles and current research and evaluation findingsrelevant to the emergency food and nutrition sector.The main target audience of the publication are food andnutrition workers involved in emergencies and thoseresearching this area. The reporting and exchange of fieldlevel experiences is central to ENN activities.The TeamJeremy Shoham (Field Exchange technical editor) andMarie McGrath (Field Exchange production/assistant editor)are both ENN directors.Rupert Gill is ENNadministrator and projectcoordinator, based in Oxford.Dan George is the ENNfinance assistant, workingpart-time in Oxford.Matt Todd is the ENN financial manager,overseeing the ENN accounting systems,budgeting and financial reporting.On the coverWomen on their way to Concerndistribution site, Tahoua, Niger.Jenny Mathews, ConcernWorldwide, NigerOrna O’ Reilly designsand produces all ofENN’s publications.Jon Berkeley managesENN’s website and supportsthe production of ENNpublications.The Emergency Nutrition Network (ENN) is a registered charity in theUK (charity registration no: 1115156) and a company limited byguarantee and not having a share capital in the UK (company registrationno: 4889844)Registered address: 32, Leopold Street, Oxford, OX4 1TW, UKENN Directors/Trustees: Marie McGrath, Jeremy Shoham, BruceLaurence, Nigel Milway, Victoria Lack, Arabella Duffield30

Emergency Nutrition Network (ENN)32, Leopold Street, Oxford, OX4 1TW, UKTel: +44 (0)1865 324996Fax: +44 (0)1865 324997Email: office@ennonline.netwww.ennonline.net