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Document 52013SC0072
COMMISSION STAFF WORKING DOCUMENT Addressing Undernutrition in Emergencies Accompanying the document COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL Enhancing maternal and child nutrition in external assistance: an EU policy framework
COMMISSION STAFF WORKING DOCUMENT Addressing Undernutrition in Emergencies Accompanying the document COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL Enhancing maternal and child nutrition in external assistance: an EU policy framework
COMMISSION STAFF WORKING DOCUMENT Addressing Undernutrition in Emergencies Accompanying the document COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL Enhancing maternal and child nutrition in external assistance: an EU policy framework
/* SWD/2013/072 final */
COMMISSION STAFF WORKING DOCUMENT Addressing Undernutrition in Emergencies Accompanying the document COMMUNICATION FROM THE COMMISSION TO THE EUROPEAN PARLIAMENT AND THE COUNCIL Enhancing maternal and child nutrition in external assistance: an EU policy framework /* SWD/2013/072 final */
TABLE OF CONTENTS I. INTRODUCTION.. 3 II. SUMMARY.. 5 1 Background. 7 1.1 The scaleof the
problem.. 7 1.2 Undernutrition
as an increasing global priority. 8 1.3 Undernutrition
in crises. 9 2 Scope of Nutrition
in Emergencies. 10 2.1 The conceptual
framework of undernutrition. 10 2.2. Recent advances
in the management of undernutrition in crises. 13 2.3 Key Challenges
in Addressing Undernutrition in Emergencies. 14 3 Objectives,
Priorities and Principles of The European Commission's Assistance to Nutrition
in Emergencies 16 3.1 Principal
objective. 16 3.2 Specific
objectives. 16 3.3 Strategic
priorities. 16 3.4 Principles that
guide the European Commission's assistance to nutrition in emergencies. 17 4 Operational Scope
of Assistance. 19 4.1 Entry and Exit
Criteria. 19 4.2 Additional
aspects necessary to achieve the European Commission's Objectives. 20 5 Programmatic
Responses. 24 5.1 Health and
Nutrition. 24 5.2 Humanitarian
Food Assistance and Nutrition. 29 5.3 Water,
Sanitation and Hygiene (WASH) and Nutrition. 32 6 Humanitarian and
Development Actors' Shared Concerns. 34 6.1 Chronic
undernutrition (stunting) in emergencies. 34 6.2 HIV/AIDS. 34 The link between
HIV/AIDS and nutrition. 35 6.3 Coherence,
Coordination and Complementarity. 36 Annexes. 39 A.1 List of Abbreviations. 39 A.2 Note on
Technical Terms. 39 A.3 Policies and
Guidelines in Support of this Staff Working Document 42
I. INTRODUCTION
In accordance
with the orientation of the Humanitarian Aid Consensus and to promote best
practice in the provision of humanitarian assistance for nutrition in
emergencies, this Staff Working Document (SWD) is intended to complement
Commission Communication on 'Enhancing maternal and child nutrition in external
assistance: an EU Policy Framework'XXX to increase the effectiveness and
efficiency of humanitarian assistance . In particular, this document seeks to: ·
Clarify
the objectives, priorities and principles of the Commission's humanitarian
assistance for nutrition with regard to populations facing humanitarian crises;
·
Identify
issues and approaches that enhance the effectiveness of humanitarian assistance
for nutrition in humanitarian crises whilst highlighting the necessary linkages
with longer-term support; ·
Contribute
to the elaboration of an EU strategic framework on undernutrition in developing
countries. The scope of
this document covers the support already provided by the Commission to improve
the nutrition outcomes of its humanitarian assistance. It therefore embraces
the multiple sectors that collectively help avoid a negative nutrition impact
in situations of humanitarian crises, including health, humanitarian food
assistance, and water, sanitation and hygiene responses. This SWD marks
an important step in the process of developing guidelines for the Commission’s
humanitarian assistance in the area of nutrition. It is also a further step
towards elaborating a common perspective on principles and priorities that
support the integration of nutrition objectives across all the sectors of
humanitarian assistance. To this end, this SWD explores: The issues and trends
that need to be considered (Section One); the conceptual framework and key
challenges (Section Two); the objectives, priorities and principles driving
humanitarian assistance for nutrition (Section Three); the operational scope of
assistance, with a focus on criteria for entry and exit (Section Four); the
programmatic responses (Section Five); and shared concerns (Section Six). The SWD
also draws on relevant experiences from the rapidly evolving field of
humanitarian assistance for nutrition. Such experiences are presented as
operational case studies throughout the paper, in order to offer the reader
valuable technical insights into issues of programming, implementation and
coordination. Note on Terminology A humanitarian crisis is an event or series of events which represents a critical threat to the health, safety, security or wellbeing of a community or other large group of people. A humanitarian crisis can have natural or manmade causes, can have a rapid or slow onset and can be of short or protracted duration. The term undernutrition covers short-term (acute) or long-term (chronic) situations, and includes several physiological conditions which frequently co-exist: i) wasting (low weight for height) and nutritional oedema (a form of severe acute undernutrition); ii) stunting (low height for age, an indicator of chronic undernutrition); iii) intrauterine growth restriction which leads to low birth weight; and iv) deficiencies of essential micronutrients. The causes of undernutrition are multiple and context-specific. The term malnutrition, in its exact meaning, refers to any form of physiological impairment caused by the body’s use of nutrients, i.e. overnutrition as well as undernutrition. However, in the past, it has been used synonymously with undernutrition. It is for this reason that certain acronyms denote ‘malnutrition’ rather than the more correct term ‘undernutrition’ – such as CMAM, GAM, MAM and SAM (community-based management of acute malnutrition; global acute malnutrition, moderate acute malnutrition; and severe acute malnutrition, respectively). (In Annex A, the Glossary provides a fuller description of all technical terms used in this document.) II. SUMMARY More than a third of deaths in children under five years old
worldwide are attributable to undernutrition. An estimated 52 million (8%) children under five years old are wasted. 70% of them
lived in Asia[1]. Undernutrition
in childhood makes children more susceptible to diseases and prevents proper
brain development. Irreversible damages caused by undernutrition of individuals
have indirect repercussions in terms of loss of national productivity and
economic growth. Undernutrition is an increasing
global priority. In 2008, the Lancet series on maternal and child
undernutrition played a crucial role in raising international awareness on
undernutrition in developing countries. Each year, the European Commission
allocates well over EUR 100 million to humanitarian assistance actions that are
explicitly associated with specific nutrition objectives. The allocation to
nutrition interventions in the Commission Humanitarian assistance has doubled
between 2008 and 2011. Undernutrition and deaths related to
undernutrition are largely preventable. Key high impact nutrition interventions
have been clearly identified. However the commitment, the capacities and the
resources to scale up the interventions to address undernutrition still lack.
Wasting has decreased only by 11% since 1990[2]. Undernutrition is the result of
multiple immediate, underlying and structural causes, yielded in various
sectors: food security, health, water and sanitation, care and their enabling
environment. Addressing undernutrition requires a multi-sectoral approach and a
joint humanitarian and development framework. The present document reaffirms the Commission's
commitment to
address undernutrition in humanitarian crises and sets the framework for these
interventions. The Commission's objective is to reduce
or avoid excess[3] mortality and morbidity due to
undernutrition in humanitarian situations. EU humanitarian policy is also concerned with
addressing the immediate and underlying causes of undernutrition. In addition to the humanitarian principles
of neutrality, independence, impartiality and humanity, the Commission upholds
a set of more specific principles already outlined in its Communication on
Humanitarian Food Assistance[4]. Nutrition interventions need to: §
Respond to the needs of
the individuals the most vulnerable to undernutrition : mothers and children
under 5; §
Use methods and tools
which have demonstrated their efficiency and cost-effectiveness; §
Respond to well-defined
humanitarian risks as well as immediate emergency needs; §
Promote a multi-sector
approach, which is essential to tackle the causes of undernutrition; §
Promote a joint
humanitarian and development approach to help build resilience. Specifically, in emergency situations Commission
interventions strives to: §
Reduce
levels of moderate and severe acute undernutrition, and micronutrient
deficiencies, to below-emergency rates, through timely, efficient and effective
humanitarian response; §
Prevent
significant and life-threatening deterioration of nutritional status by
ensuring access by crises-affected populations to adequate, safe and nutritious
food, through food and non-food responses depending on the context; §
Reduce
the specific vulnerability of infants and young children in crises through the
promotion of appropriate child care, with special emphasis on infant and young
child feeding practices; §
Reduce
specific vulnerability of pregnant and lactating women in crises through
appropriate support of maternal nutrition; §
Address
the threats to the nutritional status of people affected by crises from an
inadequate public health environment, by securing access to appropriate health
care, safe water, sanitation facilities and hygiene inputs. Other areas of possible support have been identified
as key to reach the above objectives, namely information systems, quality
programming, capacity building, research and advocacy. However, these are
neither entry points nor stand-alone activities.
1 Background
1.1 The scale[5]of the problem
The following information illustrates
the extent to which undernutrition constitutes a massive crisis in its own
right – one that is global and persistent in nature. Undernutrition kills thousands
of people on a daily basis all over the world, including in many countries that
are widely considered to be stable and on a positive development trajectory. ·
Although undernutrition
is largely preventable, it is the underlying cause of over a third of the deaths
of children under five years of age worldwide, taking the lives of an estimated
three million small children and over 100,000 women every year. ·
Around 52
million (8%) of the world’s children under the age of five are wasted. 70% of
them are in Asia. Around 165 million (26%) of children suffer from stunting
globally.[6] ·
Stunting,
severe wasting, and intrauterine growth restriction are estimated to be
responsible for 21% of disability-adjusted life years lost. In an analysis that
accounted for co-exposure of these nutrition-related factors, together they
were found to be responsible for about 11% of the global disease burden. ·
Undernutrition
also causes sub-optimal physical and cognitive development, lower resistance to
infections and hinders the productivity of adults, thereby lowering the
economic potential of societies and perpetuating poverty. ·
Micronutrient
deficiencies, essential for the growth and development of individuals, affect
almost two billion people worldwide, also in developed countries. ·
Suboptimum
breastfeeding, especially non-exclusive breastfeeding in the first 6 months of
life, results in 1.4 million deaths and represents 10% of the disease burden among
children under the age of five. ·
Progress in
the achievement of the relevant Millennium Development Goals (MDG) (1,4 and 5) is
still slow: Ø
MDG 1 ‘Eradicate
extreme poverty and hunger’ has shown some progress as extreme poverty decreased
in every region, even if some regions have seen more progress than others. Hunger
remains a global challenge. The most recent FAO estimates of undernourishment
set the mark at 850 million living in hunger in the world in the 2006/2008
period - 15.5% of the world population. This continuing high level of
undernourishment reflects a lack of progress on hunger reduction in several
regions, even where income poverty has decreased. Ø
Although MDG 4 ‘Reduce
Child Mortality’ has gained momentum, progress is still too slow to meet the
target: Sub-Saharan Africa and Oceania have experienced child-mortality reductions
of only around 30%, less than half of what is required by the MDG. Southern Asia is also lagging behind with a 44% decline in the child mortality rate between
1990 and 2010 - insufficient to achieve a two-third reduction by 2015.
Ø
MDG 5 ‘Improve maternal
health’ has shown progress as maternal mortality has nearly halved since 1990.
Nonetheless, current maternal mortality levels are still far from the target
set for 2015. An estimated 287,000 maternal deaths occurred in 2010 worldwide, indicating
a 47%decline from 1990 levels. Sub-Saharan Africa (with 56 percent of these
deaths) and South Asia (29 percent) together accounted for 85% of the global
burden in 2010, with a joint total of 245,000 maternal deaths.[7]
1.2 Undernutrition
as an increasing global priority
In recent
years, and with the growing realisation of its significance in terms of MDG
progress, considerable advancement has been made in re-energizing the fight
against undernutrition. As a result, new strategies and initiatives for
tackling undernutrition in developing countries are underway in several EU
member states.[8] Due attention
should also be devoted to recent publications[9]
presenting evidence on the most effective interventions to address
undernutrition. In particular, a landmark publication in The Lancet in
January 2008 (five papers, referred to as the Lancet Series, cited above), gave
new momentum to the fight against undernutrition. Much of this momentum is
embodied in the Scaling up Nutrition movement (SUN).[10] This initiative aims
to build a multi-stakeholder and multi-sectoral alignment to support
national-level strategies and efforts to address undernutrition. Each year, the
Commission allocates well over EUR100 million to humanitarian assistance actions
that are explicitly associated with specific nutrition objectives. This funding
supports nutrition interventions in emergency contexts implemented by United
Nations Agencies, the Red Cross/Red Crescent Movement and International
Non-Governmental Organisations. Furthermore, the promotion of more effective
nutrition outcomes in all response sectors is increasingly recognised as a core
priority. The Commission has adopted
a Communication on Humanitarian Food Assistance2 which addresses
undernutrition concerns associated with inadequate food consumption. The
Commission has also adopted two other Communications[11] (one on health and
one on food security) that call for more comprehensive strategies to tackle
undernutrition and for a strengthened link between health and food security
(both transitory and chronic) to bring about more effective responses. Furthermore, a Commission Reference
Document on Addressing Undernutrition in External Assistance[12]
was adopted, providing practical guidance on how nutrition objectives can be
incorporated into different sectors, thematic areas and funding modalities. In addition, the recently
renegotiated Food Assistance Convention[13] reflects the
nutritional aspects of food assistance and effectively integrates nutrition in
its principles and objectives.
1.3 Undernutrition
in crises
Crisis
situations, whether acute or protracted, impact on a range of factors that can
increase the risk of undernutrition, morbidity and mortality. They may involve:
the large-scale destruction of property and infrastructure; the erosion of
livelihood strategies and purchasing power; a breakdown of and reduced access
to essential services including health services, water supply and sanitation;
and displacement of large numbers of people. Emergencies can also disrupt
social systems and the quality of care/feeding practices. Household access to
food may be negatively affected and people may find themselves in over-crowded
settlements with their families being divided. As a result, at the individual
level, there is often an increased risk of deteriorating health and nutritional
status, resulting in a greater likelihood of death (see Figure 1: Conceptual
framework). Young children
and pregnant and lactating women are particularly vulnerable to undernutrition
from a physiological point of view, due to their increased nutrient
requirements for growth and development. Young children are also exposed to a higher
risk (compared to other population groups) of contracting infections, which can
further increase nutrient requirements, impede nutrient use and reduce
appetite. For this reason, young children often demonstrate the fastest
nutritional deterioration in crisis contexts, as well as the highest rates of
disease and undernutrition-related mortality. Young children are therefore
considered a primary target group for assistance. Furthermore, older and
disabled people, as well as people living with chronic illness such as HIV and
AIDS may also suffer from reduced appetite, difficulties in chewing and
difficulties in accessing food, which increase their nutritional vulnerability.
Gender also plays an
important role in determining individual vulnerability to undernutrition.
Women/girls and men/boys face different risks in relation to the deterioration
of their nutritional status during crises as a consequence of both their different
nutritional requirements and a variety of socio-cultural factors related to
gender: ·
Undernutrition
has particularly serious consequences for women, as stunted women face higher
risks of complications during childbirth; Anaemia (the most widespread
nutritional problem affecting girls and women in developing countries) is responsible
for a significant proportion of maternal mortality. ·
Maternal
acute undernutrition is associated with intrauterine growth restriction and constitutes
a risk factor for poor neonatal health. ·
Undernutrition
has an intergenerational cycle, as undernourished adolescent and adult mothers are
more likely to give birth to low birth-weight babies. This in turn, increases
the risk of undernutrition in early childhood. Gender and nutrition vulnerability during crises · When food is in short supply, women and girls are more likely to reduce (voluntarily or as a result of external pressure) their intake in favour of other household members, thus worsening their own nutritional status. · Women may face constraints in accessing essential humanitarian services as a result of insecurity, cultural discrimination and limited mobility. · Pregnant and lactating women are particularly exposed to undernutrition due to their increased physiological requirements. · While remaining the primary caregivers of children and other dependents, women undertake additional activities during crises, particularly where male heads of households are absent. This often leads to the disruption of infant and young child feeding practices and care. · Men who are single heads of households may be removed from their normal support structures during crises and if they do not know how to cook or care for young children, this results in a greater risk of acute under-nutrition for themselves and their children.
2 Scope of
Nutrition in Emergencies
2.1 The conceptual framework of
undernutrition
There are
numerous possible causes of undernutrition, many of which impact on both acute
and chronic undernutrition. These causes are usually analysed at three levels:
immediate, underlying and basic. These three levels are based on the conceptual
framework developed by UNICEF in the 1990s, which is still regarded as a
valuable guideline today (see Figure 1). The humanitarian
assistance for nutrition provided by the Commission is primarily aimed at
preventing and alleviating the short-term consequences of maternal and child
undernutrition by addressing their immediate and underlying causes at the
individual and household levels.
Immediate causes are to be found at the
individual level and have two dimensions: dietary intake and the presence
of diseases. This distinction emphasises the limitation of the term ‘hunger’
in denoting undernutrition, as hunger may or may not be a cause of
undernutrition. The Commission's humanitarian interventions address
immediate causes of undernutrition by providing immediate access to food,
in order to improve food intake, and free access to life-saving healthcare.
Underlying causes operate at the household
and community levels. They comprise three categories: (i) household food
security, (ii) care for children and women and (iii) health environment
and health services. Income poverty affects all three. Household food insecurity
can be alleviated through measures aimed at durably increasing household
food availability, accessibility (e.g. purchasing power) and utilisation
(e.g. cooking). Inadequate care practices can be addressed through
measures aimed at ensuring maternal nutrition and appropriate and regular
feeding of infants and young children, as well as providing safe feeding spaces.
Unhealthy environments can be addressed through water, sanitation and
hygiene measures as well as through the provision of accessible health
services and disease control measures (e.g. long-lasting insecticide-treated
mosquito nets, environmental interventions).
Basic
causes include a range of factors operating at the sub-national, national
and international levels, ranging from the availability of natural
resources, to social and economic environments, to political contexts.[14]
Basic causes that are linked to political, cultural, religious, economic,
educational, demographic, and social systems can only be addressed through
long-term development strategies.
Undernutrition therefore has to be
understood as a multi-sectoral challenge, requiring a sound
understanding of the specificities of each context of intervention. Figure 1: Conceptual Framework of
Malnutrition showing the relationship between poverty, food insecurity, and
other causes of maternal and child undernutrition Source: The State of the World's Children, UNICEF 1998 Figure 2: The underlying causes of undernutrition (adapted from the Communication
on Humanitarian Food Assistance) Inadequate Care · Maternal nutrition · Maternal Care (workload, gender imbalance etc.) · Child care · Infant and young child feeding · Eating habits · Food preparation · Intra-household food distribution · Capacity to care for dependent individuals Household Food Insecurity Lack of safe access to adequate and safe food throughout the year through: · Food production · Purchase/barter · Gifts, other sources · Food safety and quality · Cash transfers Unhealthy Household environment and lack of health services · Water quality and quantity · Hygiene and sanitation · (Free) access to and use of health services
2.2. Recent
advances in the management of undernutrition in crises
The following important developments in recent years have taken place: (i) The publication of
new WHO growth standards (2006), based on the growth of children under conditions of
optimal nutrition and health from a variety of countries, provides a better
tool for diagnosing undernutrition, and defining and identifying nutritional
risk and nutritional needs. (ii) The emergence and
expansion of Community-based Management of Acute Malnutrition (CMAM). Extensive
evidence is now available on the heightened efficiency and effectiveness of
such approach compared to models that only offer inpatient treatment. This is
linked to an improvement in the identification of cases and in the mobilization
of communities around situations of undernutrition, as well as to a reduction
in the barriers to accessing treatment as a result of better resourced and
managed programmes. This approach uses a new
classification of severe acute malnutrition (SAM), which categorises children either
as suffering from SAM with complications or without complications, based on
clinical symptoms. The latter can be treated as outpatients with ready-to-use
therapeutic foods (RUTF), while children with medical complications are treated
following specialised medical protocols through the administration of therapeutic
milk in inpatient facilities. (iii) An increasing focus
on the quality of food inevitably contributes to nutritional improvements. The adaptation
of therapeutic milk into RUTF, and the development of improved formulae of
fortified blended foods and specialized ready-to-use supplementary foods (RUSF)
are playing a key role in this sense. Use of these products has been extended
into other areas such as the treatment of moderate acute undernutrition, the prevention
of undernutrition, the nutritional rehabilitation of acutely ill patients, etc.
Such advances provide an opportunity for the development and adaptation of new
intervention strategies. (iv) The recognition that children
under five years of age constitute the most vulnerable age group in terms of acute
malnutrition. Although in humanitarian settings the provision of assistance
should be guaranteed to all nutritionally-vulnerable age groups, particular
emphasis should be given to children under five years of age. (v) The understanding
that the period between conception and 2 years of age is crucial in defining
the future nutrition and health status of the individual. This period provides
a critical window of opportunity in which the impact of interventions to
improve maternal and child undernutrition - including measures to improve
micronutrient intake in the under twos (U2s) - on the survival, growth and
development of young children is maximised [15]. (vi) A focus on population-based
strategies to prevent moderate undernutrition is combined with more common
interventions targeting individuals. These range from blanket distributions of
(fortified) supplementary foods to social protection schemes such as cash
transfers. For example, there is increasing evidence of the value of
integrating household and community food security and livelihood support with
nutrition rehabilitation interventions. At the same time, access to free
medical services has also proved to have a great impact on nutrition, as
nutrition security is not exclusively linked to food security. (vii) The standardisation of survey methods
to assess the prevalence of undernutrition in emergencies, in particular the
Standardized Monitoring and Assessment of Relief and Transition (SMART)
methodology, and progress towards new survey techniques to assess programme
coverage (e.g. SQUEAC). (viii)
The recognition
of the importance of acute undernutrition in non-emergency contexts such as areas
with persistently high levels of undernutrition in the long term, or during
‘seasonal hunger gaps’, and of the need, therefore, to integrate undernutrition
prevention and treatment into national food security and healthcare systems, as
well as cross-sectoral development planning. (ix) A consensus on the importance
of Infant and Young Child Feeding practices in Emergencies (IYCF-E) in order to
save lives and improve health and the development of children. This includes
measures that assess the IYCF-E context; the integration of breastfeeding and
IYCF-E support into other services for mothers, infants and young children; and
the provision of food that is suitable for infants and young children. Although
the promotion of breastfeeding is a priority, in certain humanitarian
situations it is preferable to support formula feeding. The importance of
preventing and avoiding donations of breast-milk substitutes, bottles, teats
and other milk products in emergencies is also recognised. (x) There are several
key areas where progress has been made which, despite not being 'new', have a bearing
on how undernutrition should be managed in crisis contexts. These include: a
better understanding of the multifaceted causes of undernutrition, the identification
of links between HIV and Tuberculosis and nutrition/undernutrition, the identification
of the benefits of a holistic multi-sectoral approach and a heightened
understanding of the importance of tackling micronutrient deficiencies in the
management of undernutrition and in the improvement of health conditions.
2.3 Key Challenges in Addressing Undernutrition
in Emergencies
The following list presents the key
challenges to be faced when addressing undernutrition in emergencies: ·
Good
coordination, which requires effective leadership and the establishment
of mechanisms to build consensus for an appropriate and context-specific
strategy. Such a strategy must be able to ensure multi–sectoral capacities and
commitment to clearly identified nutrition objectives. ·
Accurate
analysis of the causes of undernutrition and interpretation of information from
multiple sectors including gender and age disaggregated indicators of food
and/or nutrition security, to feed into timely and appropriate responses.
Challenges include the absence of regular and reliable monitoring mechanisms
for nutritional status, especially in areas where, despite SAM being a persistent
or recurrent concern, it is not adequately recognised or addressed by concerned
governments or development partners. ·
Availability
of skilled human resources (human resources
shortage)
and strengthened capacity to respond to nutrition emergencies (emergency
preparedness). ·
Promotion
and scaling-up of effective interventions such as community-based
approaches for the prevention and management of acute undernutrition, while ensuring
adequate attention and resources for other crucial sectoral response options. ·
Promotion
of quality management of humanitarian assistance for nutrition
through evidence-based decision-making and implementation. This requires
cross-sectoral approaches; collection and analysis of gender and age
disaggregated data; innovations in programme design (including, for example,
adapting effective local practices); sound management; good documentation; and
investment in research to fill evidence gaps. ·
Ensuring
a gender-sensitive approach to the assessment of needs and nutrition
programming, particularly in the areas of community consultation and
participation, awareness raising and nutrition education. ·
Contributing
to efforts to build an evidence base, in order to assess the impact of
interventions; development and dissemination of new survey methods that are
easier to undertake in difficult contexts; diagnostic tools to analyse
micronutrient deficiencies without requiring sophisticated laboratory analyses;
and treatment of infant acute undernutrition in emergencies. ·
Measuring
impact
in relation to reducing and preventing undernutrition and mortality in
emergencies and drawing lessons to inform future responses. The absence of
standardised reporting mechanisms for programme performance (including
programme coverage) is an important constraint on impact monitoring. ·
Taking
advantage of the opportunities and resources that humanitarian assistance can
bring to strengthen national capacity for the prevention and management
of undernutrition – while at the same time striving to secure long term
strategic planning and investment in capacity-strengthening. ·
Ensuring
long-term, sustained support from development actors for tackling undernutrition
prior to, during and after an emergency. ·
Developing
a holistic and integrated approach to undernutrition ·
Ensuring
availability of appropriate capacities for sectoral and/or multi-sectoral
coordination in addressing both existing and upcoming needs In the
sections below, these challenges will be further discussed and emerging
experience regarding how best to address them will be presented to chart the
road ahead.
3 OBJECTIVES,
PRIORITIES AND PRINCIPLES OF THE COMMISSION'S ASSISTANCE TO NUTRITION IN
EMERGENCIES
Considering all these recent developments and
challenges, and building on existing policies, the Commission identifies the
following objectives, priorities and principles for its work on nutrition in
emergencies.
3.1 Principal objective
The principal objective is to reduce and
avoid excess mortality and morbidity caused by undernutrition in humanitarian
situations.
3.2 Specific objectives
The principal objective
is to be achieved through the following specific objectives: ·
To
reduce levels of moderate and severe acute undernutrition to below-emergency
rates, and prevent/correct micronutrient deficiencies through timely, efficient
and effective humanitarian responses. ·
To
prevent significant and life-threatening deterioration of nutritional status by
safeguarding the availability of, access to and consumption of adequate safe
and nutritious food while protecting livelihoods and promoting conditions for
the restoration of self-reliance. ·
To
reduce the threats to the nutritional status of people affected by crises stemming
from an inadequate public health environment, by securing access to appropriate
healthcare, safe water, sanitation facilities and hygiene inputs. ·
To
reduce the specific vulnerability of infants and young children in crises
through the promotion of appropriate child care, with special emphasis on
infant and young child feeding practices. ·
To
reduce the specific nutrition vulnerability of pregnant and lactating
women/women of reproductive age.[16]
·
To
reduce the specific nutrition vulnerability of most affected groups (such as
the elderly, disabled, HIV- positive, children over five, and adolescents). ·
To
strengthen the capacities of the international humanitarian aid system to
enhance efficiency and effectiveness in the delivery of humanitarian assistance
for nutrition.
3.3 Strategic priorities
In populations affected by emergencies, the
priority focus is on acute (moderate and severe) undernutrition, which is
associated with a higher risk of mortality and morbidity. In line with the
above objectives, the Commission responds to underrnutrition and its causes in
emergencies by funding interventions that meet the following strategic
priorities: i) Interventions to
treat MAM and SAM ii) Interventions
through the nutrition, health and food assistance sectors that tackle the immediate
causes of undernutrition (inadequate dietary intake and disease); iii) Interventions
through the nutrition, health, food assistance and WASH (water, sanitation and
hygiene) sectors that tackle the underlying causes of undernutrition (food
insecurity, inadequate care practices and inadequate access to healthcare and
environmental health); iv) Integration of nutrition
interventions within an overall resilience strategy in coordination with development
partners.
3.4 Principles
that guide the Commission's assistance to nutrition in emergencies
In pursuit of the above-mentioned objectives, the following principles
underscore the Commission's support to nutrition in humanitarian situations: i)
The
nutrition interventions aiming at treating and preventing undernutrition are
based on individual needs. The individual nutritional status is assessed using
standard methods, measures and threshold. The preventive interventions and
indirect interventions on the causes of undernutrition are based on appropriate
needs assessment, using standard indicators such as GAM and SAM prevalence,
access to food and access to basic health care. ii)
The choice of the most
appropriate intervention(s) and instrument(s) must be based on evidence: the
needs assessment, the nutrition causal analysis, the context analysis and the
response analysis. The design of any response should compare alternative
activities and modalities on the basis of cost-effectiveness for meeting
identified needs. Interventions should be regularly reviewed on the basis of
local dynamics and situation changes. iii)
Nutrition interventions
respond to well defined humanitarian risks. They are targeting individuals
particularly vulnerable to mortality and morbidity related to undernutrition:
children under 5, the pregnant and lactating mothers, elderlies and chronically
ill. iv)
Understanding
the causes of undernutrition and enabling environment is crucial to identify
the appropriate combination of activities to address undernutrition and its
causes. Causes of undernutrition are often multiple. Adopting a multi-sector
approach and coordinating humanitarian and development actions are thus essential. v)
The Commission
seeks to incorporate systematically gender perspectives into its humanitarian
nutrition assessments. It also considers the gender implications of its
emergency nutrition interventions, recognising the importance of gender roles
in caring and feeding practices, livelihoods, the use and allocation of food at
household level, and beneficiaries' utilisation of food assistance resources. vi)
Nutrition assistance
upholds the principles of Linking Relief Rehabilitation and Development (LRRD).
Where possible and appropriate, the Commission works with its development
partners to maximise the sustainability of interventions by promoting their
integration into national policy frameworks and plans (e.g. in health policy,
emergency response plans, national protocols for the treatment of
undernutrition, etc.). vii) The Commission strives to do no harm
through its humanitarian assistance for nutrition. This is especially important
in relation to the safety of innovations and the use of specialized nutrition
products. The Commission always ensures that all available evidence is
considered fully, and that the best interests of the beneficiaries remain
central. viii) The Commission promotes those practices that are
efficient and effective in managing undernutrition. The care given, quality of
food products used and reliability of information[17] that guides programme design follow international
standards – such as Sphere, WHO, or guidance from the Global Nutrition Cluster.
4 OPERATIONAL
SCOPE OF ASSISTANCE
4.1 Entry and Exit Criteria
In line with the Commission’s Communication on
Humanitarian Food Assistance, the Commission follows the entry and exit criteria
for operations outlined below, always mindful of the commitment to supporting
appropriate transition through LRRD (Linking Relief, Rehabilitation and
Development). Entry criteria for operations ·
The Commission may
trigger nutrition support when emergency rates of mortality or acute undernutrition
(U5 mortality rate >2/10,000/day, GAM >15%, and GAM rates >10% with
aggravating factors) have been reached or exceeded, or are anticipated, on the
basis of firm forecasts. Such “anticipation” should be based on early warning
indicators that show a critical deterioration in the food security and/or
health environment, which, unless responded to, will become life-threatening
within a timeframe that is consistent with the Commission's humanitarian remit. ·
Recognizing that a food
crisis sometimes begins, calling for a reaction before the nutritional status
deteriorates further, the Commission does not necessarily wait for rising rates
of acute undernutrition before providing humanitarian food assistance and
nutritional support, and respond to well-defined humanitarian risks that pose a
threat to life. The Commission does not require a formal disaster declaration
in order to respond to an emergency. ·
In considering whether
and how to respond to a given crisis, the Commission pays close attention to
the comparative advantages and disadvantages of the humanitarian instruments at
its disposal. This requires: a careful analysis of the existing needs and the causes
of the crisis; a consideration of the type of response that will address those
needs in the most appropriate way without causing any harm; and a close review
of the alternative assistance mechanisms that are available. ·
In this regard, the Commission's
humanitarian assistance does generally not respond to permanently high levels
of undernutrition (whether stunting, wasting and/or micronutrient deficiencies)
except where non-intervention poses an imminent humanitarian risk of
significant scale and severity and where other more appropriate actors are
either unable or unwilling to act, and cannot be persuaded to act; and where,
in spite of its comparative disadvantages, positive impact can be expected
within the time limitations of the intervention by the Commission. In such
cases, the delivery of humanitarian assistance for nutrition is anticipated by
advocacy, dialogue and appropriate coordination with relevant development
actors. Exit criteria for operations ·
The Commission considers
phasing out its humanitarian nutrition assistance when indicators of acute
undernutrition and related mortality are stabilised below emergency levels, or
are expected to stabilise there in the foreseeable future, independently of the
Commission's humanitarian support. ·
The Commission also
considers phasing out or transitioning its humanitarian support where
non-humanitarian players (e.g. State or development actors) are able to respond
to the nutritional needs of the populations at risk, therefore mitigating the
level of humanitarian risk associated with withdrawal; or when the humanitarian
needs of the population are fully covered by other humanitarian donors and
actors. ·
The Commission, at all
times, evaluates its humanitarian exit strategies on the basis of its
comparative advantage relative to other actors. The Commission seeks to avoid
creating disincentives to the engagement of other actors by delaying its own
exit. It advocates instead for other, more appropriate, actors across the
relief and development spectrum to respond, according to the specific context
and needs. ·
The Commission also
considers exiting from humanitarian nutrition assistance operations when its
core principles cannot be respected, particularly if the risk of doing harm
outweighs the potential benefits of remaining engaged.
4.2 Additional aspects necessary to achieve the Commission's
Objectives
The Commission's humanitarian
mandate, its capacity and priorities all give it a specific comparative
advantage to respond to the above-mentioned undernutrition challenges in
crises. The Commission recognises, however, that in order to achieve the
greatest benefits in terms of improved nutrition, it is also necessary to
address two other persistent challenges in emergencies: i) The production of reliable information
to guide decisions, with special emphasis on situation and response analyses that are sensitive to gender and age-related inequalities; and ii) The strengthening of capacities for
efficient and effective delivery of humanitarian assistance for nutrition. These two areas are therefore included here so as to
enable the achievement of the Commission's objectives. However, they are not
included as stand-alone areas or entry points for response.
4.2.1 Information Systems
Where they exist, health, nutrition and food security
information systems regularly collect nutrition information (including
anthropometric data) that can be used in decisions about policies and/or guide
strategies and monitor interventions Such information systems
require long-term support, with national or regional ownership and careful
consideration of economic and political perspectives. It is therefore
imperative that any humanitarian support in this area is coherent with a longer
term strategy by the Commission and/or other donors and national systems. The closely related activities
of situation analysis (including nutrition causal
analysis) and response analysis are crucial in securing the overall
effectiveness of an intervention. The Commission recognises the
value of applying a nutrition ‘lens’ to assessments, problem and response
analysis, as well as to the monitoring and evaluation of all multi-sectoral projects. The Commission facilitates the
integration of nutrition data into other information systems and projects, such
as the IPC project (Integrated Food Security Phase Classification),[18] while continuing its support to the Household
Economy Approach in relation to the Cost of Diet analysis.[19] Finally, gender analyses should
be integrated in any situation and response analysis, and it is crucial to
ensure that specific capacities are in place to achieve this goal. The significance of gender analysis in the planning of humanitarian assistance for nutrition The commitment to strengthening a gender-sensitive approach is enshrined in the European Consensus on Humanitarian Aid which highlights the importance of: (i) integrating gender considerations, (ii) incorporating protection strategies against sexual and gender-based violence, and (iii) promoting the active participation of women in humanitarian assistance. Rationale: Crisis situations, whatever their cause, are not gender neutral. Women, girls, boys and men face different risks of deterioration in their nutritional status. These different vulnerabilities are related both to their differing physiological nutrition requirements and to socio-cultural factors related to gender.[20] Why gender and age matter:[21] Gender-blind actions are less effective because they neglect the diversity of needs, capacities and coping mechanisms of different groups of beneficiaries. Good nutrition programming must take due account of gender issues at all stages of the project cycle. In particular, there must be attention to ensuring a gender perspective in situation and response analysis. Experience shows that poor child feeding practices, lack of access to health services, economic and livelihood insecurity, cultural practices and gender inequality more broadly tend to be inadequately incorporated into national vulnerability analyses and strategic programming. A gender analysis is undertaken to better understand the division of roles, responsibilities, constraints and access to resources, mobility, specific vulnerabilities, needs and risks faced by women, girls, boys and men, including sexual and gender-based violence. To maximise the quality and effectiveness of nutrition-related
interventions, the Commission emphasises the value of utilising the full
project management cycle: needs assessment, response analysis, planning
(programme identification), appraisal, financing, implementation, and
monitoring and evaluation.[22] The Commission, especially in crisis-prone countries, pays
specific attention to the collection of quality nutrition data, and promotes
implementation of nutritional assessments according to standardised
methodologies.[23] Such assessments may include, other than
anthropometry, data that will help to identify the likely causes of
undernutrition (most notably linked to health, food security and the environment).[24]
4.2.2 Capacity Building
In the high-pressure context of humanitarian crises,
the imperative to respond quickly and professionally requires the presence of
capacity to do so. At the same time, the nutrition field is advancing very
quickly, creating additional pressure on staff to know the latest evidence that
can inform the design of humanitarian responses for nutrition. The Commission
recognises the challenges and opportunity costs of such a
widening gap between theoretical knowledge and operational capability, and will
seek to prioritize efforts to bridge this gap. In order to maximise the effectiveness of nutrition
assistance, the Commission recognises the need to invest in supporting
institutions and developing the capacity of key stakeholders involved in the
management of acute undernutrition in crises. While responding to humanitarian
needs, it is possible to develop policies, systems and skills that are
compatible both with emergency and development contexts. The Commission's
support aims to enhance local and national capacities to manage undernutrition
in emergencies and to face seasonal peaks, and to build resilience to face
existing and upcoming shocks. Where possible and appropriate, the Commission works
within the timeframe of its humanitarian operations to simultaneously enhance
national capacities for: i) nutritional surveillance; ii) nutrition surveys;
iii) health, food security & nutrition data monitoring; iv) cross-sectoral
causality studies and assessments and; v) enhance the capacity for the
implementation of nutritional activities. Such investments should be
coordinated with other Commission aid instruments to ensure continuity when the
humanitarian intervention is concluded (see section 6.3 on Coherence,
Coordination and Complementarity).
4.2.3 Integration into national
systems
A central challenge facing humanitarian assistance for
nutrition involves the need for timely engagement and rapid intervention, while
ensuring that minimum standards of quality are consistently maintained.
Experience suggests that, as far as possible, this challenge can be best met
through effective preparedness measures in the framework of an integrated
'system-strengthening' approach. Despite the fact that humanitarian crises do
not take place in a vacuum, the humanitarian imperative to provide immediate
life-saving response frequently leads to a focus on the establishment of new
mechanisms for delivery, leading to the neglect of pre-existing local systems
(not only in the health sector, but also within other relevant local
institutions and community structures). Where appropriate, the Commission therefore encourages
the inclusion of programming to address nutrition within the broader context of
national systems (including provisions for the adaptation of national protocols
for surge programming). This in turn highlights the need for a thorough
assessment of national capacities and resources prior to intervention, as well as
a commitment to reinforce government ownership and capacity where this is
conducive to the achievements of the objectives of humanitarian assistance.
4.2.4 Advocacy
The
Commission recognises that
both acute and chronic undernutrition and micro-nutrient deficiencies are
prevalent and often co-existing, to varying degrees, in many stable contexts.
Given the consequences of such persistently high burden of undernutrition on
infant and child mortality, child development, and longer-term economic growth
prospects, the Commission insists that all forms of undernutrition be
firmly placed at the centre of the development agenda. Advocacy
and public awareness building are essential to secure better policies and the
development of appropriate actions to respond to undernutrition. Key targets in
this process are national government authorities, civil society and development
partners. A major focus is placed on initiatives to improve the understanding of
those measures that are required in order to achieve the MDGs of reducing
hunger, and child and maternal mortality. Although
the Commission has a specific remit and a comparative
advantage in humanitarian action, as opposed to some local actors, the humanitarian
imperative to save lives and reduce rates of acute undernutrition should be
responded to, whenever feasible, in a manner that does not undermine local
capacities or neglect national policies. Local capacity for the routine
management of persistent burdens of acute undernutrition and for the management
of future crises, should therefore be supported and strengthened whenever
possible.
4.2.5 Research
With a growth in awareness of
the multi-sectoral causality of undernutrition and an expansion in the
programmatic options to respond to the phenomenon, the collection of robust and
up-to-date evidence on the efficiency and effectiveness of different forms of
assistance becomes today more essential than ever before. The Commission acknowledges the need to contribute to the evidence base
on the efficiency and effectiveness of various interventions to address
undernutrition, taking into account the diversity of contexts (urban, pastoral,
agricultural, acute/chronic, situations of displacement, etc.) and the needs of
specific population groups (women/men; different age groups; persons with
disabilities; ethnic and other socio-cultural groups; economically diverse
groups). The Commission therefore continues supporting operational
research on nutrition under the following conditions: ·
Research is not the
entry point for any operation - operations should be justified by humanitarian
needs and not by research ·
The context should
allow for research to be conducted effectively - the research location should
be accessible and stable for the duration of the research period in order to ensure
adequate quality outcomes ·
Partners must be
running ongoing quality operations in the proposed project area and have the
technical expertise that is necessary in order to conduct any proposed research
·
Partners' research
should respect international research standards including the validation of
research protocols by an international ethical review board and, if possible,
by a national one, through the appropriate involvement of local authorities and
communities. ·
Transparent
documentation and dissemination of research findings must be ensured at all
times.
5 PROGRAMMATIC RESPONSES
The
Commission supports comprehensive life-saving nutrition strategies to
address emergency levels of undernutrition. These include
interventions that have been demonstrated to be effective and efficient in
tackling both moderate and severe acute undernutrition, as well as specific
micronutrient deficiencies. Other
programmes are required to address the immediate and underlying causes of
undernutrition (see Conceptual framework), which also help to create the
foundations and enabling environment that are necessary in order to sustain
nutritional gains over time. These include interventions that have been
demonstrated to be effective at addressing the underlying causes of undernutrition
such as improving access to safe water and improving household food security
through agriculture and livestock interventions. Operational Case
Study Niger: "Cost of Diet" - an analytical
tool to inform nutrition interventions In May 2011, Save the Children UK (SC UK)
conducted a "Cost of the Diet (CoD) assessment" in the Zinder Region
of southern Niger. The aim was to better understand the underlying economic
causes of malnutrition. The CoD analytical tool, developed by SC UK
with support from the Commission, is designed to calculate the cost of the
cheapest diet that meets the nutritional requirements of families and
exclusively contains locally available food. The CoD combines data on food
prices, consumption, and availability with information from interviews with
household members about their eating habits and lifestyle. It can be used to
estimate the proportion of households in a region that are unable to afford a
nutritious diet, as well as the size of the gap between current income and the
amount of money needed to meet the needs of a household. In Zinder, nutritious food was available in
the market. CoD analysis found, however, that during the lean season, the
minimum cost of this diet is far beyond the income levels of poor households.
By identifying the size of this income gap, SC UK and other partners could
tailor programming accordingly (for example, through cash and voucher
assistance). Lesson learnt: There is no "one size fits all"
answer to a specific situation of undernutrition in any given emergency.
Depending on the social and economic situation of a household, the functioning
of the market, the livelihood assets and the level of resilience, humanitarian
interventions for nutrition can vary. The CoD tool can be very useful for
understanding the difficulties of crisis-affected households in accessing
nutritious food, and particularly for the promotion of IYCF practices for
children older than 6 months based on appropriate complementary foodstuff that
is available at local markets.
5.1 Health and Nutrition
5.1.1 Management of moderate and
severe acute undernutrition
Where indicated by an assessment of needs, and where
not covered by existing health provision, it can be necessary to specifically intervene
in the management of moderate and severe acute undernutrition for the most
vulnerable (generally children under five and pregnant and lactating women).
Strategies to manage acute undernutrition in crisis contexts must be closely
linked to efforts to promote the nutritional security of the entire
emergency-affected population. The choice of intervention
depends on the prevalence of acute undernutrition (moderate and severe), any
aggravating factors, the local context and the dynamic of the crisis (particularly
in terms of the possibility to gain access to affected groups). The Commission emphasises
the relevance of: ·
Early detection of
acute undernutrition at the community level and intensive case finding through community
mobilisation; ·
Provision of outpatient
treatment for individuals suffering from severe acute undernutrition without
medical complications. The caseload of SAM without complications is estimated to
be 80-90% of the total SAM caseload; ·
Facility-based
treatment of individuals suffering from SAM with medical complications
(estimated at 10-20% of total SAM caseload). This might include therapeutic
feeding centres, hospitals or stabilisation centres; appropriate identification
of medical complications and access to the appropriate (lifesaving) treatment; and
appropriate follow-up after referral and after discharge, particularly in the
management of severe acute malnutrition (at stabilisation centres and through outpatient
programmes); ·
Supplementary Feeding
Programmes treating those with moderate acute undernutrition; ·
Concomitant access to
free healthcare.. The
Commission welcomes the advances made in recent years
through the introduction and scaling up of community based approaches for CMAM.
The Commission particularly recognises the value of ready-to-use therapeutic
foods, which have been integral to the success of this approach. CMAM aims to
provide effective treatment for all children with both severe and moderate
acute undernutrition by decentralising treatment nearer to those that need it,
removing the need for long inpatient stays and stimulating understanding and
engagement of the target population around acute undernutrition. Barriers to
accessing treatment are reduced and early diagnosis of the condition occurs
more frequently. Early diagnosis of acute undernutrition in combination with
effective treatment at the community level can largely reduce fatality rates
and increase coverage of the affected population. The burden of undernutrition in emergencies is felt in
terms of numbers affected (more children have moderate acute undernutrition)
and in terms of mortality (the risk is greatest for those with severe acute
undernutrition). The management of acute undernutrition, therefore, needs to
consider strategies for MAM alongside those for SAM, so that there can be
coherence and sustained progress. Crucially, a multi-sectoral approach is
necessary to address moderate acute malnutrition, e.g. through humanitarian
food assistance, improved access to healthcare and improved access to
sanitation and drinking water. Operational Case Study Ethiopia: Strengthening of the capacity of the Ministry of Health for more effective humanitarian response and improved resilience Ethiopia has one of the highest under-five mortality rates in the world and is chronically vulnerable to food and nutrition crises. In 2003/4, a widespread food and nutrition crisis highlighted the low capacity of existing Therapeutic Feeding Centres for the treatment of severe acute malnutrition. This situation prompted the Ministry of Health (MoH) to begin working with partners to scale-up services dealing with nutrition across the country. The international non-governmental organization Concern Worldwide launched a programme to support the MoH in establishing adequate services to treat a large number of children with SAM during ‘normal’ times. The intervention included the strengthening of capacities in order to enable these services to rapidly scale-up at times of crisis. The project aimed to mitigate delays in setting up new therapeutic programmes in response to crises. The programme provided a package of ‘minimal support’ to the MoH, consisting of training, joint supervision, experience-sharing visits, workshops and community mobilisation assistance. In addition, support was provided for the incorporation of CMAM into the National Nutrition Strategy and its guidelines. In 2008, a dramatic increase in the prevalence of SAM was recorded across two regions in Ethiopia, primarily due to the effects of drought. In many districts the magnitude of caseloads overwhelmed treatment capacities. The MoH made the decision to decentralise CMAM services to primary healthcare posts through the employment of health extension workers. This was rapidly achieved by mobilising support from a number of agencies (UNICEF, WHO, and NGOs). The results have been striking: · Within 4 months, 455 health posts (50% of the districts) in the two affected regions were managing outpatient therapeutic programmes (OTP), reaching over 27,000 children with SAM. The results[25] fulfilled Sphere standards. This prompted an acceleration of major efforts to scale-up CMAM across other regions. · Extensive CMAM scaling-up has enabled increased access to information on SAM admissions in a considerable proportion of the country. Programme monitoring data increases the potential for humanitarian actors to respond in a timely manner to increases in the prevalence of SAM, rather than having to rely on the longer-term completion of nutrition surveys. In March/April 2011, CMAM reports showed a 90% increase in the number of admissions, which led UNICEF and implementing partners to trigger a humanitarian response using contingency/reserve funding while discussions for additional support were still under way. Lesson Learnt: This case highlights the gains associated with a "system approach" where nutrition interventions in emergencies build on existing capacity. This approach is only possible in the presence of an appropriate funding mechanism that promotes bridges between humanitarian and development interventions.
Infant
and young child feeding in emergencies (IYCF-E)
In
the context of humanitarian assistance for nutrition, IYCF refers to a range of
nutrition and care interventions that improve child survival and growth. These
include appropriate and evidence-based support for (exclusive) breastfeeding
and counselling, formula or emergency feeding interventions when necessary, nutrient-dense
complementary feeding interventions for children > 6 months, support for
improved care practices, child development and child protection. In more general
terms, IYCF covers maternal and child nutrition, including the management of
acute undernutrition in infants. Special attention should be paid to address
any cultural practices surrounding breastfeeding and feeding that may
discriminate girls. The Commission seeks to uphold
the provisions of the International Code of Marketing of Breast-milk
Substitutes and subsequent relevant WHO Resolutions (and requires its partners
to uphold the same standards). Inappropriate in-kind donations (such as infant
formula, powdered milk or bottles and teats) are discouraged by the Commission,
in accordance with the Operational Guidance on IYCF-E and the International
Code on the Marketing of Breast-milk Substitutes. In a humanitarian crisis, other
less recognised influences on IYCF practices must be addressed including
security, privacy and shelter for mothers. The psychosocial components of
nutrition (including the psychological, emotional and social dimensions of a
child and mother's health and well-being) are of crucial importance, as they
can have a considerable impact on nutritional status. Nutrition has extremely
close links with care practices and a child's nutritional status is often
determined as much by feeding practices, home environment and the attention
received from primary caretaker as by the food consumed. Evidence also
indicates that inclusion of psychosocial stimulation for mothers and children
in programmes for the treatment of undernutrition can improve long-term health
and development of children.[26] The
recent review of the Management of Acute Malnutrition in Infants (MAMI)[27] confirms that a high
prevalence of wasting in
infants below 6 months of age is a public health problem requiring a humanitarian
response. There is an urgent need to increase our knowledge on how to diagnose
acute undernutrition in this age group, improve understanding of causes and
consequences, and improve interventions to treat it. More specifically, there
is a need to explore the modalities, costs and impact of integrating IYCF
support in CMAM programmes, and interventions addressing acute undernutrition
in infants need to be updated through innovation, research and the
considerations of past lessons. Operational Case Study Myanmar: The experience of a young mother during the 2008 cyclone and subsequent floods Jasmine’s mother was nearing the end of her pregnancy when the cyclone hit. She and her four boys were hit by the storm while they were at several days' walk from her village. She sought refuge in a monastery where she met a woman who had three boys of her own, all over 8 years old. When they were forcibly evacuated from the monastery, Jasmine’s mother knew she was too close to giving birth to make the journey back to her village with her boys. So she stayed with the family she had met at the monastery. When Jasmine was born, weighing 2.5kg, her mother decided she could not care for her and left her with the family she had been staying with. Six weeks later, Jasmine weighed 2.3kg. Breastfeeding counsellors were supporting Jasmine’s foster mother to re-lactate for about 10 days. She was instructed to put Jasmine to the breast as often as she could during the day (at least every 2 hours) and to allow her unrestricted access to the breast all night (the whole family slept on one mat under the only mosquito net in the house). The foster mother was also instructed in the preparation of powdered infant formula and cup feeding. She was told to feed Jasmine enough formula to satisfy her (about 6 or 7 times a day) and to drink any leftovers herself or give it to one of the boys. When Jasmine was observed breastfeeding, it was evident that she was transferring milk from the breast effectively (active rooting followed by long slow sucks, big swallows, relaxed expression, hand becoming more open through the feed, and sleepy after the feed). Her bowel movements also indicated that she was getting a significant amount of breast-milk. From that point, Jasmine’s foster mother was instructed to reduce the number of times she offered her formula during the day. Under two weeks later, Jasmine’s foster mother stopped offering formula milk altogether. Jasmine is now exclusively breastfed, and has regained and exceeded her birth weight. Lesson learnt: this example demonstrates the importance of prioritising IYCF-E. Through expert and dedicated support, vulnerable infants can be prevented from deteriorating nutrition situations to the extent where therapeutic feeding would be required.
Acute
undernutrition in adolescents and adults
Although the management of
acute undernutrition in children under five years of age has improved
considerably in the last decade, there are still gaps in evidence concerning
the treatment of acute undernutrition in adolescents and adults. Experience
shows that the specific nutritional needs of adolescents and adults require
adapted life-saving strategies beyond food assistance. It is therefore
imperative that undernourished adolescents and adults have access to
appropriate treatment and support. Women and adolescent girls can
be particularly vulnerable due to their productive, reproductive and social
roles.[28] Undernutrition in women
contributes to maternal deaths and is directly related to faltering nutritional
status and growth retardation in children. Maternal undernutrition is also
linked to low birth weight, which in turn results in higher infant morbidity
and mortality as well as long-term disability and chronic illness. The Commission
therefore encourages systematic attention to interventions that address
undernutrition among women in reproductive age, particularly during pregnancy
and lactation in the framework of all humanitarian contexts and closely monitors
the quality of the work of those partners whose work has a specific impact on
this group. The Commission also ensures that the special
needs of other specific groups within its beneficiary caseload (e.g. disabled,
elderly, chronically ill) are integrated into the design of humanitarian
nutrition responses.
5.1.2 Management of
micro-nutrient deficiencies (MND)
The Commission acknowledges the
growing international evidence gathered in recent years in relation to MND and
their specific impact on children’s morbidity, mortality and cognitive
development. Over 10% of deaths among children under five years of age are
attributed to deficiencies in Vitamin A, zinc, iron and iodine.[29] On the basis of assessed needs, the Commission
therefore supports nutrition strategies to both treat and prevent MND during
emergencies. The combination of response options adopted depends on the level
and severity of the problem: ·
Provision of fresh food
items that are complementary to a general food ration (e.g. through fresh food
vouchers); ·
Provision of fortified
food aid commodities[30] such as fortified cereal, CSB+/++ (corn
soya blend), lipid-based nutrient supplement and iodized salt and/or powders or
sprinkles for home fortification in the general ration; ·
Special attention to
the quality of complementary feeding for children under two years of age; ·
Distribution of
micronutrient supplements[31] either as single micronutrient (e.g. Vitamin A for
children, iron/folic acid for pregnant women) or population-level
supplementation[32] in the case of widespread deficiencies of specific
micronutrients, such as scurvy (vitamin C deficiency), pellagra (niacin
deficiency) and beri-beri (vitamin B and thiamine deficiencies); ·
Integration of
micronutrients into the prevention and treatment of certain diseases. Zinc has
been shown to be effective in the management of diarrhoeal diseases (prevention
of future episodes as well as reduction in the duration of current episodes),
which in turn can have serious nutritional consequences; ·
Provision of vitamin A
alongside, for example, measles vaccinations, can help to protect children against
infection. The Commission therefore supports interventions aimed at
incorporating zinc and vitamin A into delivery of healthcare services (e.g.
through the provision of zinc with low-osmolality oral rehydration salts (ORS).
5.1.3
Prevention of disease-related undernutrition
Undernutrition can be caused
and aggravated by diseases, therefore supporting free access to healthcare and
promoting a healthy environment is an essential component of the prevention and
treatment of acute undernutrition The synergistic relationship
between undernutrition, micronutrient deficiencies and various infectious and
parasitic diseases is well known (including diarrhoeal diseases, HIV/AIDS,
tuberculosis, Leishmaniosis, intestinal helminthic infection, respiratory
infections, malaria and measles). Undernutrition and micronutrient deficiencies
facilitate infection, and some infections may result, directly or indirectly,
in the development of undernutrition and micronutrient deficiencies. However,
in the current programmatic structure of nutritional programmes, the importance
of underlying diseases is often unaddressed. While tackling undernutrition
in emergencies, the Commission seeks to provide adequate emergency healthcare,
taking into account the specific needs of children below five years of age and
their mothers as well as pregnant women. These interventions may include: ·
De-worming as part of
integrated child health programmes, ·
Prevention and early
treatment of diarrhoeal diseases,[33] ·
Prevention and early
treatment of measles and malaria.[34] Access to (basic) primary healthcare
should be safeguarded for those who are most vulnerable to undernutrition. According
to the Commission's position on user fees[35] in
humanitarian situations, healthcare should be free at the place of delivery, in
order to ensure, as much as it is possible, that access to healthcare is
guaranteed to all potential beneficiaries. The Commission seeks to ensure
appropriate procurement (taking into account product quality and safety) and
storage of the necessary medical and nutritional inputs required to prevent
disease-related undernutrition. Regional prepositioning of essential supplies,
or support to national emergency preparedness stocks can facilitate timely
responses, if appropriately managed and supported by reliable information
systems.
5.2 Humanitarian Food Assistance and
Nutrition
Response options must be
context-driven and could include: General Food Assistance: - Provision
of free cash or vouchers (commodity-based or value-based)
distributed on a blanket basis - Distribution
of free food commodities on a blanket basis (general food distributions) including the provision of appropriate
fortified food items suitable for young children; Targeted Food Assistance: Targeted Food Assistance (TFA)
aims at reaching the most food insecure households (regardless of
whether General Food Distribution is under way). These interventions shall be
informed by a Household Economy Analysis (HEA): - Provision
of targeted free cash or vouchers (commodity-based or value-based) - Distribution
of free food on a targeted basis (targeted food distributions); -
Distribution of food, cash or vouchers on a targeted and/or
self-targeted basis, in exchange for a beneficiary’s time or labour (e.g. cash
for work, food for work, food for training, food for assets); Blanket
supplementary feeding distribution aims at reaching the most nutrition
insecure individuals (particularly young children, pregnant and lactating
women). These interventions shall be informed by sound nutrition surveillance. Food security and livelihood
interventions are potentially effective[36] instruments
for the prevention of undernutrition (as outlined in the conceptual framework).
Where response analysis is
appropriately performed, existing evidence suggests that cash transfers can
have a positive impact on dietary intake and therefore should be considered as
a key tool in the management of undernutrition. However, as is also the case
with in-kind food aid, assessing the exact impact of these transfers on changes
in nutritional status remains a challenge[37]. The Commission is committed to
addressing this gap through: (i) the promotion of a systematic inclusion of
nutrition-relevant objectives and indicators in the humanitarian food
assistance operations it supports (including food security information
systems); and (ii) consideration of operational research that contributes to
the collection of evidence on comparative performance between different strategies
and products. In the case of (i), this can be achieved for instance through
anthropometric measurements or dietary diversity indices and food consumption
scores. Where addressing undernutrition
is an important objective of food security interventions, the Commission starts
intervening in those areas where the prevalence of acute undernutrition is
highest. Operational case study Niger: The role of cash transfers in
reducing undernutrition in extremely poor households Save the Children UK (SC
UK) piloted a cash transfer social safety net programme in the Tessaoua
district of Niger’s Maradi region in 2008. In collaboration with local
authorities and with Commission
funding, SC UK assisted 1500 of
the poorest households to close the gap between the cost of food they needed to
purchase and their income during the lean season. Beneficiaries were
identified on the basis of a Household Economy Analysis (HEA) and wealth
ranking. Special consideration was given to households that included widows,
people with disabilities, and mothers and caregivers of children under five.
All beneficiaries lived in severely food insecure areas. One woman in each of
the families received direct cash assistance in three equal distributions,
contingent upon their participation in undernutrition and public health
awareness sessions. SC UK monitored 100
households three times: prior to the project, one month after the first cash
distribution (at the peak of the hunger gap), and one month after the final
distribution. Results showed that cash transfers allowed the poorest households
to meet their minimum food needs while enjoying a more diverse diet. The
injection of cash into the community stimulated petty trade and increased local
wage rates as people receiving the transfer worked in their own fields rather
than competing for work as wage labourers. Children under five were
found to have experienced an improvement in their nutritional status. This
phenomenon, however, was not sustained throughout time. An explanation could be
that cash transfers to families with young children may be more effective if
accompanied by micronutrient supplements and disease prevention measures as
cash alone might not address the complexity of nutrition insecurity. Nonetheless,
families were better able to meet their energy requirements and less likely to
take loans or mortgage assets during the hunger gap if they received cash
transfers. Lessons learnt: Cash transfers potentially have a positive
impact on the stimulation of local markets and dietary diversity. However, they
need to be accompanied by specific nutrition/health interventions to address
the complexity of nutrition security, with a particular focus on children under
five years of age. With regard to the management
of MAM, the requirement for evidence demonstrating the comparative advantage of
specialised nutrition products (including RUSF, and improved fortified blended
food) remains a priority. In general, however, supplementary food – as the name
indicates – is meant to supplement an existing diet (when such diet is deficient
in quantity and/or quality) and therefore a thorough situation analysis is
required to justify this specific choice of response. The Commission recognises
the potential effectiveness that improved fortified and/or nutrient-dense food
products could have on the treatment and prevention of acute undernutrition.
However, the Commission exclusively supports the use of specialised nutritional
products where specific conditions are deemed to be appropriate and upon close
monitoring of their effectiveness and impact.[38] Furthermore, it is recognised
that supplementary feeding should under no circumstances compete with or compromise
breastfeeding (for children 6-23 months even though no longer exclusively
breastfed). Therefore it is important that supplementary feeding is accompanied
by measures aimed at promoting and monitoring the continuation of
breastfeeding. Operational case study Somalia: Emergency cash transfer and food vouchers programme The 2011 drought in the Horn of Africa had a very serious impact on vulnerable people in Somalia, who were already affected by the long-lasting war. On 20 July, for the first time in almost 30 years, the United Nations officially declared the presence of a situation of famine in two regions in the southern part of the country (IPC Phase 5). Children in Somalia continued to be caught up in chronic and recurrent malnutrition crises with a country-wide median Global Acute Malnutrition (GAM) consistently and considerably above the emergency threshold. To respond to the urgent needs of the most vulnerable population, UNICEF, with support provided by the Commission, launched its widest ever cash/voucher programme in an emergency situation: The programme targeted 360,000 people (60,000 households) - the direct beneficiaries being the severely undernourished children under five years of age and drought-affected families in Southern Somalia. The objective was to reduce to (at least) below the emergency threshold excess mortality caused by nutritional deficiencies. The intervention was based on the provision of nutritional supplies and the distribution of cash transfer/vouchers. UNICEF completed 6 rounds of distribution worth a total of 60 million USD, each monthly round comprising 58 USD in vouchers and 100 USD in cash given to individual households. Given the high volume of funds devoted to cash transfer/vouchers and the novelty of cash interventions, the expectation in terms of results was very high: After three cash distributions, the first signs of resilience recovery could be seen; the improvement of the purchasing power of the very poor households targeted caused an increase in the purchasing of food, livestock and small business investments. The positive nutrition impact of the intervention was evident: the number of meals per day increased (from 1 to 2 for adults and 1 to 3 for children) and dietary diversity improved as well. Furthermore, between October 2011 and February 2012, SAM prevalence decreased from 12% to 8%. Lessons learnt: Overall, large-scale cash-based programming can be successful. · Large-scale, collaborative monitoring can be done also in complex conflict-affected environments · Functioning, efficient markets and the Hawala system (local Western Union) were key factors that allowed for the rapid impact of the intervention · Common monitoring improved programming and the assessment of the overall impact
5.3 Water, Sanitation and Hygiene (WASH) and
Nutrition
Environmental factors can be
major contributors to the occurrence and severity of undernutrition. Lack of
safe water, poor sanitation and inadequate hygiene practices all contribute to
the spread of infectious diseases. As such, they are directly linked with
faltering growth, lowered immunity and increased morbidity and mortality.[39]
The Commission therefore promotes the incorporation of
nutrition-specific objectives into WASH humanitarian responses in crisis contexts
where undernutrition is a major humanitarian concern.[40]
In these contexts, the Commission
supports those basic sanitation and behavioural change interventions that are considered
to be essential for the creation of a safe environment.[41]
These include: §
Water supply
interventions aimed at ensuring the provision of a clean and safe water supply,
in sufficient quantities and in a short timeframe. §
Sanitation
interventions focusing on immediate and safe excreta disposal. Priority is
given to the protection of drinking water sources from possible contamination,
particularly through human and animal excreta. §
Hygiene Promotion
focusing on immediate actions that have the greatest potential to reduce the risk
and spread of environmental health-related outbreaks (in particular hand
washing). Where possible, these actions are designed
and implemented in coordination with all relevant stakeholders including
community leaders and/or representatives and in accord with local/national
authorities. Equal participation of men and women
in planning, decision-making and local management of Emergency WASH operations
helps to ensure that the entire population obtains safe and easy access to WASH
services and that access to these services does not negatively impact on the
nutritional status of vulnerable groups, particularly women and children. There
are important gender dimensions related to WASH that would need to be fully
considered so as to prevent consequences that could be detrimental to women's
(and children's) well-being. Such gender and
nutrition-sensitive design supports, for instance, reduced burden and a shorter
water collection time for women, as well as improved protection for women and
young girls to be attained through an appropriate design of WASH facilities in
refugee or displacement camps. Specific measures to strengthen the
linkage between WASH and nutrition interventions and improved nutrition outcomes
include: ·
The
promotion of a Minimum WASH Packages in health facilities (including mobile
clinics) to improve the health environment; ·
Ensured
access to water for the poorest through the avoidance of user fees or, for
example, the provision of cash transfers to cover the costs associated to
minimum levels of consumption;[42] ·
Latrine
construction should avoid the risk of contamination by ensuring adequate
distance from food preparation, drinking water, storage of utensils, etc.;
Latrines should be properly constructed (e.g. concrete slab) to prevent
helminthic infections. ·
The
integration of nutrition awareness in hygiene promotion strategies; ·
Analysis
of the significance of water sources for livelihoods and the household economy
prior to interventions, in order to establish drinking water supply services and
avoid tensions between the potentially competing priorities of different groups; ·
Harnessing
humanitarian WASH operations as an opportunity for conditional cash or food
transfers, through the engagement of beneficiaries in the construction of their
own WASH services.
6 HUMANITARIAN AND
DEVELOPMENT ACTORS' SHARED CONCERNS
While it is important that
pre-existing high levels of chronic undernutrition are taken into account in
the design of any emergency response, this alone does not generally grant the
triggering of humanitarian mechanisms to provide nutrition assistance. In
contexts that are characterised by either chronic undernutrition (stunting) or
persistently high rates of acute undernutrition (wasting), or both, a longer-
term approach is required in order to ensure predictable funding modalities and
close cooperation with national government authorities. Understanding that such contexts are
primarily the outcome of serious structural factors lying outside the scope of
humanitarian assistance is essential. However, it is also crucial for all
actors involved to recognise that high levels of persistent undernutrition
imply an increased risk of morbidity and mortality and that the burden of
undernutrition associated with underdevelopment is far greater than the one
associated with crises of short duration. This section of the paper discusses
those aspects of nutrition crises that are best addressed by combining
interventions of humanitarian and development actors.
6.1 Chronic undernutrition (stunting) in emergencies
Although it is recognised that high
levels of stunting can lead to an increased risk of morbidity and mortality, stunting
is the effect of sustained nutritional deficit and development failure, and it
is not by addressing its effects alone that the phenomenon can be halted. Contrasting
stunting requires a long-term approach, with predictable funding modalities and
close cooperation with national government authorities. Humanitarian assistance for
nutrition offers no comparative advantage in this regard. Therefore, the Commission,
in principle, does not resort to humanitarian assistance in order to address
chronic undernutrition, and instead advocates for other instruments/actors to
respond. Although not justifying an
emergency response, pre-existing high levels of chronic undernutrition are
taken into account in the design of responses, as they can indicate the
vulnerability of any given population.
6.2 HIV/AIDS
HIV infection can cause nutritional
deficiencies in the form of reduced intake, higher metabolic needs, and
impaired nutrient use. Poor nutritional status may accelerate the progression
towards AIDS-related illness, undermine the use of and response to
antiretroviral therapy, and exacerbate the socioeconomic impact of the virus.
This in turn may have even broader impacts, as HIV infection reduces economic
productivity and thus food security. The Commission recognises the
positive impact that adequate food and nutrition can have on the management of
HIV and AIDS.[43] HIV-infected children
require special attention to secure their additional needs for growth and
development, in line with the WHO guidelines.[44] In accordance with its
guidelines on support to people living with HIV/AIDS[45]
in humanitarian situations, when nutrition or food crises occur in areas with
high prevalence of HIV/AIDS, the
Commission considers expanding
its nutrition support to HIV/AIDS affected persons (through adapted nutrition
interventions, or through food supplements in conjunction with anti-retroviral
treatment). The entry point for the humanitarian assistance for nutrition,
however, must be the threat or presence of a food or nutrition crises, and not
the prevalence of chronic illness with nutritional implications. The link between HIV/AIDS and nutrition HIV can exacerbate the effects of humanitarian crises. Likewise, displacement from a stable environment, food insecurity and poverty may increase vulnerability to HIV. Humanitarian disasters often occur in areas of high HIV prevalence. In emergencies, there is reduced access to basic food, health services, water and sanitation. These factors represent particular problems for people living with HIV who have specific nutrition needs. People living with HIV (even those without symptoms) have increased energy requirements, so access to food is of particular importance for them. In emergencies, the essential health services and HIV support and treatment services are often disrupted. Antiretroviral treatments, home-based care programmes, nutritional support programmes, and palliative care programmes are therefore likely to be in disarray. The health status of people living with HIV can deteriorate rapidly under these conditions, causing an additional burden on already strained emergency services. As gender inequalities may also be exacerbated in emergencies, there is a considerable probability that such inequalities may result in a disproportionate increase in the vulnerability of women to HIV, as opposed to the rest of the population. Furthermore, emergencies often result both in the separation of families and the breakdown of social support systems for individuals outside traditional family structures, which can have a particular impact on people suffering from HIV. Important activities to be supported 1. Integration of HIV into all aspects of emergency care: prevention, education, health, basic services, planning and management; 2. Targeted food support; 3. Maternal and infant health and feeding; 4. Treatment and care of HIV; 5. Treatment of severe acute malnutrition; 6. Support networks, including livelihood support and home-based care; 7. Food hygiene, sanitation, water, shelter; 8. Protection Specific recommendations for maternal and infant health and feeding · Exclusive breastfeeding for the first 6 months should be recommended for all infants regardless of HIV exposure (note: minimum requirements for safe formula feeding for babies born from HIV-positive mothers are usually not applicable in crisis settings). · HIV testing should be performed within maternal health services to identify HIV-positive women. HIV-positive women should receive ART (antiretroviral therapy) during pregnancy and delivery to reduce the likelihood of transmitting the virus to their children. · HIV-positive women should be encouraged to continue breastfeeding for 12 months along with the introduction of complementary feeds. When breastfeeding women are HIV-positive, both mothers and infants should receive ART for the duration of breastfeeding and for one more week after breastfeeding has stopped. · Because these women and children are at increased risk of malnutrition, they should be regularly screened for growth, nutritional status and illness. Adapted from: Global Nutrition Cluster, Harmonized Training Package/Module 18, 2011
6.3 Coherence, Coordination and Complementarity
6.3.1 Being more effective
in coordinating humanitarian and development aid: steps towards Resilience
In line with the new political framework on resilience
and the Commission
Communication on Resilience[46], the Commission stresses the need to maximise sustainable,
inter-sectoral, multi-stakeholder support to undernutrition over the longer
term, and to avoid the isolation of efforts within humanitarian response, with
the aim of strengthening the resilience of the most vulnerable communities. In particular, while respecting the difference in
principles and objectives, this should include joint analysis and planning with
development partners, in order to increase synergies.[47]
The Commission ensures as far as possible that short term and longer-term
nutrition-related needs are addressed in an integrated and articulated way to
prevent gaps in assistance, avoid duplication, ensure continuity and maximise
sustainability. To do this, close coordination is promoted with other
international donors and national actors. For instance, the work that is
currently underway in global and regional initiatives such as SUN may present
significant opportunities for more effective joint planning. In order for
interventions to be effective, however, each country situation should be
analysed individually and interventions should be designed according to needs
and the comparative advantages of available actors. The Commission strives to operationalize the commitments and
principles laid out in the 2007 Consensus on EU Humanitarian Aid[48]
and in the Commission Communication on Resilience. In particular, attention is
given to articulating the different Commission aid
instruments and ensuring appropriate consideration of nutrition issues in the Commission's
development policies and planning, with a specific focus on the relevant
country strategy papers. Operational Case Study Pakistan: Joint humanitarian-development
programming in a natural disaster situation The major floods in Pakistan in 2010 shed light on the
serious situation of undernutrition that was already prevalent in the country, both
at chronic and acute levels. In this context, most of the international
humanitarian responses were usually concentrated on addressing acute undernutrition
through food-based responses, with limited attention to those longer-term
investments that are necessary in order to prevent such decline. Support to
food security, livelihoods and agriculture was not explicitly linked to
combating undernutrition. DG ECHO and the Delegation of the European Union (DEU)
in Pakistan acknowledged the need for more explicit attention on programme
design in order to better address undernutrition. On the "Humanitarian side", the Commission’s interventions in nutrition
and food assistance are based on a comprehensive mix of activities addressing
the likely causes of the undernutrition in flood-affected areas of Pakistan. These include: - Support to the CMAM programme through UNICEF and
NGOs - Support to WFP for large-scale food and cash
distributions (mostly conditional on work programmes) - Flexible food security programmes designed according
to the local context through an alliance of 6 international NGOs On the "Development side" the following interventions are supported
by the Food Security Thematic Programme (FSTP) - Conditional cash transfers for flood-affected
communities - Integrated protection, offering women and their
children a safe place where they could take part in
nutrition and childcare related discussions - Monitoring of child acute undernutrition and women’s
diet Challenges: this ongoing experience indicates that systematic,
informed and structured exchanges between humanitarian and development actors
are necessary for addressing the immediate, underlying and basic causes of
undernutrition. The Commission therefore strives to achieve better
coherence and complementarity between humanitarian and development interventions.
To this end, and taking into consideration the holistic approach required when
tackling acute undernutrition, the Commission encourages, whenever
possible, the adoption of a robust policy and the promotion of programme
dialogue between all emergency and development stakeholders who are directly
or indirectly involved in the nutrition field. Preparedness measures play a vital part in ensuring the
connectivity between the fields of development and humanitarian action.
Efficient avenues of work should emphasise training, capacity-building,
awareness-raising, the establishment or improvement of local early-warning
systems and contingency-planning – all of which are highly relevant to
nutrition assistance. Operational Case Study Mali: Joint Humanitarian-Development programming in Nutrition The separation between emergency and development can create challenges in the design of appropriate responses to any given context. In Mali, for example, a firm distinction between emergency and development interventions is not always possible for several reasons: - Nutrition crises triggered by a shock (e.g. increases in food prices or droughts) are the result of both entrenched chronic poverty and vulnerability. The same shock in a less poor/vulnerable context may not lead to any crisis (or to crises of a similar magnitude). - Given their frequency, these crisis situations have become ‘chronic’ and a regular feature of the Malian landscape. - The ordinary levels of wasting in Mali, outside crisis conditions, tend to be above commonly accepted emergency thresholds. In Mali, it is of paramount importance that a package of measures be implemented to respond comprehensively to the existing situation. Such measures shall include addressing chronic poverty, food insecurity and vulnerability alongside specific actions to prevent and treat undernutrition. Such a package has been provided through the combination of European Humanitarian and Development assistance: -The European Humanitarian assistance funds the treatment of acute undernutrition; the provision of nutrition information and advocacy, calling on the government and development actors to give greater priority to nutrition. -The European Development assistance funds UNICEF to: · continue to support nutrition information and the treatment of acute undernutrition; · enhance prevention work through, for instance, a government/UNICEF breastfeeding campaign; · expand advocacy work (e.g. through a series of national and international media events) to increase awareness on the existing nutrition problem and mobilise actors to address it (e.g. at central and decentralised government levels, among community networks); and · strengthen the institutional setup and strategic environment that govern nutrition in the country. These practical links between humanitarian and development interventions were made possible through the coordination of European development assistance in the health sector and humanitarian assistance for nutrition. Lesson learnt: Effective coordination of humanitarian and development aid is not limited to technical complementarity, but requires a strong political commitment towards long-term strategic priorities in the field of nutrition. To this end, the Commission is actively involved in the initiative AGIR (Alliance Globale pour la Résilience) in the Sahel.
6.3.2 Global Governance and
Coordination for Nutrition in Emergencies
Effective coordination is paramount for the successful
management of undernutrition in emergencies. To this end, the Commission supports the work of the Global Nutrition Cluster[49]
(with UNICEF as the lead agency), the Food Security Cluster and the Health
Cluster. The Commission advocates for coherence and supports improved
coordination for nutrition across all relevant sectors and through the
engagement of all international actors who are involved in emergency nutrition
activities. In addition, coordination and cooperation need to go
beyond operational contexts, in order to ensure coherence in the scientific
evidence-base that informs policies and practice. For this reason, the Commission communicates with other global mechanisms which are concerned
with nutrition such as the UN Standing Committee on Nutrition (UNSCN), SUN and the
WHO’s Nutrition Guidance Expert Advisory Group (NUGAG), as well as the
Committee on World Food Security (CFS).
Annexes
A.1 List
of Abbreviations
AIDS Acquired immunodeficiency syndrome ART Anti-retroviral therapy BMI Body-Mass Index CFS Committee on World Food Security CFW Cash
for Work CMAM Community-based Management of
acute Malnutrition CoD Cost of Diet CSB (+/++) Corn-Soy
Blend (+/++ refers to the addition of micronutrient mix/micronutrient mix and
dried skim milk powder – replacing the basic CSB) DALYs Disability adjusted life years DEU Delegation
of the European Union DFID Department for International Development
– British Aid DG ECHO Directorate General for Humanitarian Aid and
Civil Protection EDF European Development Fund EU European Union Fe Ferrous/Ferric - Iron FSTP Food Security Thematic Programme GAM Global Acute Malnutrition GFD General Food Distribution HEA Household Economy Analysis HIV Human immunodeficiency virus infection IASC Inter-agency Standing Committee INGO International Non-Governmental
Organisation IPC Integrated Phase Classification IYCF(-E) Infant and Young Child Feeding (in
emergencies) LRRD Linking Relief Rehabilitation and
Development MAM Moderate Acute Malnutrition MAMI Management of acute Malnutrition in
Infants MDG Millennium Development Goals MN Micronutrient MND Micronutrient Deficiency MoH Ministry of Health MUAC Mid-upper arm circumference NGO Non-governmental Organisation NUGAG Nutrition Guidance Expert Advisory Group ORS Oral Rehydration Salt OTP Outpatient Therapeutic Programme RUSF Ready-to-use supplementary food RUTF Ready-to-use therapeutic food SAM Severe Acute Malnutrition SC UK Save the Children, United Kingdom SQUEAC Semi-Quantitative Evaluation of Access and
Coverage SUN Scaling up Nutrition
(imitative/movement) TFA Targeted
Food Assistance TB Tuberculosis USD United States Dollar U2s/U5s Under two(s) (children under two/five
years of age) UNICEF United Nations Children's Fund UNSCN United Nation Standing Committee on
Nutrition WASH Water, Sanitation and Hygiene WFP World Food Programme WHO World Health Organization
A.2
Note on Technical Terms
Nutrition is the science of how nutrients and other substances in food act and
interact in relation to health. Nutrition security[50] encompasses good health; a healthy environment;
good care practices and household food security (see Figure 1). Food security occurs when people, at all times, have physical and economic
access to sufficient, safe and nutritious food that meets their dietary needs
and food preferences for an active and healthy life.[51] A family (or country) may be food secure, yet include
individuals who are nutritionally insecure. Food security is therefore a
necessary but not sufficient condition for nutrition security. Hunger is
an outcome of food insecurity, where dietary intake, at population level, falls
below minimum requirements (typically averaged as 2,100 kcal per person per
day). Nutritional status is the physiological condition of a person resulting
from the balance between nutrient requirements, intake and the body’s ability
to use these nutrients. Anthropometry is human body measurement used as
a proxy for nutritional status (as per nutrition surveys). Malnutrition is a physical condition related to the body’s use of
nutrients. There are two forms of malnutrition: undernutrition and overnutrition.
This document deals only with undernutrition, since it is that form of
malnutrition that is of specific public-health concern in emergencies. An emergency or humanitarian crisis
is an event(s) which
critically threatens the health, safety, security or wellbeing of a large group
of people. The Commission
defines an emergency based on a combination of absolute thresholds (such as
Sphere or WHO) and relative indicators set against a contextual norm. A crisis
is triggered by a hazard that may be natural or man-made, with rapid or
slow-onset, and of short or protracted duration. Undernutrition includes: i) intrauterine growth restriction which
leads to low birth weight; ii) stunting; iii) wasting and nutritional oedema;
and iv) deficiencies of essential micronutrients. The causes of undernutrition
are multiple and context-specific. Undernutrition can be short-term (acute) or long-term
(chronic). Acute undernutrition in children under 5 years of age is
characterised by wasting (low weight compared to height) and/or nutritional
oedema. Wasting (marasmus) is a condition resulting from rapid
weight loss, or a failure to gain weight, over a short period of time. Acute
undernutrition can be moderate or severe. Together, these constitute the total
(or ‘global’) rate of acute malnutrition (GAM). Moderate acute malnutrition
(MAM) is defined as wasting > -3 and < -2 Z-scores[52] of the median weight-for-height of the reference
population; severe acute malnutrition (SAM) is < -3 Z-scores and/or
nutritional oedema (bilateral pitting oedema). Nutritional oedema may mask
wasting and therefore weight-for-height may not be observed. An alternative
rapid way to estimate acute undernutrition in children as well as in pregnant
and lactating women is the measurement of the mid-upper arm circumference
(MUAC). The management of acute undernutrition may involve the
use of specialised nutritional products[53] designed to supplement the diet with specific
micronutrients, energy/protein or both. These foods are usually intended for
home consumption, and are distributed through general rations, blanket
distributions (to groups at risk) or programmes targeting acutely
undernourished individuals. Chronic undernutrition results in stunting i.e. low height compared
to age (defined as <-2 Z-scores of the median height-for-age according to
WHO growth standards for children). The longer time-scale over which
height-for-age is affected makes it a better indicator for protracted
nutritional deficiency. The measurement of stunting is more useful for
long-term planning than for emergencies. Micronutrient deficiencies (MND) are a form of undernutrition that is
related to vitamins and minerals. Deficiencies of iron, iodine, vitamin A and
zinc are amongst the top-10 leading causes of death through disease in
developing countries[54]. Other deficiencies which are more
specific to emergencies include those of thiamine (B1), riboflavin (B2); niacin
(B3) and vitamin C. Underweight in children is a non-specific indicator of
undernutrition, since it includes children with low weight-for-height (wasting)
or low height-for-age (stunting). It is defined as < -2 Z-scores of the
median weight-for-age of WHO growth standards. Growth charts based on
weight-for-age, are used for growth monitoring in health centres. In
emergencies, weight-for-age can be used to indicate the presence of a problem
if data on acute undernutrition is not available. Adult undernutrition is usually assessed using Body Mass Index (BMI)[55] or Mid Upper Arm Circumference (MUAC).
Undernutrition in pregnant and lactating mothers is identified through MUAC and
clinical signs (lack of appropriate weight gain during pregnancy). Short
stature in women resulting from past stunting (height below 145cm in females
aged 15-49 years) can result in poor pregnancy outcomes. Undernutrition and mortality are late indicators of a crisis.
It is imperative that information on health, food security, water, sanitation
and hygiene is used to interpret estimates of undernutrition. The WHO
definition of thresholds[56] to guide such interpretation varies and has to be
used with caution and specificity to the context (also, thresholds for the
prevalence of moderate and severe acute undernutrition in children under five
years of age are subject to adjustments in light of the revised WHO growth
standards from 2006). Trend analysis can reveal a worsening situation even if
thresholds have not been crossed. Nevertheless, the WHO definitions provide a reasonable starting point
in assessing the severity of a crisis.
A.3
Policies and Guidelines in Support of this Staff Working Document
This document draws
on numerous internal and external policies, norms and guidelines. These are
listed here so that the present document can be read and understood within this
context. Internal The legal basis of EU humanitarian mandate
is defined in the Humanitarian Regulation (June 1996)[57]. In line with this, nutrition
interventions in crises are provided to meet humanitarian needs, but include
support to prevent or mitigate disasters and short-term post-emergency
recovery. The position paper incorporates the core
principles, objectives and standards for EU humanitarian action which are
delineated in the Humanitarian Aid Consensus (2008)[58] The Commission Communication on
Humanitarian Food Assistance Policy and its Staff Working Document[59]provides a framework for securing adequate
food consumption, necessary for nutrition security. The Commission Communication on The
EU Role in Global Health and its Staff Working Document[60] The Commission Communication on An EU
policy framework to assist developing countries in addressing food security
challenges[61] The nutritional needs of specific
vulnerable groups are addressed in DG ECHO HIV Guidelines (October
2008) and the Commission Staff Working Paper on Children in Emergency and
Crises Situations (2008); and The Commission Communication on
Disaster Risk Reduction (2009) identifies the strengthening of capacities
in disaster-prone contexts as an appropriate objective during humanitarian
response. External The Sphere Project. Humanitarian Charter and Minimum
Standards in Disaster Response. 2011 International Code of Marketing of Breast-milk
Substitutes, WHO 1977 WHO (2004) Guiding
Principles for Feeding Infants and Young Children during Emergencies UNHCR/UNICEF/WFP/WHO (2004) Food and
Nutrition Needs in Emergencies Management of Acute Malnutrition in Infants (MAMI) Project Review. Project
commissioned by the IASC Global Nutrition Cluster. Summary Report, ENN, October
2009. Guidelines on Infant and Young Child
Feeding in Emergencies. IFE Core Group, Feb 2007 Community Based Management of Severe Acute
Malnutrition. A Joint
Statement by the World Health Organisation, World Food Programme, the United
Nations System Standing Committee on Nutrition and the United Nations Children's
Fund. May 2007. Preventing and controlling micronutrient
deficiencies in populations affected by an emergency. Joint statement by the World Health
Organisation, the World Food Programme and the United Nations Children's Fund.
2007. WHO Child Growth Standards and the
Identification of Severe Acute Malnutrition in Infants and Children. A joint statement by the World Health
Organisation, and the United Nations Children's Fund. 2009. [1] 2 UNICEF-WHO-WB joint child
malnutrition estimates - 2012 [3] "Excess"
is considered to combine absolute measures in relation to establish emergency
thresholds as defined by the SPHERE handbook, UNICEF, and the UN Standing
Committee on Nutrition (SCN), and relative measures in relation to
context-specific baselines, see Communication on Humanitarian Food Assistance [4] Communication from the Commission to the Council and the European
Parliament on Humanitarian Food Assistance COM (2010) 126 [5] Unless otherwise stated, figures presented in this section are from
the first paper in the Lancet series: Black R.E. et al. (2008): Maternal and
Child Undernutrition: Global and regional exposures and health consequences. Lancet 371, 243-260.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61690-0/fulltext. [6]UNICEF-WHO-The World Bank joint child malnutrition estimates (2012) [7]
http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Progress2012/English2012.pdf [8]For instance: ‘The neglected crisis of undernutrition: DFID’s
Strategy’ (http://collections.europarchive.org/tna/20100423085705/http://dfid.gov.uk/Documents/publications/nutrition-strategy.pdf);
the French government strategy: ‘Nutrition dans les Pays en Développement —
Document d’Orientation Stratégique’
(www.diplomatie.gouv.fr/fr/ministere_817/publications_827/enjeux-planetaires-cooperation-internationale_3030/documents-strategie-sectorielle_20004/les-pays-developpement-nutrition_12
87987.html); Ireland’s Hunger Envoy Report 2010
(http://www.irishaid.gov.ie/uploads/Hunger_Envoy_Report.pdf); and Germany’s
strategy Rural Development and its Contribution to Food Security, 2011 (http://www.bmz.de/en/publications/type_of_publication/strategies/Strategiepapier302_01_2011.pdf)
[9] For example: World Bank 2010: Scaling
up Nutrition. What will it Cost? By S. Horton et al. and Save the Children
2009: Hungry for Change. An eight-step, costed plan of action to tackle
global child hunger. [10]http://www.scalingupnutrition.org/ [11]The EU Role in Global Health (COM(2010)128) and An
EU policy framework to assist developing countries in addressing food security
challenges (COM(2010)127) [12] Reference document n°13 "Addressing undernutrition in external
assistance" http://capacity4dev.ec.europa.eu/topic/fighting-hunger [13] Document “Food Assistance Convention – 25 April 2012” [14] Source: Reference Document n° 13 "Addressing undernutrition in
external assistance" [15] However, this understanding
has served to highlight the opportunities for enhanced synergies with
longer-term efforts by the Commission to prevent undernutrition, by
underscoring the crucial requirement to intervene both to save lives and to
avoid long-term adverse outcomes for this age group. This understanding has
also heightened attention to potential evidence regarding specific challenges
that can be associated with ensuring access to nutritional assistance for
children under two years of age. [16] Note: Throughout this document, where reference is made to pregnant
and lactating women and their associated physiological nutrition vulnerability,
it is acknowledged that this overlaps considerably with the nutrition
vulnerability of ‘women of reproductive age’ and ‘adolescent girls’ and that
such considerations can have significant operational implications. [17] For example, high
case-fatality rates of severe acute undernutrition have been attributed to
inappropriate case management and poor knowledge of medical staff. Wider
implementation of the WHO guidelines through in-service training and incorporation
into medical and nursing curricula is the key to substantially decreasing
case-fatality rates of SAM. Collins S. et al. Management of severe acute
malnutrition in children. The
Lancet, Vol. 368 (9551), page 1992-2000, 2 December 2006. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69443-9/abstract [18] http://www.ipcinfo.org/ [19]http://www.savethechildren.org.uk/resources/online-library/the-household-economy-approach-a-guide-for-programme-planners-and-policy-makers;
http://www.savethechildren.org.uk/resources/online-library/the-cost-of-the-diet [20]http://oneresponse.info/crosscutting/gender/Gender%20Marker%20Materials/Nutrition%20Gender%20Marker%20Kit.pdf [21] http://sites.tufts.edu/feinstein/2011/sex-and-age-matter [22] DG ECHO (2005) Manual Project Cycle Management. Brussels [23]Such as SMART (Standardized Monitoring and Assessment of Relief and
Transitions): http://www.smartmethodology.org/index.php?option=com_content&view=article&id=1084&Itemid=298&lang=en [24] See Emergency Nutrition Assessment:
Guidelines for field workers. Save the Children, November 2004. [25]77.6% recovery, 0.7% mortality and 4.2% default rates. [26] Nahar; B., Hamadani, J.D., Ahmed, T., Tofail, F.; Rahman, A.; Huda;
S.N.; et al (2008): Effects of psychosocial stimulation on growth and
development of severely malnourished children in a nutrition unit in Bangladesh. European Journal of clinical nutrition; September 2008. [27] Management of Acute Malnutrition in
Infants (MAMI) Project commissioned by the Global Nutrition Cluster; Summary
Report. ENN; October 2009. [28] Women are the primary carers of children and the main
decision-makers with regards to their children's dietary consumption. Women's
education and status in society are directly linked to the nutritional status
of the children in their care. [29] See table 6 in: Black, R.E. et al, for the Maternal
and Child Undernutrition Study Group. Lancet 2008; 371: 243 [30] See WHO/FAO 2006: http://www.who.int/nutrition/publications/micronutrients/9241594012/en/
and WHO 2009: http://www.who.int/nutrition/publications/micronutrients/wheat_maize_fortification/en/ [31] See WHO (2006): http://www.who.int/making_pregnancy_safer/publications/Standards1.8N.pdf [32] See
WHO/WFP/UNICEF 2007: http://www.who.int/nutrition/publications/micronutrients/WHO_WFP_UNICEFstatement.pdf [33] See Joint WHO/UNICEF Statement (2004): http://whqlibdoc.who.int/hq/2004/WHO_FCH_CAH_04.7.pdf [34] See Conclusions and recommendations of the WHO Consultation on
prevention and control of iron deficiency in infants and young children in
malaria-endemic areas (2006, currently under revision) http://www.who.int/nutrition/publications/micronutrients/FNBvol28N4supdec07.pdf [35] DG ECHO position paper on user fees for Primary Health services in
Humanitarian crises, April 2009. "In an emergency context, DG ECHO will
promote access to healthcare for all and in particular for the poorest and
those in greatest need and will discourage partners to apply any user fee
system. If no alternative source of income is guaranteed for payment of
salaries or the recurrent costs or for replenishment of drugs or medical
supplies, DG ECHO has to make a well informed choice and to consider covering
the financial gap. Any choice should be based on considerations of the national
and political context and the possible consequences of abolishing user fees." [36] Bhutta Z. et al 2008: What works? Interventions for
maternal and child undernutrition and survival. Maternal and Child
Undernutrition Study Group. The Lancet 371 (9610) p417–440. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61693-6/fulltext [37] Bailey, S,
Hedlun, K. (2012): The impact of cash transfers on nutrition in emergency and
transitional contexts, http://www.odi.org.uk/resources/docs/7596.pdf
[38] Minimum
standardised monitoring (e.g. SPHERE or national protocols); Minimum Reporting
Package www.mrp-sw.com [39] The Lancet Series
includes hand-washing and hygiene interventions among the core measures that
reduce the risk of diarrhoea. The hygiene and hand washing dimensions of food
preparation are an important part of the ‘childcare’ component of nutrition
programmes, especially in areas where water and sanitation are poor. Guidelines
on hand washing and hygiene are at: http://www.unicef.org/wes/index_43084.html [40] The Lancet Series include hand-washing and
hygiene interventions among the core measures that can reduce the risk of
diarrhoea. The hygiene and hand-washing dimensions of food preparation are an
important part of the 'childcare' component of nutrition programmes, especially
in areas where water and sanitation are poor. Guidelines on hand-washing and
hygiene are at: http://www.unicef.org/wes/index_43084.html [41] WHO/FAO 2006: Guidelines on food fortification with micronutrients.
At: http://www.who.int/nutrition/publications/guide_food_fortification_micronutrients.pdf [42] The humanitarian priority is that any user fee must be accompanied
by a commitment to ensuring that the needs of the most vulnerable are covered
and that no one shall be excluded from accessing WASH services. [43] The 2001 UN General Assembly Special Session Declaration of
Commitment on HIV/AIDS and the 2006 Political Declaration on HIV/AIDS,
recognise that food security and nutrition are interlinked with HIV. In
particular, Article 28 of the Political Declaration resolves “to integrate food
and nutritional support” in responses to HIV, “with the goal that all people at
all times, will have access to sufficient, safe, and nutritious food to meet
their dietary needs and food preferences for an active and healthy life, as
part of a comprehensive response to HIV/AIDS”. [44] WHO 2009. Guidelines for an integrated approach to nutritional care
of HIV-infected children (6 month-14 years); http://www.who.int/nutrition/publications/hivaids/9789241597524/en/index.html [45] DG ECHO HIV Guidelines, adopted on 8
October 2008. [46]
http://ec.europa.eu/europeaid/what/food-security/documents/20121003-comm_en.pdf [47] As an example, see the ‘Humanitarian
Development Framework – a joint methodology between DG ECHO and DEVCO, 2012 [48] EU Humanitarian Consensus, 2007: Section 2.4, Article 22;
Section 3.4, Article 53; Section 5; Annex. [49] http://oneresponse.info/GlobalClusters/Nutrition/Pages/default.aspx [50] Gross,
R. et al. (1998) in Community Nutrition: Definition and Approaches. Encyclopaedia
of Human Nutrition. Ed. by Sadler, M., Strain S. and Caballero B. London. [51] World Food Summit, 1996 [52] Z-score
(or standard deviation score) is the deviation of the value for an individual
from the median value of the reference population, divided by the standard
deviation of the reference. [53] The terms
ready-to-use food (RUF) and ready-to-use therapeutic food (RUTF) are often used.
[54] Black R. et al (2008): Maternal and Child Undernutrition: Global
and regional exposures and health consequences. Lancet 371, 243-260. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61690-0/fulltext [55] Weight divided by the square of height (kg/m2) [56] GAM emergency threshold > 15 %; Mortality emergency threshold >2/10,000/day,
WHO [57] Council Regulation (EC) No 1257/96 of 20 June 1996 concerning
humanitarian aid OJ L 163, 2.7.1996, p. 1–6 (ES, DA, DE, EL, EN, FR, IT, NL,
PT, FI, SV)
[58] European
Consensus on Humanitarian Aid, 2007 OJ L C25/01, 30.1.2008 [59] COM (2010)126
final, March 2010 [60] COM (2010)128
final, March 2010 [61] COM (2010)127 final,
March 2010