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September 2007 Issue 31ISSN 1743-5080 (print)• Managing moderate malnutrition withRUTF in Niger• Breastfeeding corners in Tanzania• Interpreting coverage survey in Ethiopia• Household food fortification in Sudan• Seed multiplication in Ethiopia• Implications of non-admission to CTCprogrammes3

Finbarr O’Reilly/Reuteurs. Niger.ContentsA mother attending a MSFprogramme in NigerField Articles2 Management of moderateacute malnutrition with RUTF inNiger10 Implications of a CoverageSurvey in Ethiopia20 Grassroots seed multiplicationin Ethiopia24 Household-based foodfortification for anaemia controlin Sudan28 Impact of non-admission onCTC Programme Coverage31 Breastfeeding support in therefugee camps of NorthWestern TanzaniaResearch4 Field testing LQAS to assessacute malnutrition prevalence5 Addressing chronicmalnutrition in South Sudan5 Caring for premature babiesin a conflict zone6 Remittances during crises7 Global factors shaping food aid8 Cash-based responses inemergencies9 Review of surveymethodology in emergenciesNews14 Mental Health among Childrenin Severe Food ShortageSituations14 Simple tools for measuringhousehold food access anddietary diversity15 Joint UN Statement onCommunity-basedManagement of Severe AcuteMalnutrition15 Food and Nutrition SecurityTraining Programme in theNetherlands15 World Conference ofHumanitarian Studies16 Translated versions of theOperational Guidance on IFE16 IASC Nutrition Cluster: KeyThings to Know17 LettersEvaluation22 Emergency school feedingprogrammes23 Evaluation of cluster approachin Mozambique27 Agency ProfileFrom the EditorOne of the longest raging debates in nutritioncontinues in the letters section of this issueof Field Exchange. Put simply, does the nutritioncommunity invest too much in magicbullets and not enough in home grown and more sustainablesolutions? In the 1970s/80s, micronutrientssupplementation became the ‘magic bullet’ to addressmalnutrition. Massive investments in Vitamin A, ironand iodine programmes were made while, accordingto critics, problems of chronic malnutrition and stuntingwere largely ignored. More recently, the roll out ofcommunity therapeutic care using ready to use therapeuticfoods (RUTF) has drawn ‘flak’ from those whofeel the approach is too dependent upon commerciallyproduced, ready-made products and therefore not sustainable– see letters section in Field Exchange issue19 (p23). The discourse on this subject is particularlyapposite given the nature of so many field articles currentlybeing submitted to the ENN, and in particular twoof the articles published in this issue.Our lead article describes MSF’s experience of extendingthe use of new therapeutic products and operationalstrategies to the treatment of moderate acute malnutritionin Niger. During 2006, MSF operated 11 outpatientfeeding centres attached to integrated health centresalong with two inpatient referral feeding units, in twodistricts of Maradi region with an estimated populationof 900,000 people.Moderately malnourished children were admittedto these units and treated with the same medical anddietary protocols used for severe acutely malnourishedpatients (with the exception of no systematic antibiotictreatment at admission). Plumpy’nut® (1,000 kcal/day)was used as the RUTF offered to all outpatients.A total of 64,733 children were admitted for acutemalnutrition in 2006 and of these, 92.5% (59,880)were children with moderate malnutrition. Analysisof results for 59,698 moderate malnourished childrenshowed a cure rate of 95.5%, death rate of 0.4%, anddefault rate of 3.4%. Average length of stay was 31.4days and average daily weight gain was 5.28g/kg bodyweight/day.As the authors of the article argue, these resultsare far superior to many emergency SupplementaryFeeding Programmes (SFPs) implemented with blendedflours. Indeed, the study just completed by SC UK andENN of data sets from 82 programmes conducted by16 agencies in 22 countries reflects a worrying situationwith this ‘standard’ method of treating mild andmoderate malnutrition in emergencies 1 . Only 41% ofthe programmes met all SPHERE standards with regardto impact at individual level and low levels of coveragemeant that impact at population level was minimal andnot significant. The main reason for poor performanceappeared to be high default rates, although managementand quality of foods also appeared to have a role.Failure of SFPs is problematic because, although severemalnutrition has a higher relative risk of mortality, themuch larger numbers of those with moderate malnutritionmeans that the population-attributable risk ofmalnutrition to mortality is much higher in this group.A second field article in this issue by Erin Tansey andDr. Ibrahim Bani is also based upon the experience ofusing a ‘ready made’ (albeit low cost) commercial productto address a long-standing micronutrient problemin Darfur. The Christian Blind Mission International,Canada (CBMI) and the Micronutrient Initiative (MI),together with the Sudanese Red Crescent Society(SRCS) and the Sudan Ministry of Health NationalNutrition Directorate (MOH-NDD), set out to implementa pilot project to test the acceptability to the internallydisplaced population of low cost micronutrient premixesand the feasibility of using it to improve micronutrientstatus in a camp in Darfur. Micronutrient deficiency isconsidered a major problem in Darfur. As well as contributingto infant mortality, over 50% of all children 6-59months are estimated to suffer from anaemia, whilevitamin A deficiency is estimated at 36%. Althoughfood rations provide some micronutrients, they arereportedly not enough to meet the needs of the mostvulnerable populations - pregnant and lactating womenand children under 5 years of age.Both these articles show how ‘high or higher tech’solutions still appear attractive to many agencies. Theexchange of views on this in the letter section in thisissue of Field Exchange centre around the use of readymade therapeutic products and can be summarised asfollows.On the one hand it is argued that the use of readymadeproducts risks creating a large-scale dependencyon expensive externally imported items. What happenswhen the emergency is over and funding dries up? Thereare also concerns about monopolies on production andtherefore ‘price fixing’. Protagonists of this view wouldprefer the use of locally made mixes with importedlow cost vitamin and mineral mix (e.g. CMV therapeutic).They also argue that there are many experiencesof ready-made F75 and F100 being used and suppliesbeing erratic or drying up, so that health centre staffhave to revert to home-grown solutions with inevitableadverse consequences for patients. There are alsomany experiences of home-based products being usedat lower cost and working, so why change to a regimethat is more expensive and may be precarious.Arguments against this are largely nutritional, e.g.home-made products may have a higher than desirableosmolarity and can induce diarrhoea in a few children,quality control may be difficult to achieve using modularfeeds, vegetable oils easily become rancid generatinghigh peroxide levels that place at risk children whohave very little in the way of anti-oxidants while locallysourced dried skimmed milk may not meet the lowsodium and iron specification that commercial manufacturerssource to make therapeutic milk. The bottom linefor those who support the use of ‘commercial’ productsis that “although we know we can ‘get away’ with usinglocal ingredients we are falling short of the recoverywe know we can achieve”. Furthermore, it is argued,issues of sustainability are more a question of commitmentand whether products are perceived as foods ormedicines. If viewed as the latter, then there is lesslikely to be questions about sustainability in developingcountries. Finally, there is no reason why therapeuticproducts, such as F75, Resomal and F100, could not beproduced locally with quality control – similar to the wayin which local RUTF manufacturing is currently beingrolled out.No doubt such arguments will continue and to someextent one cannot help feeling that the views of eachcamp are to some degree politically (with a ‘small p’)informed. However, as the ever pragmatic editor, onehas to ask whether generalisations here are necessaryor even desirable. Surely, each context needs to beexamined and assessed individually. For each context,questions should be asked regarding whether readymade products can be locally manufactured, whetherMoH policies and strategies exist or can be modified sothat budgets are assured for commercial products, andwhether existing home-grown modular feeding leads toadequate outcomes within existing health services andwhether these can be improved upon. Then it simplybecomes a judgement call.As always, there are a whole array of other articlesand research summaries in this issue of Field Exchange.A field article from the agency Self-Help DevelopmentInternational discusses the experience of establishinga seed development programme in Ethiopia, whileSaul Guererro from VALID discusses a study showingthe impact of previous non-admittance on CommunityTherapeutic Care (CTC) programmes in terms of subsequentrejection of the approach. Research summariesinclude a review of cash and voucher programming ina number of countries and experiences of more rapidnutrition survey implementation using the Lot QualityAssurance Sampling (LQAS) approach.Enjoy and finally please don’t forget to fill out yourevaluation forms (included on your mailing insert andalso online). Your feedback lets us know whether we arehitting the mark or whether you want change.Jeremy ShohamAny contributions, ideas or topics for future issues ofField Exchange? Contact the editorial team onemail: office@ennonline.net1A Retrospective Study of Emergency Supplementary FeedingProgrammes. Dr Carlos Navarro-Colarado. June 2007. ENN andSC UK. Available at http://www.ennonline.net/research/1

Field Article© Raphael Weber/MSF, Niger, 2006Screening at MSF ambulatoryfeeding centre (Crena) in MyriaManagement of moderate acutemalnutrition with RUTF in NigerBy Isabelle Defourny, Gwenola Seroux, Issaley Abdelkader, and Géza HarcziIsabelle Defourny is DeputyDesk Manager, MSF-France,ParisGéza Harczi is NutritionAdvisor, MSF-France, ParisGwenola Seroux is EmergencyCoordinator, MSF-France, ParisIssaley Abdelkader is Medical Referent,MSF-France, Maradi, NigerBetween 2001 and 2005, the MédecinsSans Frontières (MSF) therapeuticfeeding programme in Maradi, Nigeroffered treatment for severe acutemalnutrition centred on the use of Ready toUse Therapeutic Food (RUTF) and the outpatientmanagement of all uncomplicated cases.During the malnutrition crisis in 2005, theprogramme demonstrated its capacity to handlelarge numbers of patients while maintaininghighly satisfactory results. Over 40,000 severelymalnourished children were treated in Maradiregion alone, with a cure rate above 90% 1 .The 2005 crisis in Niger has led to anincreased understanding of the problem ofmalnutrition and how to extend treatment tolarge numbers of affected children. A nationalprotocol favouring outpatient treatment withRUTF for severe acute malnutrition was adoptedin July 2005. For the first time in 2006, thetreatment of malnutrition was integrated intothe national action plan against food insecurity.The government of Niger, United Nations(UN) agencies and international donors wentforward with a plan to treat 500,000 acutelymalnourished children during 2006. Nutritionalsurveillance was added to the early warningsystem, and Niger has reaffirmed its commitmentto reduce child mortality rates as a publichealth priority. With assistance from the WorldBank, the government has moved to implementfree health care for children less than 5 years ofage and for pregnant women.The results obtained in 2005 with severe acutemalnutrition suggested that the same strategyof outpatient management with RUTF wouldbe of benefit for the treatment of acute malnutritionat earlier stages of presentation. Thereforein 2006, MSF decided to extend the use of thesenew therapeutic products and operationalstrategies to the treatment of moderate acutemalnutrition.The MSF ProgrammeIn 2006, MSF operated 11 outpatient feedingcentres attached to integrated health centres(Centres de Santé Intégrés), along with twoinpatient referral feeding units, in two districtsof Maradi region with an estimated populationof 900,000 people 2 .Moderately malnourished children wereadmitted to these units and treated with thesame medical and dietary protocols used forsevere acutely malnourished patients (withthe exception of no systematic antibiotic treatmentat admission). Within the programme, thedistinction between moderate and severe acutemalnutrition was abandoned in favour of adistinction between complicated and non-complicatedacute malnutrition. Children wereadmitted according to standard criteria for acute1Defourny I, Drouhin E, Terzian M, Tatay M, Sekkenes J,Tectonidis M. Scaling up the treatment of acute childhoodmalnutrition in Niger. Field Exchange 2006; 28: 2-4.2Système National d’Information Sanitaire, Gouvernement deNiger. 2005.2

Field ArticleFigure 1Table 1Outcomes for acute moderate malnutrition casesCure Death Default Non-respondent Transfer TotalNon-complicated 49,517 50 1,729 60 5 51,36196.4% 0.1% 3.4% 0.1% 0.0%Complicated 7,514 182 278 335 28 8,33790.1% 2.2% 3.3% 4.0% 0.3%Total 57,031 232 2,007 395 33 59,698Table 2Length of Stay(days)Weekly admissions of children, MSF therapeutic nutrition programme, Maradi region,Niger, 200695.5% 0.4% 3.4% 0.7% 0.1%Average length of stay formalnourished children in atherapeutic feeding unit in Maradi,Niger, 2006Mean CI 95%Moderate 31.4 [31.3; 31.6]Severe 42.6 [41.8; 43.4]Total 32.1 [32.0; 32.3]malnutrition: weight-for-height (W/H) ratio 80% (NCHSreference) on two consecutive visits. Upondischarge, patients were given an additionalweek of RUTF treatment as well as a 25-kgration of fortified blended flour (Unimix) and 5litres of cooking oil.Table 3Weight Gain(g/kg/days)Daily weight gain for malnourishedchildren in a therapeutic feedingunit in Maradi, Niger, 2006Mean CI 95%Moderate 5.3 [5.25; 5.32]Severe 8.0 [7.81; 8.23]Total 5.4 [5.40; 5.47]ResultsResults were analysed by using individualbaseddata from MSF programme monitoring,by means of a database comprised of informationfrom individual treatment cards. A total of64,733 children were admitted for acute malnutritionin the MSF nutritional programme in2006 (Figure 1). Of these, 92.5% (59,880) werechildren with moderate malnutrition, and 7.5%(4,853) were children with severe malnutrition.Of the children admitted, 93.1% were less than36 months of age, a trend consistent with pastyears. Readmission rates were 8.9% for moderateand 4.2% for severe cases. Of the children,89.6% of moderate and 58.2% of severe caseswere admitted directly into outpatient care. Atotal of 10,651 children (8,389 moderate and2,262 severe) spent at least part of their treatmentin an inpatient centre.Analysis of results for 59,698 moderatemalnourished children showed a cure rate of95.5%, death rate of 0.4%, and default rate of3.4% (Table 1).Average length of stay was 31.4 days (Table 2),and average daily weight gain was 5.28g/kgbody weight/day (Table 3). Approximately 75%of children had a W/H ratio > 85% of the NCHSreference median on discharge.For the 4,796 severe cases discharged, thecure rate was 81.3%, death rate 3.0%, anddefault rate 10.3%. Average length of stay was42.6 days, and average daily weight gain 8 g/kgbody weight/day.DiscussionIn the past few years, thanks to the introductionof RUTF and the deployment of outpatientstrategies, significant progress has been madein the treatment of severe acute malnutrition.However, the standard treatment of moderateacute malnutrition with fortified blended flourshas continued to show disappointing results 3 .This failure is problematic because, althoughsevere malnutrition has a higher relative risk ofmortality, the much larger numbers of moderatemalnutrition means that the population-attributablerisk of malnutrition to mortality is muchhigher in this group 4 . As stated in Yip and Scanlonmore than 10 years ago, “there is no question themost severely malnourished children suffer themost, but they may not be contributing to mostof the suffering” 5 . Furthermore, although thetreatment of severe malnutrition is improving,it is still more difficult to treat than moderatemalnutrition. Treating malnutrition earlier ismore effective, less risky to the patient and lesscostly.The results obtained by MSF in Maradiconfirm the efficacy of RUTF in the treatmentof moderate acute malnutrition. Weight gainsrecorded were considerably higher than thoseobtained in classic supplementary feedingprogrammes (SFPs) using fortified blendedflours. Default rates were also atypically lowcompared with standard SFPs. Combined withthe large numbers of affected children recruited,this outcome suggests that parents are convincedof the superior effectiveness of RUTF in thetreatment of acute malnutrition. Once again, asin previous years in MSF feeding programmesin Niger, tens of thousands of mothers weregiven the role of the prime therapeutic caregiverfor their malnourished children.Moreover, despite the continuous expansion,and therefore better coverage, of services for thesevere acutely malnourished in Maradi since2002, for the first time since the programme wasopened in 2001, no detectable peak in numbersadmitted during the hunger gap period wasobserved (Figure 1). Admissions of severe casesremained stable and at unusually low levelsthroughout the year. This finding stronglysuggests that the management of the largenumbers of moderate acutely malnourishedwith RUTF successfully prevented the developmentof severe acute malnutrition in the coveredpopulation.In the countrywide nutritional surveyconducted in November 2006 by the governmentof Niger, UNICEF and the World FoodProgramme, the prevalence of global acutemalnutrition (GAM) in Maradi stood at 6.8%,with 0.6% severe acute malnutrition (SAM),compared with the national averages of 10.3%and 1.4%, respectively. For the first time, theMaradi region, which previously had amongstthe highest rates of severe and global acute3Navarro-Colorado C. A retrospective study of emergencysupplementary feeding programmes. ENN/SC UK, 2007.4Pelletier DL. The relationship between child anthropometryand mortality in developing countries: implications for policy,programs and future research. J Nutr 1994; 124: 2047S-2081S.5Yip R, Scanlon K. The burden of malnutrition: a populationperspective. J Nutr 1994; 124: 2043S-2046S.3

© Cecile Dehopre/MSF, Niger, 2007 Valerie Babize/MSF, Tchad, 2007malnutrition in the country, had becomeat the end of 2006, the region with thelowest rates of acute malnutrition. Theresults of the nutritional survey, andthe lack of increase in severe malnutritionduring the hunger gap, providestrong evidence for a major impact onthe nutritional status of young childrenin Maradi subsequent to the widespreaduse of RUTF.The nutritional crisis in Niger in2005 was notable for the unprecedentednumbers of young children treated forsevere acute malnutrition. The nutritionalsituation in 2006 was not of thesame magnitude, but it is clear that thenumbers of children affected by acutemalnutrition even in a ‘good’ year isextremely high. For example, 26,000children less than 3 years old from theGuidam Roumdji district of Maradi wereadmitted for acute malnutrition in theMSF programme in 2006. This numberrepresented well over half the estimated43,500 children of that age believed to beliving in this one district of Maradi.Despite the success of the MSFprogramme in 2006, the individual therapeutictreatment of tens of thousands ofchildren requires significant resourcesand would clearly be a daunting taskfor an already overstretched, understaffedand underfunded health caresystem in one of the poorest countriesof the world. With such large numbersof young children affected by acutemalnutrition in rural areas of Niger eachyear, it would make sense to go one stepfurther and consider effective preven-MUAC measurement of a child in a campfor displaced Chadians, Koukou, TchadField Articletive alternatives. In May 2007, MSFbegan implementing a new programmetargeting all children younger than 36months with a new ready-to-use nutritionalsupplement designed to preventmalnutrition. This supplement is beingdelivered through monthly distributionsrather than through therapeutic feedingunits. The hope is that this strategy willsignificantly reduce the incidence of acutemalnutrition amongst the young childrenof the rural poor in Maradi.ConclusionResults obtained by MSF in Maradi in2006 prove that RUTF is an effective treatmentfor moderate acute malnutrition.The large numbers treated and the lownumbers of defaulters are indicative ofthe strong participation and adherence ofthe mothers and families of these children.The treatment of acute malnutrition atan earlier stage reduced admissions forsevere acute malnutrition and eliminatedthe usual rise in severe cases during thehunger gap period.Considering the well-documentedassociation of acute malnutrition withchild mortality, it is highly likely thatthe effective treatment of acute malnutrition,or its effective prevention, usingnewly developed nutrient-dense RUTF,will have a major impact on mortalityof young children amongst the poorestpopulations of the world.For further information, contact: isabelle.defourny@paris.msf.org or geza.harczi@paris.msf.orgMother and child in Dakoro, Niger,where MSF focused on the problemof acute seasonal malnutritionField testing LQASto assess acutemalnutritionprevalenceSummary of published research 1ResearchIn emergency settings, the prevalence of global acutemalnutrition (GAM) needs to be assessed quickly, accuratelyand often repeatedly, to determine when and whereto start and stop humanitarian aid. The most commonapproach for assessing GAM is a two-stage 30 x 30 clustersurvey – which can be time-consuming and expensive.Alternative, less time-consuming and resource-intensiveapproaches are needed. One of the most frequently usedquality control statistical methods in international healthis Lots Quality Assurance Sampling (LQAS). Cumulativebinomial probabilities are used in LQAS analyses to detectif a critical threshold has been reached for an indicator. Todesign an LQA sampling plan, the threshold of interest foran indicator, e.g. GAM prevalence, and tolerable statisticalerror are defined a priori.A recently published article examines three adaptationsof LQAS to assess GAM and other child-level indicators infood-insecure settings.Computer simulations confirmed that small clustersinstead of a simple random sample could be used forLQAS assessments of GAM. Three LQAS designs weredeveloped (33 x 6, 67 x 3, sequential design) 2,3 , to assessGAM thresholds of 10, 15 and 20%. The designs werefield-tested simultaneously with a 30 x 30 cluster-surveyin Siraro, Ethiopia during June 2003. Using a nested studydesign, anthropometric, morbidity and vaccination datawere collected on all children 6-59 months in sampledhouseholds. Hypothesis tests about GAM thresholdswere conducted for each LQAS design. Point estimateswere obtained for the 30 x 30 cluster-survey and the 33x 6 and 67 x 3 LQAS designs. In order to collect data forthe study, 15 interviewers were hired and trained. Teamsused an odometer to record the distance travelled from thebase camp to the first cluster for each work-day and useda stopwatch to record the time required to complete eachsurvey.Hypothesis tests showed GAM as < 10% for the 33 x 6design and GAM as > or = 10% for the 67 x 3 and sequentialdesigns. Point estimates for the 33 x 6 and 67 x 3 designswere similar to those of the 30 x 30 cluster-survey forGAM (6.7%, Confidence Interval (CI) = 3.2-10.2%; 8.2%,CI= 4.3-12.1%, 7.4%, CI – 4.8-9.9%, respectively) and allother indicators. The CIs for the LQAS designs were onlyslightly wider than the CIs for the 30 x 30 cluster-survey,yet the LQAS designs required substantially less time toadminister.The study concluded that the LQAS designs providestatistically appropriate alternatives to the more timeconsuming30 x 30 cluster-survey. However, additionalfield-testing is needed using independent samples ratherthan a nested study design, which was the most criticallimitation of the study. Ideally, data for each design shouldbe sampled independently to allow for stricter comparisonof results between designs.Despite this limitation, the authors concluded thatLQAS designs can contribute to the methodological toolkitof humanitarian agencies.1Deitchler M et al (2007). A field test of three LQAS designs to assessthe prevalence of acute malnutrition. Int J. Epidemiology. Advance accesspublished May 21st, 2007, pp 1-7. The article is available free from http://ije.oxfordjournals.org/cgi/content/abstract/dym092v12Thirty-three clusters with six children in each, sixty seven clusters withthree children in each, etc.3A Retrospective Study of Emergency Supplementary Feeding Programmes.Dr Carlos Navarro-Colarado. June 2007. ENN and SC UK. Available at http://www.ennonline.net/research/4

ResearchCaring forpremature babiesin a conflict zoneSummary of published experiences 1S McDowell, South Sudan, 2005Addressing chronicmalnutrition in South SudanSummary of technical paper 1CARE South Sudan have recently conducted ananalysis of nine years of nutrition data providedby anthropometric surveys undertaken in thenorthern Bahr el Ghazal and Upper Nile regionsin southern Sudan. Available surveys coveredboth the war (1998-2002) and the immediatepost-conflict period (2003-2006). They are alsoone of the very few sources of quantifiable datacollected using consistent, comparable methodologiesin South Sudan during the war.Data analysis from 218 two-stage clustersurveys indicated annual severe acute malnutritionrates (wasting) averaging above 20%.Malnutrition appears to increase through thedry season and subsides with the coming ofrains. Seasonally, rates can increase by 50% inthe dry season but have rarely dropped belowthe WHO emergency threshold of 15% in thewet season. The seasonal peak does not appearto be associated with the traditional hungerperiod nor does it appear to be closely associatedwith mortality. These chronic trends persistdespite the cessation of hostilities ending 20years of civil war and concurrent improvementsin food security.Explanations for these chronic and alarmingrates of malnutrition are more likely to befound in health environments, as well as behavioursor caring practices to which under fivechildren are exposed. South Sudan has seen animprovement in food security conditions dueto increased food availability and access. Theexplanation of why that improvement has nottranslated into improvements in under-fivenutrition may simply be explained by statichealth and caring environments since the war.Malnutrition must be understood in its multifacetednature if appropriate strategies to rollback chronic high rates of malnutrition in SouthSudan are to be identified.Acute malnutrition rates from this studyimply prevalence of malnutrition affectingapproximately 250,000 children across SouthSudan. Such widespread, significant andseasonally fluctuating levels of malnutritionappear to exist with regionally comparablelevels of mortality. The scope of malnutrition isvastly beyond the capacity of traditional nutritioninterventions such as selective feeding.Solutions must be strategic and simultaneouslyaddress both acute needs and underlyingcauses.Onesmus Muinde, South Sudan, 2006Improving security/access, food securityconditions and a clearer understanding of thenature of current malnutrition offers an opportunityto reduce rates that was not affordedduring the war.CARE South Sudan makes a number ofrecommendations for both immediate andmedium term action.Immediate recommendations include:• Nutrition interventions that actively findand support children-at-risk in theDecember to February period.• Integrating therapeutic feeding/supplementary feeding response capacityinto Northern Bahr El Ghazal/UN healthsystem.• Identifying options to improve waterquantity and quality and household waterstorage and access during the dry season.• Small, well timed targeted food aid tovulnerable households.Medium term actions include;• Women’s education to improve the qualityof her role as a caregiver.• Support growth of agrarian, livestockbasedrural economy through supportivetrade policy and taxation schemes.• Develop infrastructure that promotestrade and the continued emergency of arural economy.• Promote policies or interventions thatreduce transport costs, storage constraintsimprove information flow andcommunication options.For more information, contact Steve McDowell,email: mcdowell.stephen@gmail.com1CARE South Sudan, Nairobi, Kenya. April 2007. The technicalpaper was prepared by Steve McDowell of CARE SouthSudan. Requests for the full paper can be directed to mcdowell.stephen@gmail.comChildren collecting waterin Menime, South SudanA dry season waterpointin Koch, South SudanThis paper describes aspects of the authors workas a midwife with Médecins Sans Frontieres(MSF) in a north-western regional hospital inCôte d’Ivoire during the civil war (2004-2005).In Cote d’Ivoire, skilled birth attendantsassisted with 62.5% of births (2000). The InfantMortality Rate was 118/1000 of live births andthe child mortality rate for children under 5years was 162/1000 for girls and 225/100 forboys. In this resource poor context, breastfeedingis a matter of life or death.MSF provided primary health care at a ruralhospital in Danané and from daily mobileclinics. Most of the population lived in smallvillages scattered throughout the bush. Almosthalf of the pregnant women seen in the clinicstested positive for malaria and many otherssuffered concurrent opportunistic infectionsincluding STDs (sexually transmitted diseases)and were often chronically anaemic. Many firsttime mothers were in their early teens. Of the160 or more births per month at the hospital, atleast six or more per month who survived theirbirth were significantly premature – weighingless than 1500 grams, with a number around1000 grams or less that were mostly girls.In four case studies, the author describesaspects of the care including initiating afeeding regimen for premature babies, theuse of kangaroo care to aid thermoregulation,initial stabilisation of premature infants includingfeeding methods maintaining oxygenation,and feeding multiple infants.Most premature babies who survived thebirth were around 29-33 weeks gestation.After birth, most babies had an intravenousline inserted for antibiotics and for parenteralhydration when they were not toleratingoral nutrition. Following initial stabilisation,the aim of management was to avoid/treatinitial hypoglycaemia, maintain hydration,minimize weight loss and ensure weight gain.Thermoregulation was greatly improved bythe introduction of Kangaroo care – skin toskin contact can raise a baby’s temperature by1 degrees C in 1 hour. Both staff and mothersneeded reassurance that this technique woulddo no harm. Also, newborns tended to bewrapped loosely rather than swaddled whichmay suit a robust full term infant in a tropicalclimate, but not a premature baby.Feeding premature infantsIf they survived the first 4-5 days, most prematurebabies were able to breastfeed early(contrary to the author’s midwifery teaching).Many were partially breastfed at 1100-1200g,and by 1400-1500g were fully breastfed. Anumber of techniques were used to support themother in establishing breastfeeding, includingnasogastric feeding of expressed breastmilkwhen initiating feeding, and breast compressionduring a breastfeed (where a mothersqueezed and held her breast, pushing a bolusof milk that dripped into the baby’s mouth).Expressing breastmilk was not a normal activ-5

An infant receives colostrum (the first breastmilkproduced on birth) via a nasogastric tubeResearchH Harris/MSF, Cote D’Ivoire, 2006H Harris/MSF, Cote D’Ivoire, 2006ity for women but with support this was mastered.Expressed breastmilk was also given by cup or fingerfeeding (the latter where a mother inserted her cleanlittle finger in the baby’s mouth, touching the palateto stimulate the sucking reflex. Staff then gave breastmilkslowly via a syringe inserted alongside the finger– see picture below).Where there was insufficient expressed breastmilk(there were no facilities for storage or milk banks),then 10% dextrose was given orally. Infant formulawas rarely used as it was unsafe and unsustainable inthis context and would remove the impetus to establishbreastfeeding. Staff also felt it would have giventhe wrong message if formula was supplied by aninternational NGO, suggesting that it was acceptableand even preferable to mother’s milk. The cost of acan of infant formula in the town pharmacy was morethan a day’s wages and there were inadequate facilitiesto support its safe preparation.The average hospital stay for premature babieswas approximately three weeks and most went homeweighing around 1700 – 1800 grams. Many of themothers of these premature babies had small childrenback in their village and had to balance the needs ofother family members with the new baby.In this setting, the author describes how “infantformula is a death sentence” and if efforts to increasesupply were not successful, a message would be sentto the family to find someone else to donate breastmilkor arrange a wet-nurse. Sometimes this was easy,at other times, very difficult. A number of grandmotherswere breastfeeding their orphaned grandchild. Inone instance, a woman arrived who had four infantsunder her care all under six months of age (she hadtaken in her sister’s 3 month old triplets, when hersister died). In this instance, the clinic fully suppliedinfant formula, the infants were monitored monthlyat the clinic and did well.The author concludes with a heart-felt tribute tothe dedication of the national staff in supportingthese infants, particularly in a setting where thereis virtually no technology and survival depends onclose monitoring, commitment, innovative thinkingand lots of dedicated care.1Harris, H (2007). A little help from my friends: caring for prematurebabies in a war zone. International Breastfeeding Journal2007, 2:3 doi:10.1186/1746-4358-2-3. The full version of thisarticle can be found online at: http://www.internationalbreastfeedingjournal.com/content/2/1/3A mother ‘fingerfeeds’ herpremature babyRemittancesduring crisesSummary of published paper 1In disasters, remittances can play an importantpart in how people survive and recover.A recent Humanitarian Practice Group(HPG) briefing paper reports on a studyinto the role that remittances play in crises.The study was based on a review of relevantliterature, as well as detailed case studiesin Haiti, Pakistan, Somaliland, Sudan,Indonesia and Sri Lanka.Globally, remittances have grownsignificantly in the last decade. In 2006,remittances through formal channels –banks and other financial institutions – wereput at $268 billion; informal mechanisms,such as traditional money-transfer systemsand hand-carried remittances – account for,perhaps, half as much again.Humanitarian agencies and other actorsconcerned with the welfare of migrantshave tended to neglect the importance ofmigration in livelihoods, or to see migrationpurely in negative terms, as a symptom ofdistress.Remittances are often of importancefollowing disasters, as they represent arelatively stable form of income, usuallyincrease in times of crisis and directlycontribute to household income. Forexample, in the months following thetsunami, the Sri Lankan Central Bankrecorded a substantial increase in remittances.Remittance flows can be vulnerableto disruption during disasters. Transportand communications may fail, people maybe displaced and, in the case of conflict,borders may be closed or communicationsshut down. Border closures and restrictionson movement due to the conflict in Darfurhave had devastating consequences forpeople reliant on hand-carried remittancesfrom family members working in Libya,Chad and Saudi Arabia. Physical damage topeople’s homes and property may includethe loss or destruction of documentationneeded to access remittances.The study findings have important implicationsfor humanitarian action in disasterrisk reduction, relief and recovery. Helpingin the restoration of remittance flows maybe a quick and effective way of supportinglivelihoods recovery and also impact therest of the community.In responding to crises and disasters, aidagencies should continue to develop assessmentapproaches that more explicitly takeaccount of the important role migration andremittances play in people’s livelihoods.However, as people are understandablyreticent to talk about remittance receiptsopenly, for fear that they will receive lessaid, it may be necessary to draw uponpre-disaster secondary data about migrationand remittances and use qualitativeapproaches to understand the impact of acrisis on remittances.Humanitarian agencies also need todesign their assistance programmes inways that complement and enhance remittanceflows. For example, agencies haveused existing remittance systems, such as‘hawala 2 ,’ in their aid programming andcash assistance may open up access to financialinstitutions for recipients.Agencies also need to account for migrationin programme design, e.g. cash or foodfor work can restrict mobility.In addition, remittances may be supportedby polices that help cut the cost andbureaucratic difficulty of sending them,measures to improve the legal status andlevel of integration of immigrants withinhost societies, and steps to promote access toemployment and education. Replacing lostdocuments is usually a government responsibility,but where a government is unableor unwilling to do this, aid agencies mightbe able to provide identity cards linked tobeneficiary registration.All disaster-affected populations shouldhave rapid access to national and internationaltelecommunications. This might meansetting up internet cafes in displacement orrefugee camps, distributing mobile phonesand working with private sector companiesto establish or re-establish mobile networksor supporting small scale enterprises providinginternet or mobile phone access.Remittance senders should also beconsidered by aid actors and governmentsresponding to emergencies. The need toreturn home to help loved ones may meanthat jobs abroad are lost or migrant statusis rescinded, forcing migrants further intodebt. Governments could consider special,free visa measures to enable people toreturn home during emergencies withoutjeopardising their migrant status. Assistancecould be given to cover the costs of transport.Employers of migrant workers couldbe encouraged to grant compassionate leaveto allow people to go home, and remittancetransfer companies could be encouraged towaive or reduce fees for sending money todisaster-affected countries.1 Savage. K and Harvey. P (2007). Remittances duringcrises: implications for humanitarian response. HPGBriefing Paper 26. May 20072 Hawala (also referred to as hundi) is an alternativeor parallel remittance system that originated in SouthAsia but is now used extensively worldwide. The componentsof hawala that distinguish it from other remittancesystems are trust and the extensive use of connectionssuch as family relationships or regional affiliations.6

ResearchPablo Recalde/WFP, South Sudan, 2007USAID funded vegetable oil being distributedat Kassab IDP camp, North DafurGlobal factors shaping food aidSummary of published paper 1A paper in a recent special issue of Disasterson food aid, reviews global trends affecting thefuture of food aid and food aid programmingand possible implications for WFP. Three majorfactors are deemed to shape the foreseeablefuture of food aid;i) the mechanisms for the global governanceof food aid are under review and mayundergo major changes in the coming years– most notably the renegotiations of theFood Aid Convention (FAC)ii) donor agency trendsiii) the extent to which best practices in foodaid programming are implemented.i) Mechanisms for global governance of foodaidAccording to the authors, the global mechanismsand institutions that govern the allocation, utilisationand reporting of food aid resources arein disarray, outdated and dysfunctional. TheWorld Trade Organisation (WTO) negotiationson a new Agreement on Agriculture broke downin July 2006 and it seems unlikely that seriousnegotiations on an agreement, and thereforenew food aid disciplines, will be restarted anytime soon. Major unresolved issues include theform of loans or pure grants and the tying statusof food aid. While the European Commission(EC) and Canada have untied their food aidin recent years, the United States (US) remainstied to its own domestic market, which somesay is an export subsidy in disguise. However,the view of the US (and some others) is that anyattempt to untie contributions would result inthe loss of political support from powerful USagribusiness and shipping interests, and hencea substantial reduction in US contributions.There has been widening agreement that localand regional purchase should be the first option,but disagreement about who may declare anemergency, whether food aid must be wholly ingrant form and over the controversial practiceof monetisation. Given the stalling of the tradetalks, the major arenas for the reform of food aidare likely to be the renegotiation of the FAC andthe upcoming US Farm Bill.The FAC, originally drafted in 1967, waslast renewed in 1999 and extended in 2002. Itmay be renegotiated in the coming years. It hasshortcomings. The FAC contains a legal agree-ment on the minimum tonnage obligations ofdonors, but, because it has no mechanism foreffectively monitoring or enforcing complianceby signatories, these obligations are nowroutinely ignored. There is currently an effortby non-governmetnal organisations (NGOs) tobroaden the membership of the FAC, strengthenits needs-based focus and ensure that minimumcommitments are reported in a transparent,timely and consistent manner. How this willplay out remains to be seen. With regard to foodaid, further efforts to improve its role need toinclude: allocation on the basis of need, vulnerabilityand impartiality, operations backed byappropriate analysis, appropriate utilisationand management of resources, and clarity ofobligations and accountability of stakeholders.ii) Donor trends in food aidAt least three key donor trends in food aid canbe identified that will shape the nature of futurefood aid programming. These include decliningresource levels and the strong priority given toemergency programming,; a growing preferencefor local and regional purchasing,; andthe need for greater complementarity with cashprogramming.Overall, levels of food aid have been decliningsteadily – from an average of 12-15 milliontonnes in the late 1980s and early 1990s, to8.2 million tonnes in 2005. There has beena much greater focus on emergencies and amarked decline in government-governmentor programme food aid. This has inevitablyled to declining resources for developmentand a greater concentration of those resourcesin fewer countries. Competition for food aidresources is likely to increase, particularly inthe light of increasing demand for bio-fuelsand other demands on world grain supplies. In2005, despite a slight increase in overall resourceavailability, there was a substantial shortfallin resources for emergency food assistance. In2006, there were cuts early in the year in Sudan.Programmatically, between relief and developmentthere is an emergent grey area aroundsocial protection and safety nets for the chronicallyfood insecure and around the reductionand mitigation of disaster risk. The safety netcategory is relatively predictable, permittingdonors to allocate resources without waiting forassessment appeals.WFP Photolibrary, Zambia, 2004Currently, significant cash resources areallocated to local or regional purchase. In 2005,just under half of all food aid was of US originand virtually all of that was sourced from USmarkets. About half of the remainder of food aidwas purchased in local or regional markets. Ifwell managed, local or regional purchase has anumber of advantages. Shorter shipping distancescan lead to quicker responses in emergencies,it can be more cost-efficient, and hence partiallyhelp to address the resource shortfall issue andit can also be less market-distorting and supportmarket development objectives in developingcountries. The authors of the paper argue that itis imperative that operational agencies becomemore adept at managing local purchasing.The US administration is proposing (againstsignificant political opposition in Congress) toincrease the amount of locally and regionallyprocured food in the US food aid portfolio – andthis is likely to be suggested as part of the USFarm Bill, the authorising legislation behind theUS food aid portfolio which is currently beingnegotiated. For obvious reasons, the practicefalls foul of the interest of both the agribusinesscompanies that procure and supply US foodaid, and the shipping industry that is legallymandated to deliver the majority of it. Given thedominance of the US among food aid donors,the outcome of this process may be the singlebiggest factor affecting the future of food aid.Amongst some European and private donorsthere is a recent trend towards more cash-orientedinterventions rather than in-kind aid. ThetTsunami response, in particular, provided a lotof experience of working with direct cash transfers,partly as there was an unprecedented levelof unrestricted cash donations to humanitarianagencies. Deciding what is the appropriatemix of cash and in-kind will be a significantchallenge.iii) Best practiceThe extent to which WFP and it’s implementingpartner agencies are able to incorporatebest practice into operations constitutes thethird major factor determining the future offood aid. Key areas are information systems,emergency analytical imperatives, innovationsin programme design and implementation,focusing particularly on improved targeting andimprovements in supply chain management.WFP has been a critical actor in improvinginformation systems, particularly in the areaof vulnerability assessment and more recentlywith the SENAC (Strengthening EmergencyLocal purchase of foodcommodities by WFPin Zambia7

ResearchNeeds Assessment Capacity) initiative.Among practices that still require attentionis the guarantee of a separation of informationgeneration and analysis from operationsand operational budgets. The IntegratedPhase Classification System, developed inSomalia but in widespread use in the droughtcrisis affecting pastoral area s of the GreaterHorn in 2006, is a significant attempt to drawmultiple sources of information into a singleanalysis of food security and humanitarianneed. Other important recent work includesthe understanding of so-called poverty traps– asset thresholds below which people cannot‘pull themselves up by their bootstraps’, butwhich can be overcome if people acquire abasic portfolio of assets.Developing tools to estimate the appropriatemix of resources, e.g. cash versus food,is another major challenge. Targeting is afurther difficult area where, it is argued, thelimited amount of research is not encouraging.There is ample evidence of both exclusionand inclusion error. Furthermore, althoughearly warning and supply chain managementinnovations have helped to reduce delays andensure supplies in that interim, as long as foodhas to be shipped long distances, the timingof deliveries as well as amounts providedand duration of programmes all result insignificant inclusion and exclusion targetingerrors. A review of the literature on targetinggenerally shows that there are no universalrecommendations with regard to targeting.Many innovations in supply-chainmanagement have improved the timelinessand management of food aid. Pre-positioningfood aid, either in strategic reserve or in localwarehouses, now routinely provides resourcesto cover a gap between when needs areidentified and when the requested resourcesarrive.The paper concludes by applying theseconsiderations to Sudan, which (accordingto the authors) is likely to continue to needfood assistance for the foreseeable future. It issuggested that advocacy for appropriate typesand amounts of resources will probably be anincreasing part of ‘doing business’ in Sudan orin any complex emergency. WFP has been atthe forefront of advocating for food resourcesfor emergencies – a role that will, no doubt,continue. It is a major challenge to advocatefor the appropriate resources for the context,whether emergency, chronic low-grade crisisor long-term poverty. Increasingly, this willmean not only food resources but also cashfor either direct transfer or to fund inputsor activities that are complementary to food.Advocating for more appropriate governancemechanisms is a joint task for WFP and otheroperational agencies.Finally, WFP Sudan already has a trackrecord of local purchase for both domesticconsumption and emergency operationsin neighbouring countries. Building onthe lessons learned from this experience toengage more broadly in local purchase is bothan important challenge and an opportunityfor WFP Sudan.1Maxwell. D (2007). Global factors shaping the future offood aid: the implications for WFP. Disasters, 2007, 31 (s1):s25-s39Cash-based responsesin emergenciesSummary of published research 1A recent study explores the suitability of cashand vouchers in the full range of emergencycontexts and finds that such responses arepossible, even where states have collapsed,conflict is ongoing and there is no bankingsystem.The authors of the study describe howrecent years have seen a rapid growth in theuse of cash-based responses in emergencies,e.g. following the tsunami, in southern Africaas alternatives to food aid, as safety nets inEthiopia and northern Kenya and in conflictaffectedSomalia and Afghanistan.It is argued that typical questions aroundcash, presented in terms of its supposed advantagesand disadvantages against commodityapproaches, are unhelpful. Instead it is best topresent issues as open questions, which need tobe thought through on a context specific basis.Key issues in comparing cash and in-kindassistance are as follows;• Cost effectiveness• Security risk• Corruption and diversion risks• Anti-social use (e.g. buying alcohol)• Gender considerations (disadvantages towomen)• Choice, flexibility and dignity (can peoplebuy what they want)• Market impacts (positive or negative)• Consumption/nutrition (food aid can befortified but cash may promote fooddiversity)• Targeting (will targeting be impaired)• Skills and capacity (to implement theprogramme).A central question around cash transfers ishow effectively markets will be able to respondto an injection of cash. Put simply, will peoplebe able to buy what they want at reasonableprices. The key questions to ask about marketsare;• What are people likely to buy?• How have markets for key goods beenaffected by the crisis?• Can people buy what they need in localmarkets?• How competitive is the market?• What is likely to happen to the prices overthe course of the project?• Will the cash transfer cause price increases?Assessing whether cash can be deliveredsafely by agencies and spent safely byrecipients is one of the keys to determiningfeasibility. Evidence suggests that ways canbe found to deliver and distribute cash safelyeven in conflict environments, in some situations,cash has been less prone to diversionthan in-kind alternatives. The use of banks andother financial institutions potentially reducesthe security and corruption risks associatedwith cash transfer. Where banks do not exist,aid agencies have been able to use a varietyof innovative delivery mechanisms, includingmobile banking services, sub-contractedsecurity companies and remittance and moneytransfer companies.Evidence from monitoring and evaluationsoverwhelming suggests that people spendcash on the basic items they need to surviveand protect their livelihoods and that there isvery little evidence of cash being used on whatmay be labelled ‘anti-social’ or inappropriateways. Where cash grants have been providedfor particular types of recovery after disasters,such as shelter or business recovery, evidenceshows that cash is spent for these intendedpurposes. Furthermore, there is little evidencethat cash is more likely than in-kind assistanceto be controlled by men and therefore lesslikely to be spent on food.The authors of the study ask why, given theadvantages of cash, have agencies remained soresistant to using cash and conclude that thestructure of the humanitarian system seemsto inhibit it’s use. This may partly be as thedominant UN agency (WFP) provides foodaid that may, in turn, relate to issues aroundthe tying of food aid to food surpluses in donorcountries. There are, however, recent signs ofmovement. WFP is piloting cash-based responses,and has started to debate whether it couldprovide cash as an alternative to food aid whenappropriate. There is also an issue around thelack of skills and expertise to implement cashprogrammes, although numbers are expandingas people learn on the job. Manuals andguidelines are also starting to be developed.The study concludes that cash-basedprogramming will continue to grow, probablyat the expense of in-kind mechanisms in somecontexts. Furthermore, humanitarian actorsneed to develop the skills to assess whethercash-based responses are appropriate, and toimplement them when they are. Donors willalso need to develop the skills and capacityto make informed decisions about whether tofund cash responses. The central role played bynational governments in providing cash aid inPakistan and following the Indian Ocean tsunamisuggests that, where governments have thecapacity, they are the most appropriate deliverychannels. This may imply a reduced rolefor international aid agencies in some contexts.The growing interest and investment in cashtransfers as part of longer-term safety netswithin social protection strategies may alsolead to a reduced need for the regular provisionof large volumes of food aid, particularlyin parts of Africa.An overarching conclusion of the report isthat giving people cash to enable them to buywhat they needs is a simple concept, and shouldbe a staple part of humanitarian response.1Harvey. P (2007). Cash-based responses in emergencies.Humanitarian Policy Group Briefing Paper 25. January2007. Access online at http://www.odi.org.uk/hpg/papers/hpgbrief25.pdf8

ResearchReview of surveymethodologyin emergenciesA Seal, Bangladesh, 2003Summary of published research 1Spinning the stick to selectclusters during a UNHCRsurvey in BangladeshA recent paper set out to identify commonmethodological errors in nutrition and mortalitysurveys conducted in humanitarian emergencies,to examine trends over time and to providerecommendations on how to improve surveysin future.The sample of surveys was selected from948 reports of nutrition surveys received bythe Nutrition Information in Crisis Situations(NICS) between October 1993 and April 2004from 34 countries. Of these, 17 countries wereselected using a random number generator andall of the survey reports in these countries werereviewed for analysis. Survey reports wereevaluated for validity of sampling methodology,precision of estimates, quality of measurementsand calculation of prevalence of acute malnutritionand mortality rates.Three hundred and sixty eight survey reportsconducted by 33 non-governmental organisations(NGOs) and international agencies in 17countries were eventually evaluated.Criteria for sampling validity were met for85.9% of surveys. All of the random samplesurveys that used sample sizes of 450 childrenfor random and systematic sampling and 900children for cluster sampling were sufficientlyprecise. However, cluster surveys that sampled

Field ArticleScreening using MUAC in the GOALcommunity based programmeS Karanja/Goal, Ethiopia, 2006Implications of a CoverageSurvey in EthiopiaBy Simon Kiarie KaranjaSimon Karanja is currently the regionalnutrition advisor with GOAL in East Africa.Previously he worked as the CTC Coordinatorfor GOAL Ethiopia and as the nutritionist ona Merlin International CTC programme inWajir, Kenya.The author gratefully acknowledges the assistance of GOAL Ethiopia RapidResponse programme staff for working hard and ensuring that the data werecollected and recorded in the best way possible. Particular thanks to JessicaBarney for her help in organising the survey and special thanks to AngelaDavis and Hatty Newhouse for their technical advice and for reviewing andediting the survey report.S Karanja/Goal, Ethiopia, 2007This article presents the results of a survey that took place in December2006 to assess the coverage of a community-based programme anddiscusses the implications of the findings.Fedis woreda is located in East Harerghe Zone of Oromiya regionalstate. The woreda consists of 25 rural and one urban kebeles 1 .The total population is estimated at 246,437, with children underfive years estimated at 28,057 (Fedis woreda Council, 2005). Thepopulation is predominantly of the Oromo ethnic group, are Muslim, andAfaan Oromo is widely spoken.The woreda lacks many basic essential services and traditionallysuffers from high prevalence of malnutrition and high morbidity rates.Fedis, which is vulnerable to recurring droughts and shocks, is one of themost food insecure woredas in the East Harerghe zone and has receivedaid relief for over twenty years.A team measuringlength duringcoverage surveyThe livelihood of people in the area centres on agriculture, complementedby livestock holdings. The predominant cash crop is chat. All kebelesmembers are recipients of various relief activities including the ExtendedOutreach Strategy/Targeted Supplementary Feeding Programme andSafety Net Programming (general food distribution, Cash for Work andFood for Work).There are nine functional health facilities within the woreda includingone health centre at Fechatu, three clinics and five health posts. There area total of 27 professional health workers in these facilities including 14nurses, seven health assistants, two environmental health technicians, twohealth extension workers, and two frontline health workers. The overallhealth service coverage is 32% of the total population. The facilities areunderstaffed and lack basic facilities and equipment. The facility utilisationrate is low in the woreda. The nearest referral hospital for patients inthe woreda is Hiwot Fana in Harar City, which is located approximately35 kilometres away from Fedis.Community based approachGOAL Ethiopia has been managing severely malnourished children inFedis woreda using the community based therapeutic approach since mid2005, following an initial joint assessment by Care and GOAL Ethiopia atthe end of July 2005 that revealed an extensive nutritional crisis, confirmingthe findings of an earlier survey 2 . The GOAL intervention was designed topromote sustainable capacity within the woreda to address malnutrition.Goal’s community-based approach targets all 26 kebeles in the woreda,through five outpatient therapeutic programme (OTP) sites, one stabilisationcentre (SC) and eleven targeted supplementary feeding programme(TSFP) sites. The catchment area for the community-based programme isdefined by Gandas (villages) within kebeles in Fedis woreda, which theoutreach workers visit to find new cases and do follow-ups. The catchmentarea includes all kebeles currently within what was one but nowcomprises two defined woredas: Fedis and Midegha (Midegha woredawas initially part of the larger Fedis woreda but was recently created as aseparate woreda). As of November 30, 2006, a total of 2352 cases had beenadmitted to the community-based programme and 442 outreach workerstrained. Table 1 presents GOALs OTP and SC admission criteria.1A term used to describe both urban dwelling associations and peasant associations in ruralareas.2Conducted by the Federal Disaster Preparedness and Prevention Commission (April 2005)where a Global Acute Malnutrition rate of 19.2% and Severe Acute Malnutrition rate of 2.9%were found.10

Field ArticleTable 1Outpatient TherapeuticProgramme (OTP)OTP/SC admission criteriaWeight for Height (WFH) < 70%ORBilateral pitting oedemaGrade + or ++ORMUAC < 11.0cm(age >1year or height >70cm)Table 2Area surveyedWoreda area 2 :Number of quadrats:Area of each quadrat:Area covered by the survey:Period of survey:Box 1 Sampling procedure 5Stabilisation Centre (SC)WFH< 80% AND severe medicalcomplicationsORMUAC

Field ArticleFigure 1 Point coverage for OTP/SC Figure 2 Period coverage for OTP/SC14141212Number of quadrats10864Number of quadrats108642200

Field ArticleMobilising the community oncommunty based programmeS Karanja/Goal, Ethiopia, 2006Timing of the surveyThe survey was carried out in the post harvest period which is a relativelyfood secure time of year in Fedis woreda. This correlates with the lowprogramme admissions that may, in turn, bias the point coverage resultsdownward as not many children were registered in the OTP programme.It is also possible that a number of the severely malnourished had experiencedrapidly deteriorating nutritional status due to illness and that therehad not been sufficient time to be admitted into OTP.Awareness of the CTC programmeThroughout the survey, a questionnaire was completed by 23 carerswhose severely malnourished children were not in the community-basedprogramme, but who had heard about it. Fifteen carers (65.2%) had takentheir child to an OTP site in the past but were not admitted due to variousreasons e.g. child did not fit OTP admission criteria at that time. Twocarers never took their child to an OTP ever. Reasons for not taking theirchild to the OTP/SC site are given in Table 4. These findings suggest thatmore community education about the signs and symptoms of malnutritioncould increase coverage.Past history/referralsCarers of severely malnourished children who were not in the OTP butknew about it, were asked if their child had ever been in the GOAL CTCprogramme before. The vast majority, 73.9% (17/23), said that the childhad not been in the programme in the past. Five out of 23 carers (21.7%)said that their child had been in the programme and had been discharged.Children who had relapsed were enrolled in the SFP programme. Onechild was in the programme but defaulted as the carer thought the childhad recovered. With sustained outreach efforts and by strengthening theintegration of community based management of malnutrition activitieswith the existing outreach system, this proportion of severely malnourishedchildren who have never been enrolled in the programme is likelyto decrease. Stronger linkages between the SFP and OTP programmesneed to be established to ensure that children in the SFP can be referred tothe OTP if their nutritional status deteriorates.Acceptance/rejection rates – malnourished childrenCarers of malnourished children found who were not in the OTP/SC butknew about it, were asked if the child was ever referred to a GOAL OTP/SC site. Fourteen (60.9%) of 23 respondents had while 39.1% (9/23) hadnot. On referral, over half (57.1%) were rejected because they did not fitthe programme admission criteria. A number of carers who brought theirchild to the OTP site might have done so at a time when their child didnot fit the admission criteria and was therefore rejected. Subsequently,when their child’s situation deteriorated, carers may have been unawarethat they could bring their child again for re-assessment. This phenomenoncould bias coverage downward and could be easily remedied byhaving all programme staff and health/community workers explain tocarers they should re-present children in the event of further nutritionaldeterioration.RecommendationsImproved and sustainable high coverage of the CTC programme couldbe achieved by:• Strengthening the training of CHWs with regard to the signs andsymptoms of malnutrition and encouraging CHWs to include aneducational message as part of their community mobilisation andoutreach activities.• Providing health and nutrition education to health staff and communityhealth resource persons that will have a positive impact onchanging the behaviour of the community with regard to childcareand feeding practices, with special emphasis on children withspecial needs, e.g. mentally and physically handicapped.• Developing effective techniques for identifying and managing caseswith psychosocial causes.• Strengthening community mobilisation messages to enhance thecommunities’ understanding of the community-based programme,e.g. admission and discharge criteria, importance of completingtreatment, and of returning if their child deteriorates after dischargeor was rejected and subsequently deteriorates further.• Strengthening linkages at the health facilities through ongoingcapacity building of the woreda’s health officials in order to maximisethe likelihood that all carers bringing in sick children to their localhealth facility are referred onto the OTP if their child is malnourished.ConclusionGenerally, the programme coverage is high and meets the Sphere standardset out for coverage of therapeutic feeding programmes in rural areas. Thehigh programme coverage of 66% was achieved mainly through sustainablemethods of community mobilisation. The mobilisation efforts wereintegrated into existing Ministry of Health outreach system and othercommunity based institutions. Community volunteers, TBAs, CommunityHealth Advocates (CHAs), Community Hleath Promoters (CHPs) andmalaria agents, all active in routine health facility outreach activities,have played a significant role in community mobilisation, absentee anddefaulter tracing. There is however room for further improvement andthe coverage survey has helped identify how this might be achieved.For further information, contact: Simon Karanja,email: skaranja@goalkenya.org13

NewsMental Health amongChildren in Severe FoodShortage SituationsA paper on the ‘Mental Health and PsychosocialWell–Being among Children in Severe FoodShortage Situations’ has been prepared in a WHOinter-departmental collaboration.Food shortage contributing to malnutrition andmicronutrient deficiency can inhibit intellectualand physical development. In addition, duringfood crisis, caregivers may be unable to providepsychosocial stimulation for their children due totheir own physical or mental ill health.Psychosocial stimulation refers to the extentthat the environment provides physical stimulationthrough sensory input (e.g., visual, auditory,tactile), as well as emotional stimulation providedthrough an affectionate caregiver-child bond.Children under two years are particularly vulnerableto nutritional and psychosocial deficits.Nutritional deficiencies and lack of stimulationcreates a vicious cycle where a malnourishedchild becomes less demanding and invites lessinteraction. Improving both nutritional statusand stimulation has an added impact on a child’sdevelopment and combined nutrition/stimulationinterventions should be used.In terms of micronutrients, both iron andiodine are essential for cognitive development. Itis critical to prevent deficiency of either duringpregnancy and the first two years oflife especially.Prevention strategies outlined in thepaper include:• Information on appropriate feeding practicesand psychosocial stimulation to key groups,including donors and humanitarian aidworkers.• Psychosocial support and education tocaregivers, with extra support to caregiverswith mental or physical health problems.Improving maternal mental health may beone of the most important interventions fora mother and child in situations of severefood shortage.• Protection and support of breastfeeding, forits nutritional, anti-infective and motherchildbonding properties• Ensure all households have adequate quantityand quality of food.Wherever possible, community or home-basedselective feeding programmes with a psychosocialstimulation component should be used totreat malnutrition.Where centre or health facility based treatmentis needed, psychosocial elements should bein-corporated that include:• Educating caregiversand healthcareproviders about thenegative consequences ofsensory deprivation in aculturally sensitive matter,e.g. practice ofwrapping or tying undernourishedchildren.• Encouraging the caregiver to be present inthe feeding centre and to actively be involvedin the feeding and care of the child.• Encouraging informal child-based playgroups and creating a stimulating environmentfor children.Guidance on psychosocial stimulation, withexamples to improve child-caregiver interactionin programming, are included in the paper, andkey resources are listed to support the psychosocialcomponent of inpatient and communitybased care.For further information, contact Dr JodiMorris, email: morrisj@who.int or Dr Mark vanOmmeren, Mental Health: Evidence and ResearchTeam,email: vanommerenm@who.intThe paper is available online at: www.who.int/mental_health/mental_health_food_shortage_children2.pdfSimple tools for measuring household foodaccess and dietary diversity Summary of international workshop 1An international workshop on simple toolsfor measuring household access to food anddietary diversity was held on March 21-23, 2007in Nairobi. The workshop was sponsored bythe Nutrition and Food Safety Division of FAO(AGN) as part of the EC/FAO Food SecurityInformation For Action Programme, in collaborationwith the Food and Nutrition TechnicalAssistance Project (FANTA)The purpose of the workshop was to bringtogether experts in food security and nutritionfrom governments, universities, and internationalagencies, to discuss the utility of the tools thatAGN is promoting and to identify potential areasfor their integration into food security informationsystems at national and decentralised levels.The main workshop objectives were to:• Generate an increased understanding ofinnovative and simple methodologies andtools for measuring household access to foodand dietary diversity.• Explore how the tools can be applied andintegrated to improve food security informationsystems.• Discuss how the tools could be used indecision making for programming andtargeting.• Strengthen collaboration at national andinternational levels.The workshop brought together food security andnutrition experts from institutions and organisationsin nine countries to discuss the followingtools to measure household and individual foodconsumption characteristics:Household Food Insecurity Access Scale(HFIAS) is a 9-item scale to measure the prevalenceand severity of household food insecurityin developing countries. The HFIAS is based onuniversal situations or experiences householdsmay have when faced with limited access tofood - feeling anxiety and uncertainty aboutthe household food supply, altering personalfood preferences and reducing quantity of foodconsumed.Dietary diversity questionnaires assess thevariety of the diet by adding up the number offood groups eaten by household members orindividuals in the 24 hours prior to the interview.The assessment includes the number of differentfood groups consumed (variety), and the types offood groups consumed (quality).Culturally specific questionnaire adaptationand refinement are needed for both the HFIASand the dietary diversity questionnaires beforeapplying to a population survey.The tools were reviewed in a structuredmanner to identify their strengths and weaknessesand the feasibility of their application in anumber of settings. Overall, there was agreementthat the HFIAS and dietary diversity questionnairescould be appropriately used in a numberof data collection settings and in food securityand nutrition information systems. More specifically,the workshop had three key outcomes:• Agreement on the need to achieve standardisationof the tools and to engage in furtherwork towards this goal.• Identification of practical ways of integratingthe tools to generate information for policymakingand programming.• Agreement on the need to establish a users’network to exchange information on practicaluse of the tools.A full report on the workshop is in preparation.For more information, contact: Terri Ballard,FAO, Nutrition headquarters, Italy, email: Terri.Ballard@fao.org1Executive Summary. International Workshop. Simple toolsfor measuring household access to food and dietary diversity.March 21-23, 2007. Nairobi.14

NewsJoint UN Statement onCommunity-basedManagement of SevereAcute MalnutritionA Joint Statement by the World Health Organization(WHO), the World Food Programme(WFP), the United Nations System StandingCommittee on Nutrition (UNSCN) and UNICEFon Community-based Management of SevereAcute Malnutrition has been released.The joint statement describes how severeacute malnutrition remains a leading cause ofdeath in children under five years of age. Untilrecently, treatment has been restricted to facilitybasedapproaches, greatly limiting its coverageand impact. New evidence suggests, however,that large numbers of children with severe acutemalnutrition can be treated in their communitieswithout being admitted to a health facility or atherapeutic feeding centre.The community-based approach involvestimely detection of severe acute malnutritionin the community and provision of treatmentfor those without medical complications withready-to-use therapeutic foods (RUTF) or othernutrient-dense foodsat home. If properly combinedwith a facility-based approach for those malnourishedchildren with medical complications andimplemented on a large scale, community-basedmanagement of severe acute malnutrition couldprevent the deaths of hundreds of thousands ofchildren.The joint statement also addresses communitybased management in the context of highHIV prevalence and given the overlap betweenmalnutrition and HIV infection and AIDS, recommendsstrong links between community-basedand AIDS programmes.Investing in prevention of malnutrition isessential and interventions may include investingin high quality food and health care, supportfor exclusive breastfeeding for six months andimproved complementary feeding practicesfor children 6-24 months. At the same time,malnourished. The statement states thecommunity-based approach should be addedto the list of cost-effective interventions toreduce child mortality.The joint statement lists what countries cando, through adopting national policies andprogrammes that ensure national protocols forthe management of severe malnutrition havea strong community based component; and byensuring that coverage, training at all levels,and referral systems are addressed. In addition,countries can act by providing the resourcesneeded for management of severe malnutritionand by integrating the management of severemalnutrition with other health activities.The statement details how WHO, WFP,UNSCN and UNICEF will support countryactivities, for example by mobilising resourcesto support implementation of recommendationsand facilitating local procurement or productionof RUTF.The statement concludes with a technicalannex on RUTF, including referenced informationon producing RUTF locally 1 .The joint statement is available in English andFrench and can be found at:http://www.who.int/nutrition/topics/statement_commbased_malnutrition/en/index.htmltreatment is urgently needed for those already1Available at http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/CBSM/tbp_4.pdf).Food and NutritionSecurity TrainingProgramme in theNetherlandsThis training programme at Wageningen International, TheNetherlands aims to provide the course participants with knowledge,skills and motivation to identify, plan and implementeffective action to address food and nutrition security at variouslevels, ranging from (national) policy level to regional, community,household and even individual level programmes.The training programme can be followed as a complete 11weeks’ programme, which leads to a diploma at postgraduatelevel or as ‘stand alone’ certificate courses.Next course dates: March 31 – June 13, 2008Course Content• Key concepts and current issues in nutrition• Nutrition communication and promotion; a new approach tonutrition education• Food and nutrition security in the context of HIV/AIDS• Monitoring and evaluation of impact on food and nutritionsecurity.A limited number of fellowships are available for the completetraining programme from the Netherlands FellowshipProgramme (NFP). Candidates who wish to apply should beginthe application procedure as soon as possible (see contacts belowfor details). The application deadline for non-fellowship candidatesis 29TH of February 2008. Further information is availablefrom fannie.deboer@wur.nl or by fax +31 317 495395.Application forms and a detailed brochure are available athttp://www.cdic.wur.nl/UK/courses or from WageningenInternational, P.O. Box 88 6700 AB Wageningen, TheNetherlands. Tel: +31 317 495 495, fax: +31 317 495 395,email: training.wi@wur.nlWorld Conference ofHumanitarian StudiesDates: 4-8 February 2009Location: University of Groningen, The NetherlandsThe Universities of Bochum, Groningen and Wageningen are organising thefirst World Conference of Humanitarian Studies to encourage debate anddialogue between different research groups, policy actors and implementingagencies over a wide range of disciplines related to humanitarian action.The World Conference aims to reflect one of the key characteristics of humanitarianstudies: the close collaboration and dialogue with policy makers andpractitioners. Hence, it is open to participation by all these groups.As a World Conference, it aims to establish a global representation of humanitarianstudies and foster interdisciplinary debate on a grand scale. Its centralaims are:• to provide a meeting ground for academic communities and practitionersconcerned with in-depth research on humanitarian issues;• to take stock of the current theory, debates, and issues of humanitarianstudies;• to reflect on current practice and identify opportunities for improvinghumanitarian practice; and• to involve Southern scholars and practitioners more strongly intohumanitarian politics, responses, debates, and studies.An estimated 500 participants from a variety of institutions, universities,NGOs and other relevant organisations, associations, governmental departments,and intergovernmental agencies will participate.The organisers have issued a call for paper and panel proposals.The deadline for submission for panels is 1 February 2008, for abstracts is 1September 2008 and for early bird registration is 1 November 2008.The conference fee is 200 euro (150 euro for early bird registration) and 100euro for PhD students.Guidelines for Participants on the Conference and updated details can befound at the website http://www.humanitarianstudies2009.orgFor more information, email: info@humanitarianstudies2009.org15

NewsTranslated versions of the Operational Guidance on IFEThe Operational Guidance on Infant and YoungChild Feeding in Emergencies (IFE) is now availablein English, French, Spanish, Portuguese,Arabic and Russian. Translations into Chinese,Japanese, Kiswahilli and Bahasa (Indonesia) arewell underway.All translations are available on the ENN website,http://www.ennonline.net, under IFE.Print copies in English and French (along with asmall stock of Spanish and Portuguese) are availablefrom ENN, email: ife@ennonline.netSpanish and Portuguese print copies are availablefrom IBFAN Latin America and the Carribean(LAC), contact: Marta Trejos, CEFEMINA,Coordinación Regional IBFAN LAC, San José,Costa Rica.Tel: 506 / 2201724, fax: 506 / 2906073,email: cefemina@racsa.co.crwebsite: www.cefemina.org or www.ibfan-alc.orgArabic print copies are available from IBFANArab-World, contact: Mohamed Marwan, email:marwan@ibfan-arabworld.orgIASC Nutrition Cluster: Key Things to KnowThe Inter-Agency Standing Committee (IASC)have recently produced a ‘Note’ about the ClusterApproach which includes details about the NutritionCluster component.Cluster ApproachThe ‘cluster approach’ is a mechanism that addressesidentified gaps in emergency response andenhance the quality of humanitarian action 1 . It ispart of a wider UN humanitarian reform process,aimed at improving the effectiveness of humanitarianresponse by ensuring greater predictability andaccountability, while at the same time strengtheningpartnerships between NGOs, international organisations,the International Red Cross and Red CrescentMovement1 and UN agencies.In September 2005, the Inter-Agency StandingCommittee (IASC) agreed to designate global ‘clusterleads’ specifically for humanitarian emergencies innine sectors or areas of activity, including nutrition,water and sanitation (WASH) and health. Thesenine sectors have been increased to eleven with therecent addition of education and agriculture. It wasagreed the cluster approach should also be appliedat the country level and for a fixed duration of twoyears at the global level.IASC Nutrition ClusterUNICEF is the designated global lead agency of theIASC Global Nutrition Cluster. There are 34 UnitedNations (UN) agencies, non-governmental organisations(NGOs), donor, and academic/researchpartner organisations at global level. At the countrylevel, the composition varies but the usual leadagency is UNICEF with partners including WHO,WFP, FAO, UNHCR and NGOs.The Global Nutrition Cluster provides supportto the international community and has providedconcrete tools and support to the country basedNutrition Cluster in the following areas:• Coordination with information sharing atglobal level and from country to global level.• Capacity Building, including training needsanalysis, roster of available people.• Tools and approaches to improve readiness,response, assessment, monitoring and reporting.• Supply, including Ready to Use TherapeuticFoods (RUTFs) and micronutrient powdersand pastes.For implementation, it is important to work withthe national structures and other clusters wherethey have been initiated, in particular the Health,Water, Sanitation and Hygiene (WASH), Education,Protection and Logistics Clusters. In addition,various NGOs work with the cluster on a geographicaland technical area basis. The Nutrition Cluster isworking in four pilot countries: Democratic Republicof Congo (DRC), Liberia, Somalia, and Uganda. Inaddition, the Cluster is active and pending in anumber of other countries including Pakistan (forthe recent floods), Ethiopia, Chad, Guinea, CAR,Haiti, Sudan, Madagascar, and Zimbabwe. It isenvisaged that the Cluster Approach will be implementedin approximately 25 countries where thereis a Humanitarian Coordinator and in a numberof other countries as a result of a sudden onsetemergency, as was the case in Pakistan with floodsin July.The Cluster Approach is envisaged as a mechanismfor improved preparedness and response bothin slow onset and rapid onset emergencies. Theconfiguration and role of the Cluster depends on thelevel of government involvement, type of emergency,needs, and extent of the emergency.Overview of Cluster goals and prioritiesA number of strategic focus areas (‘gaps andopportunities’) have been identified by the Clusterpartners. They include:Coordination: organisations often focus on oneor parts of the underlying causes of under-nutrition– disease, food, care, or water, sanitation andenvironment – often without coordination. This ispartly due to a lack of leadership amongst agenciesin the sector and partly due to the lack of incentivesto work together as agencies compete for diminishingfunds and position. Defined and measurablegoals with negotiated strategies and benchmarksto achieve these goals will provide the basis forcoordination.Capacity Building: changing needs, combined withmobile technical staff and often depleted nationalcapacity, complicate mounting a predictable,standardised and sufficient response in emergencies.Capacity building goes beyond training andincludes preparedness, response, assessment,monitoring, evaluation, reporting, protocols andsupplies. Building and supporting a surge capacityat the country and global level continues to be at thecore of the emergency response. The global clusterlead is also responsible to ensure that cross-cuttingissues (including environment, gender and HIV/AIDS) are properly mainstreamed in humanitarianresponse.Emergency Preparedness, Assessment,Monitoring, Surveillance and Response Triggers:At the onset of a humanitarian disaster, there is aneed for:• Further development of clear and unambiguousinternationally accepted criteria to classify thedifferent types of a ’nutrition emergency’.• Clear standards to guide the responseincluding eligibility and exit criteria• Transparent processes and accountability thatare established and supported by allstakeholders.• A commonly agreed upon methodology fordata collection (what to collect, from whom, bywhom) and a process for analysis, interpretationand reporting.Progress has already been made in some areas.Supply: Too many examples exist of humanitarianresponse delayed by a lack of appropriatesupplies. Pre-positioning supplies, stand-by agreements,facilitating in-country procurement, andclarifying operational procedures for procurementwould greatly remedy this situation. The selectionof products hampers response, especially in thearea of the recently developed special foods suchas RUTFs and Ready to Use Supplementary Foods(RUSF). RUTF and RUSF represent a technical stepforward that should be translated into policiesand procedures for their production, procurement,distribution and use.The international donor and emergency responsecommunity looks to the Cluster Approach as a meansto accelerate and improve emergency response.Together with the Country Nutrition Clusters,the Global Cluster partnership aims to providestewardship by improving the regulation, standardsetting and priority setting. The Cluster also aimsto assist mobilising, harmonising and ensuringbetter distribution of financial resources includingimprovements in supply in order to reducecosts and take advantage of economies of scale.The Cluster provides services including technicalsupport in the generation and management of information,as well as key technical support as needed.The Cluster does this in situations where the localgovernments are unable or unwilling to provide thatassistance themselves. Finally, the Nutrition Clusteris working with national and global partnershipsto improve training, capacity building and also toderive answers to some of the most pressing policyand operational challenges.For more information, contact Global NutritionCluster Coordinator: Bruce Cogill,email: bcogill@unicef.orgor visit http://www.humanitarianreform.org/1IASC Guidance Note on using the cluster approach tostrengthen humanitarian response. 24 November 2006. IASCNutrition Cluster. Key Things to Know. 21 March 2007. Bothavailable at http://www.humanitarianreform.org/16

LettersHaving a gold standard formula for F100/RUTF, on the other hand, now allows us tostart to develop other foods and recipes -from local ingredients - that have the samenutritional and therapeutic properties andwill allow the widespread sustainable treatmentof far large numbers of children thancan be treated at the moment.I would suggest that we should STARTwith commercial products. Where these arenot available or where there is a rupture inthe supply pipeline, we have alternativerecipes that can be used - with the caveat thatthey will need extra staff, support, supervision,quality control, training etc, when theyare used - and the staff will have to be of amuch higher calibre. In the meantime, therehas to be a research effort to emulate theresults with various blends of local foods. Butwe should not compromise on quality of careand accept an inferior treatment just to makea programme, which is already cost effectivein relative terms, cheaper (at the cost of lives).Final few wordsIt is critical to remember that these commerciallybased therapeutic diets are not magicbullets that can be simply given withoutstrict training on, and adherence to, the fullprotocol for managing severe malnutrition.In one of our analyses, we found a lowermortality with the old home-prepared highenergy-milkthan with F75/F100. At first thiswas puzzling. But it became clear thatthe metabolic changes that occur withthe modern diets are very rapid and canresult in dysequlibrium syndromes, sothat the children are even more vulnerableto therapeutic mistakes, certainly interms of electrolytes.I think we should emphasise that theseare THERAPEUTIC products (i.e. they aremedicines), that they are quite differentfrom milks or infant formula, which arenot available to the general public andare not advertised per se. Although a lotof people do know about them, these aremainly technical people so the productionis DEMAND driven rather than advertisementdriven, and the products arenot replacing any natural process (such abreastfeeding).We are in the middle of a nutritionalrevolution - let us be at the forefront ofthinking and advocacy and not shootourselves in the foot by negative sustainabilityconsiderations - if it is needed, itis needed. We need advocacy for funds,implementation and research and weneed to all be pulling in the same directionfor the sake of the children.CheersProf Mike GoldenNote from a colleagueDear Rebecca,I read with interest Mike’s perspective/experienceson the issue of use of the therapeuticmilks and RUTF in treatment of severelymalnourished children. The issues he describesare those we’ve experienced in the field. Wemake a big point of describing the therapeuticmilks as ‘medicine’, not food, and insist thatthey be used as such.What I have a real problem with is theincreasing adoption of RUTF as a substitute‘food’ to treat children whose diets are poor(and thus probably a major contributing factorto undernutrition). Isn’t the ‘right to food’that is familiar and nutritionally and culturallyacceptable (i.e. real food, not formulationsthat carry macro- and micro-nutrients) a basichuman right? It seems to me that the movein the direction of making formulations likePlumpy’nut widely available to ‘all childrenwho need it’ puts energy into a strategy thatperhaps provides an easier ‘technical’ solution,but one that must ultimately be less satisfactoryto populations who should be able (likeothers) to raise their children on real, nutritionallyadequate, food. The solution sidesteps thereal problem, in my view.Regards,Mary Lung’ahoCARE USAResponses from Prof Ann Ashworth Hilland Prof David Sanders home in on theissue of sustainability.Dear Rebecca,Nutriset F75 and F100 are certainly easier touse than ‘homemade’ (as you just tip out thepacket and add 2 litres of water). It reconstituteswell, so there is no worrying about oilseparating out. Also, all the electrolytes andmicronutrients are included, so there is noworry about organising supplies of electrolyte/mineralmix or CMV.BUT sustainability is a big issue. TakeTanzania for example. They were making‘home-made’ versions with fresh cows milkand adding sugar, oil and CMV. After theWHO/UNICEF training in Sept 2006, theMoH/Paediatric Association of Tanzaniaarranged for the UNICEF country office tosupply Nutriset F75 and F100. In April wefound a lot of wastage as the nurses wouldmake up 2 litres, even though they onlyneeded 500ml, for example. (This can beavoided by weighing out/measuring appropriateamounts for 500ml, 1000ml, etc.). But thereis no continuity of supply and they have runout. So they reverted to the homemade system,only to find that they have to start organisingCMV or electrolyte mineral mix once again,and the system creaks and groans and theylose momentum (and even the skill of makingthe home-made version). Continuity of supplycould well be improved by earlier, timelierreordering by the pharmacy - they did leave itrather late to reorder.Take Queen Elizabeth Hospital, Blantyre(Malawi) as another example. They used tomake their own therapeutic milk. Then whenthey had ‘emergency’ status, they switchedfrom homemade to Nutriset F75 and F100,as it came free and was easier. But when theemergency status ended, the MoH was in aquandary. They could not afford to buy F100.When I was there, the MoH was thinking ofbuying Nutriset F75 in the relatively smallquantities that it is used, but they were stuckabout what to do regarding the F100.TdH provides DSM and CMV. If the hospitalhas good dietary scales and a blender, thenit is easy to reconstitute. It will cost less thanNutriset milks but will be very similar incomposition. The Nutriset milks have lowerosmolarity as they use dextrimaltose instead ofsugar, but otherwise they will be virtually thesame.I would support TdH’s current practice. Ifit works, then there is no point of changing toa system that would be more expensive andmight be precarious.Best regardsAnnDear Rebecca,My feeling is one of great caution. I think thatit is much more sustainable to rely on availableproducts such as dried skim milk than onimported expensive items. I do not think thatNutriset products will be sustainable. If youare interested in an analogy, read ‘Questioningthe Solution,’ a book David Werner and I wroteabout Oral Rehdration Salts (ORS) sachetsfor diarrhoea - also not sustainable. Thereis evidence that those countries that havepromoted safe rehydration fluids made upfrom locally available items e.g. sugar and saltor cereal-based fluids, are better able to sustainwidespread and life-saving managementof dehydration, because of interruptions insupply of sachets as a result often of unaffordabilityor delivery problems.In my opinion it is, unfortunately, false toextrapolate from the emergency situation tothe ‘normal’ country situation. Availability ofcommodities, precise conduct of procedures,and indeed outcomes in severe malnutritionare generally very good in emergency situationswhere special infrastructure and, moreimportantly, good staff ratios and committed(often expatriate) staff are present. Ironically,for populations living in ‘non-emergency’situations in many African countries, thesituation is often not nearly so good. There areshortages of equipment, drugs and staff, whoare often inadequately trained, poorly paid andsupported and, understandably, demoralised.This situation will only be corrected by majorreforms (including economic policies) thatensure sustained improvements in funding,increases in staff numbers and competence,and improved support and supervision.Until such time, my view is that it is moreresponsible to base interventions on what issafe, effective AND more likely to be obtainablein the country. For, sadly, the comparisonwill often not be between made-up F75 andNutriset, but in reality between made-up F75and nothing.Best regards,David Sanders18

Field Articlebased case-definition to target supplementaryrations). The issue of indicator choicefor use in surveys intending to estimatethe prevalence of acute undernutrition indevelopmental and emergency settingsis not whether MUAC should be used inaddition to W/H (since it is now necessaryto use MUAC in order to assess need)but whether the use of W/H is useful.The available data suggests that surveysintending to estimate the prevalence ofacute undernutrition in developmentaland emergency settings could reasonablyabandon the use of W/H and use MUAC(and oedema) alone. Such a change wouldreduce survey costs and allow the use ofmore informative survey methods (e.g.methods that allowed the mapping ofprevalence) at little or no extra cost. Datamanagement and data analysis would begreatly simplified. The unification of definitionsof prevalence and need would alsosimply data-management and data analysisand eliminate the confusion caused by theuse of different case definitions.Mark MyattUniversity College London1Field Exchange 30. Van Herp et al. Can height-adjustedcut-offs improve MUAC’s utility as an assessment tool?p23-p26the most affected in these circumstancesas they are more likely to have healthproblems, have lower incomes (ready-tofeedcartons of formula are usually moreexpensive than powdered formula), lesslikely to be able to afford house insurance(to replace any damaged items such assterilisers, bottles and teats), and may beless likely to have their own transport tocollect water from depots.Grassroots seedmultiplication in EthiopiaBy George JacobGeorge Jacob iscommunicationsofficer with theIrish agency, SelfHelp DevelopmentInternational.Abebe and Tebewebch Kebretare seed multipliers in the BertaDevelopment Centre district ofBora, Ethiopia.The author would like to thank Dr. Awol Mela, AfricaDirector, Self Help Development International;Shimikat Maru, Co-Operative and Capacity DevelopmentOfficer, Self Help Development International,Butajera, Ethiopia; and Teshale Jemal, Communicationsand Planning Officer, Self Help DevelopmentInternational, Addis Ababa, Ethiopia.D Stephenson/Self Help Development Intl, 2006Yours sincerely,Sarah SaunbySheffield Area Contact, Baby Milk Action &BfN Registered Breastfeeding SupporterUKA more detailed version of this letterhas been posted online, along with otherdetails and information on infant feedingissues in the UK, at http://boycottnestle.blogspot.com/2007_07_01_archive.html1http://www.ennonline.net/pool/files/ife/module1-manual.pdfInfant Feeding in Emergencies, Module 1 for emergencyrelief staff WHO, UNICEF, LINKAGES, IBFAN, ENN, 20012http://www.guardian.co.uk/comment/story/0,,2090780,00.htmlThe Guardian Formula milk is even more deadly in disasterzones, by Marie McGrath, Wednesday May 30th, 20073http://news.bbc.co.uk/1/hi/uk/6239828.stmBBC News Floods force thousands from homes. Tuesday,26 June 20074Operational Guidance on Infant and Young ChildFeeding in Emergencies, v2.1, Feb 2007. Applies worldwide.Available at www.ennonline.net/ife5IBFAN is a global network to strengthen independent,transparent and effective controls on the marketing ofthe baby feeding industry. The UK IBFAN organization isBaby Milk Action, http://www.babymilkaction.orgProviding access for subsistencefarmers to good quality seed stockpresents enormous challenges toorganisations involved in developingrobust food and livelihood security systemsamongst the rural poor in countries acrossSub-Saharan Africa. Self Help DevelopmentInternational (Self Help) working in Ethiopiahave embarked over the past three years onan innovative capacity building programmein seed development and distribution, whichhas already succeeded in strengthening existinglocal seed supply.More than a decade ago, the governmentin Ethiopia put into place a NationalSeed Industry policy to attempt to bringabout improvements in seed distributionfor agricultural production. Considerableadvancements have been made in the developmentof high quality seeds, in streamliningof evaluation systems, and regulation of seedquality standards. However, agencies such asthe state run Ethiopian Seed Enterprise (ESE)have been unable to meet the demand thatexists for quality seed – of cereals, in particular.As a result, it is estimated that up to 80per cent of rural farmers in the country relyon the ‘non formal’ sector for their supplies,with small-holders using their own seedssaved from previous crops, or obtainingstock from neighbours, often in exchange forgrains or other commodities. Although thecountry’s agricultural research system hasdeveloped and released nearly 400 varietiesof 50 different crops in recent years, the ESEhas only been able to produce 80 differentseeds of just 20 different crop varieties.Self Help InitiativeTo overcome this supply problem, Self Helpand its Ethiopian team have worked inpartnership with the country’s Co-OperativeDevelopment Bureau and AgriculturalResearch Institutes to develop, at grassrootslevel, a system whereby local farmers andfarmer groups are supported with the developmentof a grassroots seed multiplicationprogramme. This enables them to produceand market their own high yielding droughtresistant varieties for sale and distributionto farmers across wide areas of Ethiopia’spopulous Oromia region.The objective is to provide a sustainablesupply of improved seeds to all programme20

Field Articleareas. In order to achieve this, Self Help hassupported the creation of seven primary seedco-operatives through three existing co-operativeunions, which it has been involved indeveloping, to provide inputs and marketingsupport to farmers in the Sidama Elto, Waltaand Melik regions of Oromia.Across the seven co-operative groups, morethan 350 individual farmers have becomeinvolved in seed production of improvedquality varieties of wheat, teff, haricot beanand soy-bean, amongst the major crops that aretraditionally produced by small scale farmersacross the region.To get the initiative underway, Self Helpembarked upon a programme of familiarisationand technical training amongst its participatingseed producers, and supported all of the farmerproducers with seed production management,post harvest handling, and co-operative managementand leadership training. The organisationpurchased basic seed of selected crops from theESE, and supplied this to its multiplier co-ops inorder to rear and have ready in time for the newplanting season.It was critical from the outset that the timingwas right and to ensure that good quality seedstock was available to the farmers when theyneeded it. Otherwise this would have destroyedfarmer confidence in this enterprise and theywould have found some alternative local source,and gone back to the low yielding varieties thatthey had traditionally used.Cost shareThrough the Self Help supported co-operativeunions at Sidama Elto, Walta and Melik, theimproved quality seed was provided alongwith other necessary inputs to several thousandfarmers on a credit basis – with 25% of the costSisiy Teferi and his wife, WogayenHegussi, harvesting teff on their farmin Badasa, EthiopiaMembers of the Fusa village cereal seedmultipliers with Self Help in Ethiopiabeing paid up-front upon delivery of the inputs,and the balance being paid after harvest in thefirst year of the project – 2005. During the secondyear of the initiative in 2006, the repaymentschedule was organised on a 50:50 repaymentschedule, and in the current year, the farmerswho have been involved in the programmefrom the outset are paid the full-cost of thebetter quality seeds at the time of delivery.Other infrastructure supports were alsoprovided, with Self Help supporting each of theco-op unions with the construction of warehousingand seed cleaning equipment, to ensure thatquality was maintained and spoilage of thestock kept to a minimum. The initiative has beenone of partnership from the very outset, andthe support and backing of the local communities,the unions, the Ministry of Agriculture, theCo-Operative Development Bureau, the ESE,and of the Agricultural Research Institutes havebeen vital to the success to date.The challenges faced/Lessons learnedThe venture has of course faced severalchallenges – a number of which still have to beovercome.First, there is a perception amongst potentiallocal buyers that the quality of stock thatis being produced by their Self Help farmermultipliers is not of the same high grade asthat available from the country’s seed enterprisesand research centres. Seed that is boughtfrom the seed enterprises is clean and is wellpresented because it has been separated bymechanical threshers, has been properly cleanedwith machinery, and comes in pre-packed bags.Self Help’s multiplier farmers are still threshingwith oxen however, and the sacks from whichseed is sold can therefore also contain damagedseeds, as well as beards and husks, because ithas not been cleaned in the same mechanicalway. Local farmers sometimes judge the stockby its appearance, regard it as inferior to thatsupplied through the seed enterprises, andare therefore unwilling to pay the prices beingsought by the farmer producers. As a result ofthis, the producers have been forced to accept aD Stephenson/Self Help Development Intl, 2006lower price – and will continue to have to do sountil they have improved their marketing andpresentation, and built confidence that theirfarmer produced seed will deliver the higheryields that they promise.There have also been challenges with themarketing of surplus seed outside the immediatelocality. Again it is a question of confidencein the product – which will be difficult toovercome until the quality of presentation oftheir seed stock has been improved.Steps are currently being taken to strengthenlinks between the Self Help producers and theagricultural research station advisors, so thatthe issue of presentation can be tackled as apriority, and so that the mechanisms are in placeto provide seed multipliers with the technicalback-up that they will need to ensure the longterm sustainability of their activities.Latest recruitsTwenty-five farmers of the Fursa FarmersCo-Operative in the Huruta area are amongstthe newest seed multipliers to become involvedin the Self Help initiative, having agreed totake part after visiting the programme duringa Farmers Field Day that was hosted by theagency, in Spring 2006.Sixteen members of the group set asidefive hectares of land to multiply seed stockfor the early maturing and high yielding CRCert 7 variety of Ethiopia’s teff grain – used toproduce the country’s traditional pancake-likeinjera bread. When they harvested for the firsttime last Autumn, they estimated that theyhad produced enough stock to meet the needsof up to 2,000 farmers in the locality, this year.Participating farmers were pleased not just atthe wider impact that their activity is having– for they know that they also have a highlyprofitable and marketable commodity in it’sown right. In the past when farmers sold grainfor consumption, they received approximately220 Ethiopian birr (€18) per quintal in the localmarket, but with the seed stock that they nowhave they intend to charge 300 birr (€25).This year the number of farmers involvedin teff and wheat multiplication in Hurutu hasincreased to 50 farmers, with all of the farmersbeing organized into a local farmers seed multiplicationco-operative, so that they have thenecessary structures to ensure long term sustainability,and profitability of their enterprise.For more information, contact George Jacob,email: george.jacob@shdi.orgTo find out more about the work of Self HelpDevelopment International visithttp://www.selfhelp.ieHarvesting teff21D Stephenson/Self Help Development Intl, 2006D Stephenson/Self Help Development Intl, 2006

EvaluationSUD_20030517_WFP-Debbi_Morello_4232An emergency school feedingprogramme in Rumbek,Northern Bahr El GhazalEmergencyschoolfeedingprogrammesSummary of evaluation 1WFP have recently completed anevaluation of emergency schoolfeeding programmes (ESF) 2 . Theevaluation consisted of a deskstudy, three field visits to countries with ESFoperations 2 , an e-mail survey distributed toESF project managers in country offices and ananalysis, including a workshop to review andprocess the data.The main findings of the evaluation were asfollows;In most of the projects studied, ESF objectiveswere not fully consistent with needs of benefi-ciaries. Project documents, at times, referred to‘standard’ objectives, such as reduction of genderdisparities and the increase of primary schoolattendance, or set broad objectives to cover avariety of school feeding activities in a country-wide operation. Consequently, objectives didlittle to guide implementation. WFP field stafffrequently did not follow them and sometimesformulated their own objectives that were moreconsistent with needs than the original ones.Cooperating partners were often not aware ofthe WFP objectives either and defined their ownproject objectives, for which they would merelyseek, and usually receive, WFP support.Stakeholders identified ESF aims other thanWFP’s objectives, ranging from nutritional goalssuch as ‘helping to meet nutritional require-ments’, increasing food security at schoolor closing the food gap, to goals of psycho-social and physical protection. A frequentlymentioned alternative objective was to facilitatea return to normality for children affected by anemergency.In situations characterised by high foodinsecurity and malnutrition, WFP has to focusresources on the nutritional needs of the mostvulnerable people. But some donors object thatschool feeding does not necessarily address suchproblems and may even compete for resourceswith programmes that aim to save lives.Assessing the educational situation andidentifying the main needs and constraints is achallenge in emergency contexts, exacerbatingthe difficulty of implementing ESF. Coupledwith the lack of coherence between objectivesand needs and the shortcomings in implemen-tation at the school level, this has reduced theeffectiveness of some ESF projects.The evaluators argue that school feeding canbe effective when nutritional improvements area prerequisite for achieving educational objec-tives. Supporting education through schoolmeals is a unique way of improving the qualityof learning, by alleviating short-term hungerand reducing late morning absenteeism whenchildren leave classes to find food. Unaffordableschool fees, however, can cause low enrolmentand attendance, as well as inaccessibility ofschools or discrimination against certain groups.Work to improve enrolment and attendanceneeds to be based on an understanding of suchbarriers in a given situation, not all of themcan be addressed by school feeding, and somerequire specific action.The type of modality is particularly impor-tant in volatile, impoverished or resource-pooremergency or recovery contexts in terms of, forexample, food preparation times, the relativeand perceived value of the food, support for andsupervision of food preparation and the require-ments for additional inputs and infrastructure.To prepare daily meals, schools need kitchens orcooking facilities, storage to protect food frommisappropriation and spoilage, and water forcooking and cleaning. Under-resourced schoolscannot provide these inputs and are thereforeexcluded from the programme or have difficul-ties preparing the meals. Communities also haveto provide resources and parents are often calledon to contribute food or non-food items. Manypoorer schools struggle to provide these inputsand are therefore at a disadvantage. Dependingon the objectives, less demanding modalities,such as biscuits or take-home rations, may bealternatives.The choice of food and implementationmodalities in relation to project objectives andthe target population is, therefore, a strategicone. Current guidance on modality selectiondoes not provide the context-specific informa-tion or selection criteria to enable WFP staff todesign optimum interventions for emergencysituations.School feeding programmes require sanita-tion, water, and hygienic cooking and storagefacilities. In communities where these condi-tions do not exist, WFP needs to work withpartners such as UNICEF to provide the neces-sary infrastructure. The challenge is to ensurethat schools that could benefit from assistanceare not excluded from the programme becausethey do not meet minimum conditions.Targeting criteria and processes need to takeaccount of needs and resources. This is current-ly limited because educational indicators have aminor role in geographical targeting and schoolselection, and needs assessments do not identifythe areas of greatest need where school feedingmight be most effective.WFP also has to link targeting to the logisticschallenges and delivery costs. If this is not done,the most vulnerable schools may not receivefood because unforeseen logistics problems raisethe cost of delivery to remote locations abovethe budget limit. More flexibility is needed inadjusting this limit to meet the conditions of theemergency.WFP may have to choose between allowingmore effective implementation in the short-termor taking a longer-term perspective and build-ing the capacity of the government. Where WFPuses ESF as a tool for linking relief, recoveryand development, field staff must be sensitisedand empowered to build capacity or increasecommunity involvement without requiringquantitative performance targets.ConclusionsThe evaluation concludes that the challenge forWFP is to develop responses for each contextrather than an overarching approach for ESF.Approaches developed by WFP programmes– for example, providing rations for mothersto prepare meals, as in the DRC, or providingfinancial and logistic training for new educa-tion authorities as in the Sudan, can informmore context specific EFS programme design inthe future. Also, ESF assistance does not alwaysreach the schools that would benefit from itmost, primarily because WFP is not usingopportunities for context-specific design ofESF for particular contexts. The organisationalcauses of this design weakness are the lack ofcontext-specific expertise, guidance and toolsto implement ESF and the prevailing cultureof decentralised decision-making in WFP. Thestandard tools and procedures are either notspecific enough or fail to reflect the educationalrationale of ESF projects. A significant gap islimited availability of staff that understand thestrengths, weaknesses and challenges of eachESF modality.Two factors that reduce the effectiveness ofESF projects are imprecise targeting and lackof complementary inputs. Improvements inneeds assessment and more precise targetingmay make coordination with other educationaland nutrition /health activities more difficult.Increased coordination with UN and NGOsinvolving adoption of their criteria carries therisk that WFP’s targeting principles may becompromised, for example, nutritional consider-1Executive Board Annual Session, Rome 4-8th June 2007.Evaluation report 7, Agenda item 7. Summary report ofthematic evaluation of school feeding in emergency situations.WFP/EBA/2007/7-A. April 27th 2007.2Pakistan, Sudan and Democratic Republic of the Congo22

Field ArticleA typical back garden in the IDP campsHousehold-based food fortificationfor anaemia control in SudanBy Erin Tansey and Dr. Ibrahim BaniE Tansey/MI, Sudan, 2006Erin Tansey started work as a programme officer forCARE in Bosnia in 1996. She moved on to work forUNHCR in Asia and Africa and has been a TechnicalAdvisor for Emergencies for The Micronutrient Initiativein Johannesburg since 2005.Dr. Bani is a medical doctor with many years ofexperience working in the area of Public Health. Heis a consultant to The Micronutrient Initiative (MI)and provided much of the technical inputs into thisproject.The Micronutrient Initiative (MI) would like tothank the Christian Blind Mission InternationalCanada (CBMI) for their financial support for thispilot project. MI would also like to thank theSudanese Red Crescent and the Sudanese Ministryof Health (National Nutrition Directorate) for theirinvaluable contributions to this project.This article draws on a report prepared for theChristian Blind Mission International Canada(CBMI) by MI.Nearly two million internally displac-ed people (IDPs) and refugees inDarfur are entirely dependent onthe World Food Programme (WFP)distributions of food aid in order to survive.Micronutrient deficiency is considered a majorproblem in Darfur. As well as contributing toinfant mortality, over 50% of all children 6-59months are estimated to suffer from anaemia,while vitamin A deficiency is estimated at 36%.Although food rations provide some micronu-trients, they are reportedly not enough to meetthe needs of the most vulnerable populations– pregnant and lactating women and childrenunder 5 years of age (CDC/WFP EmergencyNutrition Assessment, Sept 2004).The Micronutrient Initiative (MI), togetherwith the Sudanese Red Crescent Society (SRCS)and the Sudan Ministry of Health NationalNutrition Directorate (MOH-NDD), set out toimplement a pilot project to test the acceptabil-ity to IDPs of low cost micronutrient premixesand the feasibility of using it to improve micro-nutrient status in a camp in Darfur. There weremajor constraints to food sources other than theWFP ration during the project time period. MostIDP families had moved off their land and wereunable to return to harvest any foodstuffs. Thearea around the camps is very arid and mostIDPs did not have access to gardening space.Prices of food on the local market were alsosteadily increasing, making it very difficult forIDPs to make any purchases.The project timetable was a four month period(January – April 2006) and had three inter-relat-ed components:• Sourcing, procurement, supply (to the camp)and local storage of an appropriate multi-micronutrient premix in quantities sufficientto meet the needs of the target population.• Training of staff and distribution of themicronutrient premix to families.• Monitoring and evaluation focused on acc-eptability and feasibility studies (to which anadditional efficacy study was later added).All the above were supported by technical assis-tance and project management from MI.Sourcing micronutrient premixThe initial intent was to procure and deliver2.1 million micronutrient sachets (Sprinkles TM )to the specified camps in Sudan. However, as aresult of the initial assessment and field visit, itbecame clear that due to the eating habits of theintended beneficiaries, the individual micronu-trient sachets would not be appropriate. Theeating culture/practice in Darfur is that a familyeats from one single plate, with no individualbowls or plates for children. As such, individualsachets intended for children would have to bemixed into the single family pot, thereby dilut-ing the content to such an extent that it wouldno longer benefit the child. MI decided it wouldbe more appropriate to use a free-flowing micro-nutrient premix (Rahama) that would be addedto the family pot and would benefit the entirefamily, not just children. The premix would beadded to the sauce that accompanies the staplefood (usually sorghum or wheat) and is addedafter cooking. The fortification would be carriedout for a period of two months.The free-flowing micronutrient premix, usedby MI in its large school feeding projects inAsia, has been shown to be effective in reducinganaemia and iron deficiency in children under5 years of age. A very similar premix compo-sition was sourced for this project using threemicronutrients (see table 1). This premix is alsosignificantly less expensive than the individualsachets, mainly because there is no packagingfor individual servings.In practice, 500kg (25 bags of 20 kilogramseach) of premix was produced in India, flownfirst to Khartoum and then to Nyala (air trans-port was used because of poor road conditionsand security issues). An additional 100kg waslater sourced to support an efficacy study (seenext section). The premix was then distributedTable 1NutrientRahama content (with dextrose filler)Vitamin A(μg retinol equivalent)Micronutrient levelper dose (0.25g)premixinto individual family containers (10,000 plasticresealable containers were sourced in Sudanand transported to Darfur) by the SRCS and theMOH.Efficacy studyAs this was the first time that such a micronu-trient premix was distributed in an emergencyenvironment, an efficacy study was conductedby MI to review the impact on haemoglobinlevels of women and children consuming theRahama. Some 250 IDP families from the twocamps were randomly selected and asked totake part in the study over a four month period.Baseline and post-intervention data weregathered from women and children (under 5years) using a HemoCue 1 ® machine. A further125 families in an IDP camp not receivingRahama also took part in the study and wereused as a control group.TrainingAt the beginning of the project in January 2006,MI organised a two-day workshop for 65 peoplein Nyala for the SRCS and MOH staff and volun-teers. MI considered the particular advantageof working with the SRCS was their networkof volunteers who have worked throughoutthe country for over 20 years, who understoodthe local culture and speak the local language.Capacity building at community level wouldhopefully add to the sustainability of the projectin the event of scaling up.The workshop, conducted in Arabic, coveredthe basics about nutrition, including the impor-tance of vitamins and minerals, especially% RNI* children1-3 years% RNI children4-6 yrs150 38% ~40% 30%Iron (mg) 14 100% 100% 25%Folic Acid (μg) 50 33% 25% 10%*Recommended nutrient intake1The HemoCue® Hemoglobin Systems is a method forquantitative haemoglobin assessment in the field. Anyblood source (capillary, venous or arterial) can be used. Theunbreakable, disposable cuvette collects the exact amount ofblood and mixes the sample with the reagents automatically.The cuvette is placed into the portable analyzer. Results appearon the display screen in less than a minute. It uses only 10μL of blood. The machines can be used by non-laboratorypersonnel after a brief training session.%RNI women ofchild-bearingage24

Field ArticleTable 2 Comparative data for the child groupVariable Mean ± SD P valueChild’s weight (kg):Pre in terventionPost interventionChild’s height (cms):Pre interventionPost interventionChild’s haemoglobinlevel (g/dl):Pre interventionPost intervention13.4 ± 4.313.9 ± 2.592.2 ± 11.594.1 ± 12.410.9 ± 1.812.8 ± 4.20.2290.090.01Table 3 Comparative data for the mother groupVariable Mean ± SD P valueMother’s weight (kgs):Pre interventionPost interventionMother height (cms):Pre interventionPost interventionMother’s haemoglobinlevel (g/dl):Pre interventionPost intervention50.9 ± 6.955.9 ± 8.9155.5 ± 20163.2 ± 6.311.9 ± 1.913.0 ± 1.60.080.090.090.10Table 4 Haemoglobin (Hb) levels in control groupVariable Mean ± SD P valueWomen’s Hb (g/dl):Pre interventionPost interventionChild’s Hb (g/dl):Pre interventionPost intervention12.5 ± 1.912.7 ± 1.510.3 ± 1.411.0 ± 1.50.3820.282Vitamin A, folic acid and iron, and information on their food sourc-es. It also informed staff of the proper use of the Rahama premix forprevention and treatment of nutritional anaemia and other micro-nutrient deficiencies. Staff were given training on how to conducta survey and gather data and how to hold focus group discussions.The Federal MOH-NND provided some of the support for thistraining, along with MI.To support the efficacy study, 20 staff were given further train-ing and undertook practice tests on how to use the HemoCue®machines, supervised by the MI technical consultant and theFederal MOH.Graph 1 Overall acceptance of Rahama premix using Hedonic scaleNote on Hedonic Scale: As part of the acceptability test, the Hedonicscale was used. The scale is part of a sensory evaluation of a foodor other product, and is a subjective test. The method measuresthe level of the liking of foods, or any other product and relies onpeoples ability to communicate their feelings of like or dislike.Hedonic testing is popular because it may be used with untrainedpeople as well as those with experience. A minimum amount ofverbal ability is necessary for reliable results (O Mahony, 1986).Graph 2Graph 3Overall acceptance of Rahama premixRahama premix colour changeDistribution to FamiliesIn the first month of the project (26 March to 25 April 2006), 3,975 containers ofpremix were delivered by SRCS volunteers to individual households in Derigand Serif camps. During the family-level distribution, mothers/caregiverswere sensitised about the reasons for consuming Rahama and its proper use,storage, etc. Volunteers then made monitoring visits every two weeks to eachfamily for the entire two month intervention period. A total of 32,000 peoplewere reached, or 3,975 families (varying in size from 5-10 members), with 4,800women of child-bearing age and 13,984 children under 5 years of age.Twelve SRCS supervisors and eight State MOH staff continued to conductmonitoring of the cases that took part in the efficacy study, using Rahama for atotal of six months after the initial blanket distribution of two months.FindingsAcceptability Baseline Study and EvaluationThrough focus groups, an acceptability baseline study on the overall attitudes,knowledge of good nutrition and current eating habits was carried out by theSRCS staff in the camps (see graphs 1-3 for summary results). Also, an accept-ability questionnaire was prepared by MI and incorporated into the bi-weeklyhousehold data gathered by SRC during their monitoring visits. Analysis wascarried out by MOH Khartoum.The overwhelming majority of IDPs questioned found the premix easy touse and store and that it did not change the colour or taste of the food. Over90% of the people interviewed said that they “accepted” this new premix.Several mothers also commented that their children were generally healthierwhile taking this premix. Overall, 191 families (63 families from Serif camp and128 families from Derig camp) refused to use the Rahama during the secondmonth of distribution. This represents less than 1% of families, and is likelydue to a misunderstanding of the intended benefits of the premix.Efficacy StudyMI and its partners conducted a baseline survey before the first distributionof premix in March 2006 in three camps. Two camps were due to receive thepremix (2000 subjects or 250 families) and one camp was not and used as acontrol group (Otash camp with 1000 subjects or 125 families). The familieswere chosen at random from a list of refugee families.The beneficiaries participating in the efficacy study continued to use thepremix on a daily basis for a further four months in addition to the two months.The post-intervention survey was conducted in early December 2006, a fullmonth after the beneficiaries stopped using the premix, after roughly 210 daysof premix consumption. MI had hoped to conduct the survey immediatelyafter the final distribution of premix, but several religious holidays in Sudanduring that time made this impossible. The post-intervention data were thentransferred to the Federal MOH Statistician for data entry.The data analysis shows that there was a statistically significant increase inhaemoglobin levels of children under 5 years of age (table 2) and also an increasein the haemoglobin levels of women (table 3). In the control camp, it was onlypossible to collect data from 39 families (31.2%) (table 4). The response rate inthe control group was low due to several reasons, including some families hadmoved away from the camp and could not be located, while others refused toparticipate in the end line survey, as they were not offered any incentives. Thiscould be a source of bias in interpreting these results and a secondary analysisof the data, looking at the reasons for non-response, is currently under-way.Technical assistance and project managementAs a result of the project, the SRCS’s overall capacity to carry out projects in thefield was strengthened. Over 50 SRCS volunteers now have a solid understandingof the importance of nutrition, and of micronutrients in particular, in theoverall health and well being of women and children. These volunteers havealso gained knowledge and experience of conducting focus group discussionsand other means of collecting information.Much of the technical support was provided by an MI consultant who isa medical doctor and who is from Sudan, and speaks Arabic. He carried outthe 2-day training, prepared all the questionnaires for data collection and all25

Field Articlethe training material for the workshop. He provided much of the technicalfollow-up throughout the project and also acted as the liaison between MI andthe Federal and State MOH.MI’s technical assistance/support also benefited both the Federal and StateMOH, as they were part of the initial training on the use and importance ofthe Rahama, and on the use of the HemoCue® machines. This training hasnow increased the MOH’s overall capacity to conduct nutritional surveys (asthe HemoCue® machine is almost always used in nutritional surveys). Manynutritionists from the Federal MOH, who were not involved in this pilot project,took part in the final Lessons Learned workshop in Khartoum. In July 2006,once the acceptability study had been completed, a small ‘Lessons Learned’workshop was also held in Nyala. Many nutritionists from the Federal MOH,who were not involved in this pilot project, took part in the final LessonsLearned workshop in Khartoum. This exercise brought up several usefulsuggestions that could be used for improving and scaling up this project or infuture Rahama projects.Issues and Lessons LearnedImprove Customs Clearance:More attention must be paid to ensure the smooth passage through customs ofpremixes in order to ensure timely delivery. Staff need to work in advance withcustoms officials while, in the longer term, work may be needed to help amendcustoms clearance regulations to ease the import of micronutrient powdersand premixes for food fortification.Integrate premixes with the general food basket:Once the premix cleared customs, a further delay occurred in transporting thepremix to Nyala. In future, it will be important to advocate in advance forpremixes and micronutrient powders to be considered as part of the generalfood basket, so that it can be transported using the existing transport systems.Using indigenous organisations like the SRCS, already involved in camplogistics, to distribute Rahama along with the general ration and to train andsensitise the population on the use and effectiveness of Rahama can greatlyadd to the sustainability of the project.Select ferrous fumarate for use in areas with high temperature andhumidity:During the distribution of the premix into individual containers, black spotswere found in the premix. After analysis, it was found that this was due to thefact that the chemical company used ferrous sulfate as the iron compound,which may show colour changes when exposed to excessive heat and humidity,despite good quality packaging. As this may affect acceptability, wheresupplies run the risk of exposure to extreme heat and humidity, orders forsuch supplies must specify the more stable (but more expensive) ferrousfumarate compound as the form of iron, as it is much less sensitive to heat andhumidity.Extend the expiry date of premixes to improve their utility in emergencies:The standard expiry date on this product is 6 months. However, in order tomaximise the value of this product in emergency settings, the shelf-life of thepremix needs to be increased to a minimum of 12 months.Intensify field level IEC and monitoring:Briefing at the beginning of the project, as part of the process of obtaining theinformed consent of families in the camps for participating in such an intervention,needs to be improved and intensified in future. In this instance, 191/3973families in the blanket distribution refused to use the premix, as they did notreally understand what it was for and wanted to know why it was “only”being given to the IDP population and not the local population. Five families(2% out of a total of 250 families taking part in the efficacy study) used theirentire month’s supply of premix in one week, as they used it in every meal, notjust once a day. Although this did not result in any adverse effects on the healthof any of those families, it demonstrated the need for more intensive informationeducation and communication to ensure 100% correct use.Costing:The overall cost of this pilot project was roughly $150,000 Canadian dollars.However, much of this was spent on ‘pilot’ activities, such as the developmentof protocols, carrying out the acceptability study, etc. We estimate that the costof distributing Rahama using an existing distribution system, would be lessthan $45,000 a year for 30,000 people, or less than $1.50 per person per year.ConclusionsThe feasibility study shows that even in a challenging environment such asDarfur, with ongoing security-related issues, that it is possible to conduct thistype of project with the right partners on the ground. To achieve 90% acceptabilityof a new product in an IDP camp is very encouraging, and MI is excitedby the possibility of expanding such a project to other parts of Sudan and/orto other displaced populations in Africa.For further information, contact: Erin Tansey, email: etansey@micronutrient.org.zaSRCS volunteers in an IDP campTraining on using the HemoCueA mother receives a pot of RahamaA group of boys living in the IDP campE Tansey/MI, Sudan, 2006E Tansey/MI, Sudan, 2006E Tansey/MI, Sudan, 2006E Tansey/MI, Sudan, 200626

Agency ProfileMuslim AidBeneficaries of Muslim Aid’s operationsName Muslim Aid Director(s) Saif Ahmad CEOAddress PO Box 3, London E1 1WP Year formed 1985Telephone +44(0)20 7377 4200 Main office UKFax +44(0)20 7377 4201 Overseas staff (no) NumerousWebsite http://www.muslimaid.org HQ staff (no) 39 permanent, 13 temporaryThe ENN interviewed Hamid Azad,the Head of Overseas programmesin Muslim Aid (MA) for this issues’agency profile slot. Muslim Aidheadquarters is located at the business wing ofthe London Muslim Centre (LMC) next to theEast London Mosque in Whitechapel, Londonand sits amongst as international an array ofrestaurants, coffee bars and shops as you couldwish to see.Hamid started by telling me a little bitabout himself. Trained as a lawyer and witha long-standing interest in development andhumanitarian work, Hamid joined ‘FaithRegen UK’ as a development manager. He thenmoved from housing and regeneration to headof community development and internationalprojects. Following the Indian Ocean Tsunamiin 2006, MA approached Faith Regen UK to helpwith their work in the region and Hamid wasseconded as a consultant to work as the tsunamico-ordinator. Hamid stayed on, heading up therehabilitation programme working mainly onshelter and housing in Somalia, India, Indonesiaand Sri Lanka. In 2006, Hamid accepted thehead of overseas programme post in MA.MA was established in 1985 in response tothe Ethiopian famine, with 23 Muslim organisationscoming together to form the one entity.Yusuf Islam (otherwise known as Cat Stevensfor those of us the wrong side of 50) set up MAand was its first chairman. MA currently worksin 74 countries and has field offices in 12 of theseincluding Sri Lanka, Pakistan, Iraq, Somalia,Sudan, Lebanon, Dubai, Bosnia, Cambodia andGambia. New field offices are also about to beopened in the Philippines, India, Canada andMalaysia, with the latter two mainly having afund raising role.MA is an international relief and developmentagency with its roots in the humanitarian teachingsof Islam. As Hamid explained by citing the27Qur’anic verse ‘“and whosoever saves the lifeof one, it shall be as if he had saved the life of allmankind” is the ethos that underpins the wayMA operates.’Until recently, MA has largely depended onprivate donations from Muslims for the majorityof its funding. Hamid explained that lookingafter the needy is a central element of Islamiclife and that this creed operates irrespectiveof race or colour. Since it’s inception, privatefunding has come from three sources. Zakat –where every well-off Muslim pays 2.5% of theirsurplus income, Fitra – which is normally paidin the month of Ramadan and is obligatory forall Muslims, and Qurbani (animal sacrifice)where every year in the month of Dhul Hujjarich Muslims sacrifice animals to feed the poor.In 2006, MA distributed more than £418,000for the Ramadan programme and £430,000 forthe Qurbani programme which, with the helpof 110 partner organisations and field offices,provided food to people in over 60 countries -most of whom would normally have very littleopportunity to consume meat.However, since the Pakistan and Kashmirearthquake in 2005 and the December 26thtsunami the following year, MA’s funding basehas widened considerably with UNDP, UNHCR,WFP, World Bank and Asian Development Bank,CARE and CAFOD now numbered amongst itsfunding partners. In 2005, the total income forthe year rose to £9.8 million, compared to only£4.8 million in 2004.Hamid explained that MA has been involvedin most humanitarian sectors including fooddistributions, water and sanitation, health andmedical support, education, livelihood, shelterand construction and emergency support. MAhas provided food aid packages in countrieslike Niger, the Philippines and the horn ofAfrica and also implemented selective feedingprogrammes with partners. MA has also becomepioneers of a programme referred to as ‘FoodBank’. This type of activity started in Sudan inpartnership with Sudan Airways and varioushotels. It involves utilising food that wouldotherwise be thrown away. Volunteers collectthe food and distribute it to the urban poorand street children. The scheme has also beenexpanded to include supermarkets and foodmanufacturers as food sources. MAs approachto food insecurity is very much developmental,i.e. they see nutrition as part of livelihoods sothat as soon as an emergency is over, the focusswitches to promoting sustainable livelihoods,e.g. providing tools and livestock.In their London HQ, MA has certain technicalspecialists, e.g. water experts, but no nutritionists.MA prefers to work through specialistagencies. In the recent Pakistan floods, theyworked through partners that were expert inwater purification. MA has a large cadre ofvolunteer staff (often students and businessmen/women). At the same time, their paid staffbase is also large - around 2000. In the recentIndonesia crisis, as many as 1500 volunteerswere employed to implement the response –most were students and many were unemployedengineers. The Jakarta office is now fully runby volunteers, with the head of office being abusinessman who does not want payment.In countries where there is no field office, e.g.India, MA work via partner agencies like TamilNadu relief agency. MA signs a memorandumof understanding with the partner agency oncethey have confidence in the agency. Partneragencies will sometimes apply to an MAregional office, e.g. Calcutta agencies appliedto the Bangladesh field office. In Indonesia(pre-field office), MA worked post-tsunamiwith local partners identified by government.When an emergency developed in Niger, MAsent a delegation from HQ who identified localimplementing partners. As Hamid said “MA

Field Articletry to eliminate the causes of disasters byworking through, and building capacity of,local partners who can then get involvedin disaster prevention and preparedness”.MA has recently tightened up partnershipcriteria.MA is continually learning. Hamid feltthat the quality of emergency food and nutritionprogrammes has improved significantlywith experience, particularly with regard tofood distribution and management. There isalso now a far greater awareness and focuson making programme sustainable. Thus,food aid is always implemented in conjunctionwith seeds programmes. Distributionof milk products as part of selective feedingmay be accompanied by provision of cowsand training in how to pasteurise milk.While MA is not a Disasters EmergencyCommittee (DEC) member, it does deliverDEC programmes via agencies like Oxfam.Oxfam helped MA source funding of £2.3from the DEC for housing and livelihoodprogrammes for the victims of the tsunamiin Indonesia, Somalia and Sri Lanka. MA isalso a signatory to the IFRC and SPHEREprinciples.In response to a question about whatsets MA apart from other agencies, Hamidsingled out the fact that all field officesendeavour to employ almost exclusivelylocal people (99%) and that there is a hugepool of dedicated volunteers that implementprogrammes. He also highlightedtheir enormous private donor funding base,e.g. more than 7000 individuals in the UKalone.MA is nothing if not ambitious. Long termgoals include “becoming a significant playerin poverty alleviation by 2015”. They aim toachieve this by targeting a few countrieswhere they already have field offices.Hamid cited a number of challenges forthe organisation. These included obtaininglonger-term institutional funding, overcomingpreconceptions about a ‘Muslimorganisation’ – MA is humanitarian andserves anyone affected by crisis or poverty,and the fact that competition for fundingappears to be getting greater.In response to a question about what itis like for a Muslim organisation to workin the UK, Hamid felt that while dealingswith the UK Department for InternationalDevelopment (DFID) have so far beenoverly bureaucratic, their relationship withUK agencies like Oxfam, CAFOD and CAREInternational are thriving. As Hamid put it“any agency that gets to know MA ends upbecoming a friend of MA.”Given the current climate around Islamand the Muslim world in the UK and westin general, MA presents an interestingchallenge for the humanitarian sector. Theagency operates in some of the most difficultareas of the world and yet delivers aidto enormous numbers of needy people. Thechallenge for humanitarian stakeholderswill be to increasingly engage with, supportand cooperate with agencies like MA whoclearly occupy a unique niche and have acritical role to play in future humanitarianand developmental work.Impact of non-admission onCTC Programme CoverageBy Saul Guerrero, Valid InternationalThis article presents the findings of a preliminaryanalysis by Valid International of questionnairesand Centric Systematic Area Sampling (CSAS)surveys implemented in seven countries by a varietyof agencies and organisations, with a view to investigatingthe impact of non-admission on estimates ofCTC programme coverage.The desire, and proven capacity, todeliver high programme coverage hasbeen one of the main forces behind theshift from centre-based treatment tocommunity-based nutrition programming. Assuch, programme coverage has become, alongsidemortality, recovery and defaulting rate, oneof the primary indicators of programme success.Increasingly, community-based programmes– and Community-based Therapeutic Care(CTC) interventions in particular – are includingcoverage surveys as an integral part oftheir monitoring and evaluation procedures.The Centric Systematic Area Sampling (CSAS)method in particular, has produced usefulinformation by exploring the spatial dimensionof coverage data. Less known, however, isthe fact that these surveys have also been keyin enhancing our understanding of the reasonsfor non-attendance, or the barriers to access thathinder higher programme coverage.Over the last few months, data from questionnairesconducted as part of CSAS surveysA mother with herchild attending theOPT in Awassa,EthiopiaSaul Guerrero is a Social and Community Development Advisor workingfor Valid International. Over the last four years, he has assisted inthe design, implementation and evaluation of community mobilisationstrategies for Community-based Therapeutic Care (CTC) programmesin Ethiopia, North and South Sudan, Malawi, Zambia, Niger, DRC andIndonesia.have been collected and analysed. The analysishas been conducted by Valid International,with support from Concern Worldwide, withdata from CTC programmes implemented byagencies such as Save the Children-UK, Savethe Children-US, Concern Worldwide, Merlin,GOAL, COOPI, World Vision, InternationalMedical Corps, and UNICEF as well as Ministriesof Health. This comparative analysis, acrossdifferent programmes and countries (Ethiopia,Sudan, Malawi, Niger, Kenya, Burundi andDemocratic Republic of the Congo), has startedto reveal clear trends in health seeking behavioursand programme attendance. The mostimportant result has been the importance ofcarers’ first experience with a community-basedprogramme in determining their subsequentwillingness to re-visit the sites, either voluntarilyor when referred. Results show that one inevery three malnourished children not enrolledin CTC programmes have refused to go followinga negative experience of rejection at anearlier date.This article discusses the role of qualitativeanalysis in identifying the impact ofrejection before describing some of the processesinvolved in rejection, and its transformationfrom a routine part of screening and referralsinto one of the primary barriers to access. Thearticle concludes by calling for ‘rejection’ tobe addressed proactively in order to ensureoptimal programme coverage.Valid International, Ethiopia, 200528

Field ArticleAccess and the Importance of Coveragein (Emergency) Nutrition ProgrammingAccess to emergency nutrition programming isa multidimensional problem, which involvesissues as pragmatic as distance between communitiesand programme sites, to the more subtle(but equally influential) aspects of awareness,local perceptions, acceptability of the bio-medicalapproaches and socio-cultural norms andtaboos. The identification of ‘a barrier to access’has been an integral part of CTC programmingsince its early days. Initially, ‘barriers to access’were mostly identified qualitatively – throughinformal dialogue with programme staff, localleaders and carers. The informal analysis rapidlygrew into more concerted and organisedefforts, such as rapid socio-cultural assessments(often referred to as ‘anthropological studies’),to identify barriers to access. These assessmentsbegan to shed light on some of the commonalitiesthat affected CTC programmes intra andinter-nationally. For the first time, cross-culturalexamination of these barriers became possible.This more formal qualitative analysis wasinstrumental in the identification of trends incommunity perceptions and responses to CTCprogrammes. Awareness about the programme,treatment at the sites, local perceptions of malnutrition,acceptable forms of treatment (vis-à-visFigure 1% (of total non enrolled)CTC services), distance to the sites, and rejectionwere all identified as qualitative factorsinfluencing CTC programme performance longbefore their quantitative impact on programmeindicators was known.The introduction of CSAS coverage surveyswas partly a reflection of the need to knowhow efficiently barriers to access were beingaddressed by the new community-based model.Coverage thus became one of the primarymeasures of programme success.CSAS offered the first quantitative look intothe precise impact of rejection on programmes.Since 2004, CSAS surveys have included aquestionnaire survey to be conducted withcarers of severely malnourished children notenrolled in the programme. The survey aimsto identify common barriers to access, so as toinform mobilisation activities. The surveys havegone through a process of iterative change, soas to create a template for widespread use thatalso allows context-specific variations to beadequately represented. The standardisation ofthe questionnaires has allowed for comparativeanalysis between the programmes – for trendsto emerge, and for issues that were known tobe crucial in ensuring success in particularprogrammes to be substantiated with evidencefrom different countries and different contexts.Previous rejection of a child from the programme (% of total unprompted reasons givenfor non attendance)Figure 2 Previous rejection of a ‘known’ child from the programme (% of total unpromptedreasons given for non-attendance)%CTC Ethiopia(South Wollo,2005)CTC South Sudan(Bahr-el-Ghazal,2004)CTC Ethiopia(W. Hararghe,2004)CTC Ethiopia(Boricha, 2006)CTC Niger(Maradi, 2005)CTC Kenya(Wajiir, 2006)CTC Ethiopia(Wag Hamra,2006)CTC Ethiopia(Konzo, 2006)CTC Malawi,(Lilongwe 2006)CTC Malawi,(Mangochi,2006)CTC DRC(Ituri, 2006)CTC Niger(Maradi, 2007)CTC Burundi(Muyinga, 2007)In this new exploration of issues behindcoverage, no other issue has proven to be assignificant as previous rejection of a child fromthe programme. Understanding the elementsthat contribute to rejection and its actual impacton programme performance is crucial in therequired efforts to curb its negative impact oncoverage.How Rejection Comes About: Factorsthat Increase or Decrease RejectionThe issue of rejection is closely linked to theways in which communities get to know aboutthe programme and are encouraged to seekhelp. In CTC programmes, there are three differentways in which this can happen; communitysensitisation; active case-finding, and informalcommunication through word of mouth andself-referrals. Each of these three channels helpsensure high admissions, yet the way in whichthey are managed and organised determineswhether the rates of rejection are high or low.Optimal community sensitisation, forexample, focuses on the use of concise and clearmessages about the target population – usingcontext-specific descriptions that communitiescan understand. Although people will try theirluck, the clearer the sensitisation process is,the higher the rate of eligible children that willturn up at the sites (and the lower the rejectionrate). Low levels of inappropriate attendance,also ensures that programme staff have time toexplain why a child is being rejected, and clarifythat the child can return if their condition deteriorates.Conversely, mass sensitisation processes– aimed at attracting all children for screening –may be tempting in emergency situations withhigh mortality rates. Yet, mass sensitisation andscreenings raises unrealistic expectations. It alsoleads to high levels of rejection, whilst reducingthe time available to programme staff to explainclearly the potential eligibility of the child at alater date.Active case-finding also has the potential ofreducing the number of non-eligible childrenturning up at the sites. However, until recentlythe use of Middle-Upper Arm Circumference(MUAC) as a referral criteria and Weight forHeight (WfH) as admission criteria meant thatmany referred children (particularly youngerchildren at high mortality risk) were turnedaway at the sites. The eligibility of a child onthe basis of one and not the other is confusingto carers, and demands closer attention on thepart of programme staff. Explaining the differencehas consistently proved to be problematicand unsatisfactory, thus accounting for much ofthe frustration and ‘negative feedback’ created.Informal communication (‘word of mouth’)has also proven to be one of the most importantvectors for the exchange of ideas aboutprogramme activities. Its impact, however,is equally dependent on the experiences ofcommunity members with the programme.‘Word of mouth’ is a double-edged sword – a‘good’ programme will have positive ‘wordof mouth’, while a ‘bad’ programme will havenegative ‘word of mouth’. The admission andrapid recovery of children on Ready-to-useTherapeutic Food (RUTF), for example, is apowerful motivator for people to seek assistance.Rejection, on the other hand, has proven tobe just as powerful in discouraging communitymembers from accessing programme services.In Niger, for example, perceptions that theprogramme rejected large numbers of children29

Field Articleled to ‘fear of rejection’ as one of the primaryreasons for the non-attendance of malnourishedchildren. In other programmes, the rejection offamily members or neighbours has also becomemanifest in programme coverage. The preciseimpact of negative feedback in a communityvaries, but as the following section reveals, thisis sufficiently important to warrant close attentionby programme implementers.The Impact of Rejection on ProgrammeCoverageThe first series of analysis was based on 14questionnaires used in an equal number of CTCprogrammes across seven countries (Ethiopia,Sudan, Malawi, Niger, Kenya, Burundi, andDemocratic Republic of Congo). The resultsshow a series of factors that affect programmecoverage including distance to sites, knowledgeabout the programme and perceptions ofthe child’s health. More significantly, in termsof frequency and impact, is previous rejectionof children from the programme. In virtuallyall the programmes surveyed, mothers ofmalnourished children who have been previouslyturned away from the sites (either due toimproper anthropometric readings, or failure tomeet the criteria at the time) consistently refuseto take their children for subsequent screening.On average, previous rejection accounts for 1in every 3 malnourished children not attendingthe programme. This means that the issueof rejection is responsible for a decrease of over35% of programme coverage in the sampleprogrammes surveyed.The issue of rejection has wider repercussionsin the communities. Rejection of a ‘known’child (of the same family and/or community)also impacts on programme coverage. In fiveof the 14 programmes surveyed, rejection of aknown child decreased programme coverageby an average of 5%. In these programmes, thecombined rejection of a child and a known childreduced coverage by 42.23%.Rejection and non-admittance also has anequally negative effect on community mobilisationactivities. Case-finding and sensitisationvery often relies on trust – trust in the volunteersresponsible for identifying and referring cases,and in the community figures that mobilisecommunities to seek care. Whilst the admissionand rapid recovery of children in the programmeserves to strengthen the trust in these actors,rejection and lack of understanding about thereasons for rejection serves to erode the trust,and in many cases, alienate these actors fromthe communities in which they work and live.This in turn de-motivates workers and createsresentment which very often manifests itself inthe form of decreased referrals or a completecessation of case-finding activities in some areas.This means that children may only turn up lateat the sites thus negating the advantages of earlytreatment that allows the bulk of cases to betreated in Outpatient Therapeutic Programmes(OTP) rather than stabilisation centres.Addressing the Issue of RejectionRejection and the discontent often associatedwith it will always play a part in nutritionprogrammes. Limiting or reducing its effectson programme performance, however, is possible.This requires, above all, recognition of theimportance of rejection (and all factors associatedwith it) on programme performance, anda commitment to implementing the necessarysteps to curb its impact. Whilst the requiredsteps are likely to vary from context to context,there are three fundamental steps that haveproven to help address the incidence and impactof rejection.Standardising referral and admission criteriaMUAC has been used as referral criteria in CTCprogrammes for some time. Yet, only recentlyhas it also been introduced as admission criteria.The effects of this dual use have been positive– leading to a reduction in the numbers ofchildren turning up at the sites inappropriately,and an increase in the proportional enrolmentof those who do arrive.Explaining admission and rejection to carersAnthropometric errors will continue to leadto ‘false positives’ presenting at the sites. Thedecrease in the overall numbers of childrenattending the sites would allow programme staffto dedicate time to the crucial task of explainingthe reasons for rejection. Furthermore, theability of carers to return to sites for furtherscreening (e.g. if the child’s condition deteriorates)must also be part of this process.Monitoring community perceptionsAt a community level, mobilisation workersneed to constantly monitor communityattitudes towards the programme, so as toidentify negative feedback at an early stage.When discontent and fear of rejection manifestthemselves and start to hinder carer’s compliancewith referrals, community outreachworkers must devote time to explaining thereasons for rejection and the risks associatedwith non-compliance. The role of communityleaders in restoring trust in the programme hasalso proven to be critical.For further information, contact SaulGuerrero, email: saul@validinternational.orgValid International, Ethiopia, 2005Queing at the OTP inDowa, Malawi30

Field ArticleL Machibya/UNHCR, Tanzania, 2007A breastfeeding corner in oneof the camps in TanzaniaBreastfeeding support in the refugee campsof North Western Tanzania By Lucas Kulwa MachibyaLucas Machibya has been working for UNHCR since June 1994in the north-western Tanzania refugee operation as NationalPublic Health Nutrition Officer. His scope of work has includedthe promotion and protection of breastfeeding, infant andyoung child feeding in the context of HIV/ AIDS and managementof both moderately and severely malnourished children inthe refugee camps.The author would like to acknowledge the contributionsof the following organisations to the work reflected in thisarticle: Tanzanian Red Cross Society, Norwegian People’sAid, International Rescue, The International Baby FoodAction Network (IBFAN) – Africa, UNICEF and WFP NorthwesternTanzania, ENN, CARE International and UNHCRHeadquarters.This article describes UNHCR’s experiences ofsupporting breastfeeding in a refugee camp setting,and how the ‘breastfeeding corners’ initially establishedevolved into community based supportapproach.The refugee operation of north-westernTanzania has been ongoing for 12 years.Burundian refugees were displaced bypolitical and ethnic turmoil sparkedby the assassination of the Hutu PresidentMelchoir Ndadaye, followed by massacres in1993, and a coup in 1996. Intensification of theconflict in some provinces and the policy ofre-grouping the community in Burundi generatedsubsequent waves of refugee influx intoTanzania from 1996 to 2004. With regards tothe Democratic Republic of Congo (DRC), threemain rebel groups and numerous militia beganfighting over a complex mix of economic, ethnic,state and factional interests, leading the countryinto a devastating humanitarian crisis in 1996.In December 2006, the North WesternTanzania refugee operation was managing atotal of 282,389 refugees, from Burundi (154,412)and DRC (127,967). The refugees are located in11 refugee camps in four districts; Ngara district(Lukole camp), Kibondo district (Mtendeli,Kanembwa, Nduta and Mkugwa camps),Kasulu district (Nyarugusu, Muyovosi, MtabilaI and II) and Kigoma rural district (Lugufu I andII). In June 2006, UNHCR launched a repatriationprogramme for Burundian refugees,currently implemented in Kasulu, Kibondo andNgara refugee camps. A repatriation schemefor Congolese refugees in Kigoma rural andKasulu districts is ongoing. By December 2006,a total of 16,503 Congolese refugees and 41,908Burundians refugees had been repatriated totheir countries of origin.UNHCR’s position on infant and youngchild feedingUNHCR seeks to protect and support optimalinfant and young child feeding practice in itsoperations, which includes establishing exclusivebreastfeeding among newborn infants, protectingand supporting exclusive breastfeeding forthe first six months, timely and appropriatecomplementary feeding, and continued breastfeedingfor at least the first 2 years of life. Thisis reflected in UNHCR’s policy on the accep-1Policy on the acceptance, distribution and use of milkproducts in refugee settings (2006). Available in English andFrench. Download from http:///www.unhcr.org or http://www.ennonline.net Contact: ABDALLAF@unhcr.org or HQTS01@unhcr.org2An interagency collaboration developing policy guidance andcapacity building on infant and young child feeding in emergenciessince 1999. See online at www.ennnonline.net/ife3More detailed coverage of UNHCR and partners’ experiencesin managing artificial feeding in refugee settings, largely in thecontext of HIV/AIDS, will be shared in a later issue of FieldExchange.Box 1Feeding difficulties experienced by mothersBox 2Breastfeeding support in the breastfeeding corners• Mothers with twins and triplets had a feeling ofproducing inadequate breastmilk.• Mothers with lactation problems (who felt theycould not produce enough breastmilk to suckle thebabies).• Mothers with low birth weight babies.• Newborn infants where the mother had died inchildbirth.• Mothers with sore or cracked nipples.• Young mothers, i.e. girls aged below 18 years whohad given birth (‘early pregnancies’).• Babies rejected by their mothers• Mothers opting not to breastfeed their babies due totheir health status.• Mothers severely ill.Counselling of mothers facilitated identification of problems or poor practices related tobreastfeeding, such as poor attachment of infants during breastfeeding. Women were verywilling to discuss difficulties - mothers of more than one child often giving examples ofthe difficulties they had encountered while breastfeeding their firstborn. Mothers had lessknowledge related to effective breastfeeding and often breastfed from the second breastwithout emptying the first. Often mothers who conceived while breastfeeding immediatelystopped breastfeeding.Mothers were taught on the importance of breastfeeding the baby during the night, wheneverthe baby wanted to feed and what signs to look for that indicate a baby wanted to feed.Breastfeeding women were taught how to watch for the signs of the ‘full’ breastfed baby wherethe baby suckles until he/she releases the breast him /herself and look satisfied or sleepy.To achieve this, the baby should suckle one breast for enough time to ensure the baby alsoconsumes enough hind milk.It was important to emphasise the recommendation to breastfeed exclusively for six months, toupdate on the previous recommendation of 4-6 months with which many were familiar.31

Field Articletance, distribution and use of milk products inrefugee settings 1 , which was updated in 2006in close collaboration with the IFE Core Group 2 .This article focuses on UNHCR’s experiencesin protecting and supporting breastfeeding in arefugee setting 3 .The camp contextBreastfeeding was considered ‘natural’ amongthe Rwandans and Burundian women whogave birth in the refugee camps. However, somemothers of newborn infants were reporting difficultiesthat were heightened during emergencysituations, when mothers often presented to thecamps devastated and dehydrated (see box 1).Initially, systematic breastfeeding counsellingwas not carried out as part of the refugee operation.However in 1998, the camps experienceda severe epidemic of malaria, leading to severeanaemia among pregnant women and resultingin a high prevalence of low birth weight infantsreaching as high as 35 per 1000 live births. Thefoetal death rate was estimated at 45.6/1,000births, neonatal mortality was 29.3/1,000 livebirths and both neonatal and maternal deathsaccounted for 16% of all deaths. This situationhighlighted the urgent need for breastfeedingsupport targeted particularly at newborninfants.Breastfeeding cornersA programme was established to protect, supportand promote breastfeeding of newborn babies inaccordance with WHO and other stakeholders 4 .This took the form of ‘breastfeeding corners’that were established by humanitarian agenciesworking in the camps. These comprised rooms/areas located around the health facilities wherebreastfeeding women with feeding difficultiescould come for support. At these facilities, thewomen were given breastfeeding assistance,and taught about infant feeding, personalhygiene, and ways to cook for themselvesand their families. Babies were monitored toexclude any medical conditions that mightaffect breastfeeding. Attending women weregiven one family meal and one cup of porridgethat was prepared at the kitchen in the healthfacilities. By February 2000, all health facilitiesin the camps in North Western Tanzania hadimplemented breastfeeding corners.At the camp reception centres, ‘at risk’groups were identified, including breastfeedingmothers who arrived in a poor condition– many presented dehydrated due to walkinglong distances without water or food. Medicalscreening was undertaken by humanitarianagencies. Mothers who delivered on the waywere immediately registered for the breastfeedingcorners, along with prima gravida(first-time mothers) and other women withlactation problems.At the breastfeeding corners, newly arrivedmothers who showed a lack of confidencein breastfeeding were supported throughcounselling and encouragement (see box 2).The counselling was geared towards restoringlost competencies and building psychologicalmorale. In the camps, prima gravida were themost common group to have low confidence inbreastfeeding. As well as breastfeeding support,mothers were advised on the importance ofeating adequate food and drinking safe andclean water. They were also encouraged to usethe improved cooking stoves, as fuel was noteasily available and collecting wood involvedwalking long distances and was risky. This wasconducted in conjunction with the agenciesworking on the environment, camp managementand in community services. Mothersmostly attended the corners for three to fourweeks.Through health screening, babies or womenwho were ill were identified and treated accordingto the Ministry of Health case definition andprotocol treatment. Most mothers and babieswere found to have malaria and related fever;and mothers suffering from tiredness, lost confidenceand stress. The breastfeeding cornerswere also used to capture all postnatal womento ensure that they had postnatal checkups,that the infant was vaccinated and to establishgrowth monitoring. Vitamin A was given tothose women who had not received it immediatelyafter delivery. Women with a Body MassIndex (BMI) < 18.5 were admitted to the supplementaryfeeding programme (SFP). Howeverthis was discontinued at the end of 2001 due toa reduction in resources.Family disintegration is a common problemin emergencies. Women are left with severalchildren to take care of, making it difficult tojuggle breastfeeding a baby and look for foodfor the older children. The value of maintaininggood family relationships was emphasised.Babies whose mothers could notbreastfeedWhere an infant could not be breastfed by his/her mother (based on established criteria), theimplementing agencies worked together withthe community to identify a “wet nurse” tobreastfeed the baby – an approach that wasalready traditionally practiced. Where a wetnurse could not be identified or in the interim,infant formula or diluted therapeutic milk(F-100) were given to the infants. This necessitatedadmission of the infant together with his/her caregiver to phase 1 of a therapeutic feedingprogramme. Using diluted F100 was not idealas it was not designed for this purpose and itwas a challenge to decide on the most appropriatedilution.The use of breast milk substitutes in thisrefugee programme requires close monitoringand a careful procurement system is in placeamong the health and nutrition agencies in therefugee camps. Within the camps, infant formulais part of the pharmacy items with a smallbudget line, and is procured in line with drugsand other medical consumables. The nutritionistis responsible for providing the specifications,which includes labelling in the appropriatelanguage (English or Swahili). Careful estimationof the projected quantity is based on variousreporting indicators including the rate of maternaldeaths, early pregnancies from teenagers,prevention of mother to child transmission ofHIV/AIDS to babies, the number of womenopting not to exclusively breastfeeding theirbabies and the capacity of the agency to adhereto acceptable, feasible, affordable, sustainableand safe criteria (AFASS) 5 . In this regard, theNational Breastfeeding Policy is also respectedand followed accordingly.Review of the breastfeeding cornersIn early 2001, the breastfeeding corner approachat the health facility level was reviewed inconsultation with beneficiaries and humanitarianworkers involved in the health and nutritionprogramme, including WFP and UNICEF. Thefollowing concerns were raised:• The majority of lactating women admittedto the breastfeeding corners were having ababy for the first time. This suggested thatinadequate advice and support on successfulbreastfeeding was being offered duringpregnancy.• While the beneficiaries found that the servicewas beneficial to them, they expressed theirconcerns about time pressure to attend dailywhile leaving other small siblings at homewithout care.• Staff responsible had inadequate time tospend with mothers to provide the requiredsupport and advice they needed.• There may be enough capacity for supportin the community rather than at the healthfacility to support lactating mothers, especiallyfor those delivering for the first time.• Increased number of admission to breastfeeding corners due to increased earlypregnancies meant that staff felt overwhelmedby the situation.• There was a risk of cross infection whileattending daily breastfeeding corners.4Breastfeeding and healthy eating in pregnancy and lactation:Report on a WHO workshop; Arkhangelsk, Russia Federation,5 – 8 October 1998. WHO Regional Office for Europe.5WHO HIV and Infant Feeding Technical Consultation ConsensusStatement. Held on behalf of the Inter-agency Task Team (IATT)on Prevention of HIV Infections in Pregnant Women, Mothersand their Infants. Geneva, October 25-27, 2006. Availableat: http://www.who.int/child-adolescent-health/publications/NUTRITION/consensus_statement.htmBox 3Supplementary feeding programme and breastfeeding womenBox 4Training materials usedThe supplementary feeding programme (SFP) supports pregnant womenwith a food premix comprised of 200 grams of Corn Soy Blend (CSB), 20grams of sugar and 20 grams of cooking vegetable oil, providing approx1009 kilocaloriesFollowing a Joint Assessment of UNHCR and WFP in 2004, it wasrecommended to increase the food support to pregnant women from 2weeks to three months post delivery. Subsequently the joint assessmentsof 2005 and 2006 recommended an extension of food support tolactating women to six months post delivery in order to align with the 6months exclusive breastfeeding policy. Due to resource constraints, thisrecommendation has not been effected.Module 1 Infant Feeding in Emergencies for emergency relief staff, WHO,UNICEF, LINKAGES, IBFAN, ENN and additional contributors, November2001. http://www.ennonline.net/ife/module1/index.htmlModule 2 for health and nutrition workers in emergency situations.Version 1.0. December 2004. ENN, IBFAN, Terre Des hommes, UNICEF,UNHCR, WHO, WFP. http://www.ennonline.net/ife/module2/index.htmlBreastfeeding Counselling: A Training Course, materials online http://www.who.int/child-adolescent-health/publications/NUTRITION/BFC.htm- National Breastfeeding Policy.32

L Machibya/UNHCR, Tanzania, 2007To address these, a workshop was called inMarch 2001, in Kibondo that brought togetherMedical Coordinators, Medical Doctors,Nutritionists, Reproductive Health Managers /Officers and Community Services Coordinators.The following recommendations were made:• A strategy to be developed to incorporatesupport to breastfeeding mothers in thecommunity through mothers supportgroups and outreach activities.• UNHCR and IP’s medical and nutritionteams to identify specific activities andplans of action to successfully implement acommunity based approach to supportbreastfeeding of infants and feeding youngchildren.• Collaboration to be strengthened betweenMaternal and Child Health (MCH) services,community services, health informationteams, traditional birth attendants (TBAs),nutritionists and medical staff in order toprovide holistic support through the cycleof the pregnancy and through the periodof continued breastfeeding (i.e. up to 24months of age).• UNICEF to provide additional in-servicetraining, including health education andbreastfeeding management.• Given the benefits of the current SFP forpregnant women, WFP were requested toextend supplementary feeding to all lactatingwomen until six months post delivery,but this has yet to happen (see box 3).• Breastfeeding corners for the majorityshould not continue at the health facility butshould gradually be integrated into thecurrent MCH activities and the community.Only those few mothers with medicalproblems and low birth weight babies whocannot be managed at home should beadmitted to the health facility for breastfeedingmanagement.33A mother breastfeeding heryoung baby supported in abreastfeeding cornerCommunity based approach to supportbreastfeedingThe community based approach that was adoptedfollowing the workshop recommendationsfocused particularly on the protection, supportand promotion of exclusive breastfeeding ininfants under six months of age. The followingsteps were followed:• There was a gradual phasing out of thebreastfeeding corners from the health facilitiesin tandem with training of communitybasedworkers on infant and young childfeeding. Those trained, in turn, trained theircolleagues in the community. Collectivelyconsidered as ‘breastfeeding promotingagents’, they included community healthworkers/health information teams, traditionalbirth attendants, women representativegroups, home based care service providers,traditional healers and religious leaders.• The breastfeeding promoting agents werekey to the community based approach. Theyadvocated and supported exclusive breastfeedingand proper practices during breastfeeding,and appropriate and timelycomplementary feeding. They also addressedpsychological and moral support, includingthe importance of family unity in relationto breastfeeding and care of the infant andyoung child in general. They were alsoassigned various streets/blocks/villages ineach camp to assist and support womenwho were breastfeeding.• Existing women’s income generation groupssuch as weaving groups, basket makinggroups, kitchen gardening groups, andrestaurants groups along with groupsinvolved in artisan activities were targetedby breastfeeding promoting agents. Newmothers were encouraged to join thesegroups, so that they could benefit both fromthe income generated and receive breastfeeding support.• Cooking demonstrations were conductedto encourage preservation of nutrientsduring preparation and cooking. Motherswere taught about food preservationtechniques and the importance of kitchengardening activities that would support andsupplement their household food security.• Related topics included the importance offamily hygiene and promotion of goodhealth in the family, how to clothe and bathethe baby, and how to access safe and cleanwater in the camps for drinking and whenpreparing and cooking of their family foods.The community based staffalso promoted proper disposalof babies/children excreta(in this population, children’sexcreta were considered safenot harmful) and educated onthe importance of familylatrines and their propermaintenances and use.Capacity buildingFrom 2001, both the UN andnon-governmental agenciesimplementing the health andnutrition projects in the refugeecamps began coordinating theirapproaches to infant and youngchild feeding in emergenciestraining, based on key trainingmaterials (see box 4).National facilitators from theTanzania Food and NutritionCentre in Dar es Salaam areused for training of trainersField Article(TOTs). The use of national facilitators is crucialbecause it ensures that new developments arerecognised by the government in the sphereof infant and young child feeding, includingbreastfeeding. The local trainers continueto train on the ground. They collaborate andagree on a common work plan to follow whenrolling out training in their MCH centres, outpatientdepartments, inpatient departments,SFPs, TFCs, paediatric wards and at large in the‘villages’ within the camps.Humanitarian workers who are trainedin these courses includes Medical Doctors,Nutritionists, Clinical Officers, Nurse midwives,Nurse Officers, Reproductive Health Managers/Officers, and all nurses working in MCHprogrammes, in feeding centres, and paediatricand maternity/delivery wards.One of the key challenges faced is adequatecoverage of the camp because of frequentturnover of trained personnel exacerbated bythe ongoing repatriation. For example, in onecamp there are only 40 breastfeeding promotingagents, which is not sufficient to cover all villages– there are 52 villages in the camp. Ongoingtraining of newly recruited TBAs and communityhealth workers is therefore paramount.It is also important to expand the skills andknowledge base regarding breastfeeding toother cadres of the staff in the camps, to ensurethat the programme reaches the majority of thebreastfeeding women in the camp’s villages/zones or blocks.Conclusions and recommendationsBreastfeeding corners built around health facilitiesare a valuable intervention during the acutephase of an emergency where a populationis displaced, as most families will have beendislocated from normal support structures.Once the acute emergency period is over, otherservices in the camps are set up and functioningproperly, and the community has re-establishedsome level of support structures, breastfeedingsupport is best implemented as a communitybased approach.For further information, contact: Lucas K.Machibya, Associate Nutrition Officer, email:machibya@unhcr.org, Ms. Fathia Abdala, SeniorNutritionist, UNHCR Geneva,email: abdala@unhcr.org, Dr. Raoufou Makou,email: makou@unhrc.orgA mother supported tobreastfeed her twins.L Machibya/UNHCR, Tanzania, 2007

Editorial teamDeirdre HandyMarie McGrathJeremy ShohamOffice SupportRupert GillDan GeorgeDesignOrna O’Reilly/Big Cheese Design.comWebsitePhil WilksContributors forthis issueSimon KaranjaLucas MachibyaErin TanseyDr. Ibrahim BaniSaul GuerreroGéza HarcziIsabelle DefournyIssaley AbdelkaderGwenola SerouxRebecca NortonJean-Pierre PapartMark MyattMike GoldenGeorge JacobSarah SaunbyBruce CogillPicturesacknowledgementField Exchangesupported by:The Emergency Nutrition Network (ENN)grew out of a series of interagency meetings focusing on food andnutritional aspects of emergencies. The meetings were hosted byUNHCR and attended by a number of UN agencies, NGOs, donorsand academics. The Network is the result of a shared commitmentto improve knowledge, stimulate learning and providevital support and encouragement to food and nutrition workersinvolved in emergencies. The ENN officially began operations inNovember 1996 and has widespread support from UN agencies,NGOs, and donor governments. The network aims to improveemergency food and nutrition programme effectiveness by:• providing a forum for the exchange of field level experiences• strengthening humanitarian agency institutional memory• 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 field levelarticles and current research and evaluation findings relevant tothe emergency food and nutrition sector.The main target audience of the publication are food and nutritionworkers involved in emergencies and those researching thisarea. The reporting and exchange of field level experiences iscentral to ENN activities.The TeamJeremy Shoham (Field Exchange technical editor) andMarie McGrath (Field Exchange production/assistant editor)are both ENN directors.Oliver YunHelen HarrisLucas MachibyaErin TanseySaul GuerreroGéza HarcziAndrew SealDavid StephensonRaphael WeberCecile DehopreAnne YzebeJulien PoublanDebbi MorelloWFP Photo LibrarySusan Markisz, UNICEFGeorge JacobOn the coverMUAC measurement of a child ina camp for displaced Chadians,Koukou, TchadValerie Babize/MSF, Tchad, 2007Rupert Gill is ENNadministrator and projectcoordinator, based in Oxford.Matt Todd is the ENNfinancial manager,overseeing the ENNaccounting systems,budgeting and financialreporting.Dan George is the ENNfinance assistant, workingpart-time in Oxford.Orna O’ Reilly designsand produces all of ENN’spublications.Phil Wilks managesENN’s websiteThe opinions reflected in Field Exchangearticles are those of theauthors and do not necessarily reflectthose of their agency (whereapplicable).The Emergency Nutrition Network (ENN) is a registered charity inthe UK (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, Bruce Laurence,Nigel Milway, Victoria Lack, Arabella Duffield34

Emergency Nutrition Network (ENN)32, Leopold Street, Oxford, OX4 1TW, UKTel: +44 (0)1865 324996Fax: +44 (0)1865 324997Email: 2 office@ennonline.netwww.ennonline.net