PA Nutrition in emergencies

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FOOD SECURITY ASESSMENTS \*
Food security refers to access by all people at all
M times to sufficient, safe and nutritious food for
a healthy and active life. Food insecurity is oneERof the three underlying causes of malnutrition.
There are three components to food security: Gavailability (sufficient quantities of appropriate
food are available from domestic production, EF commercial imports or food assistance); access
(adequate income or other resources to access O appropriate food through home production,
buying, barter, gifts, borrowing or food aid)R and utilization (food properly used through
appropriate food processing and storage practices,
M adequate knowledge and application of
nutrition and child care, and adequate health andATsanitation services).
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In emergencies, the way people obtain food is often disrupted. Conducting emergency food
security assessments (EFSA) is essential to plan interventions to protect food security and
prevent potential malnutrition through distribution of food aid or cash, agricultural and economic
support.

Approaches to food security assessments

There is no single standard method for assessing food security in emergencies. Different
agencies have developed their own approaches and there is a broad variation in the indicators
collected, methods used, and the degree to which nutrition data are included. EFSA approaches
can be classified into three groups.

a) Early warning and surveillance approaches

This form of assessment depends on the continuous collection and interpretation of information.
Many early warning systems and surveillance systems have been set up at country, regional and
international levels. Systems rely heavily on secondary data (information already collected by
another agency), which come mainly from national government statistics on rainfall, crop
production, prices and imports/exports and from satellite imagery. Such systems have generally
been successful in predicting impending food crises, although not as accurate at pinpointing
exactly when a crisis is likely to occur.

b) Economic and livelihoods approaches

These approaches view food security within a broad economic or livelihoods (means of living)
context. One-time surveys are usually carried out and information collected on a variety of
indicators both quantitative (based on amounts or numbers) and qualitative (based on qualities or
opinions). The information is used to estimate the household food deficit and to project what the
deficit may be in the future.

c) Nutritional status approaches

Food security has an indirect effect on nutritional status and is one element that is assessed along
with other factors that impact on nutritional status. Nutritional status approaches tend to be one-
time surveys that collect a variety of information.

Implementing a food security assessment

Although the specific approaches to EFSA use different methods, there are a number of steps
that many approaches typically follow and can be applied to most situations.
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Step 1: Preparation \*
This includes setting objectives, selecting and M training assessment teams and organizing
logistics. Most EFSAs are carried out to addressERfour broad objectives:
1. Estimation of the severity of food security G
2. Projection of future food security EF
3. Identification of vulnerable groups O
4. Identification of appropriate interventions R
M
Step 2: Secondary information collection AT
This involves collating relevant government and1agency reports.
Step 3: Primary information collection
This involves collecting original data. Methods of data collection include questionnaires,
measurement, observation, interviews and focus group discussions. Food security, unlike
malnutrition, cannot be measured by a single indicator. There are many indicators of food
security as shown below.

Table 4: Indicators of food security

Categories of indicators Examples of indicators
Food availability Rainfall, Crop production, Livestock holdings and status
Food access Income and food sources, Essential expenditure, Assets
Livelihood strategies, Market prices of key staples and assets
Coping strategies
Food utilization Nutritional status, Health status
Feeding practices, Food consumption

Step 4: Analysis
This step covers the interpretation of the data and information collected.
Step 5: Report writing and dissemination of results

DIETARY INTAKE ASSESSMENTS

The amount of food one consumes will directly influence the nutrition status. Inadequate food
intake in respect to the recommended intake will lead to under nutrition. Inadequate dietary
intake is mainly due to,
o Lack of food
o Poor combinations
o Unbalanced diet
o Less amount to meet needs

Methods of assessing dietary intake

a) Diet history
In taking diet history you need to obtain information for the past one month or two weeks.
Information you need to obtain include;-cultural aspects of food consumption, detailed
description of food consumed in terms of frequency of consumption and portion sizes.

b) Food frequency
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In this method you obtain qualitative and\*descriptive information about variety of food
consumed. Here you have a set of all foodsMand set of frequency of consumption. Then the
interviewee is expected to indicate how many
ER times a certain food from a particular food
group is consumed or whether is not beingGconsumed at all. Before carrying out the study
you may need a preliminary survey to determine
EF foods commonly consumed in that area.
O
c) 24 hour recall R
In this method you are expected to determine
M the amount of nutrient consumed by an
individual for the last 24 hours. The purpose
AT of a 24 hour recall is to establish if intake of
nutrient was adequate. You ask the respondent
1 to remembering detail the type and quantity of
foods consumed during the previous 24 hours.

d) Estimated food records

In this method you ask the respondents to record all the foods and beverages consumed at all
the time during meal times. The respondent should give a detailed description of the foods
i.e. amount consumed and ingredients used in the food.

Approaches to the assessment of micronutrient malnutrition

There are two main approaches to assessing micronutrient malnutrition in emergencies.

1. Indirect assessment involves the estimation of nutrient intakes at a population level and
extrapolating from this the risk of deficiency and the likely prevalence of micronutrient
deficiency disease.

2. Direct assessment involves the measurement of actual clinical or sub-clinical deficiency in

individuals and then using that information to give a population estimate of the prevalence of
the micronutrient deficiency disease.

The indirect assessment approach involves two stages. First, measuring or estimating the
dietary intake of the population and, second, comparing this intake with the nutrient
requirements of the population.

Direct assessment of micronutrient deficiencies can use clinical signs and symptoms and/or
biochemical testing to diagnosis the presence of micronutrient malnutrition. These detection
methods can be combined with survey techniques to generate an estimate of the population
prevalence (rate) of micronutrient malnutrition.

Information on actual or potential micronutrient malnutrition should always be cross-checked

against other available data to try and obtain the most accurate picture of what is happening.
Micronutrient malnutrition remains a major public health issue that is far from being eliminated.

HEALTH ASSESSMENTS
Assessments are a vital component of planning and implementing an emergency response.
Malnutrition and disease are closely linked and therefore joint assessments that address both
nutrition and health are important.Emergencies can have a broad negative impact on the health of
the affected population. It is essential to conduct an assessment to determine the public health
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impact of the crisis. This includes determining \* whether there are health-related risk factors, the
actual health problems, the risk of an increase Min morbidity (illness) and mortality (death), the
resources available such as health services, health
ER staff, medical supplies and equipment, and the
needs and priorities for response. The assessment G needs to include factors that affect health, such
as shelter as type of shelter is related to the risk
EF of acute respiratory infections, and water as
water quality affects risk of diarrhoeal disease. O
R
Different types of health assessments M
Health assessments can take several forms. TheATmain distinction is between rapid (carried out in
a couple of days) and a more in-depth comprehensive1 assessment (with time spent on collecting
detailed data). Surveys are also used to assess indicators such as mortality and malnutrition.
There is a tool that combines three clusters namely health, nutrition and WASH (water,
sanitation and hygiene). This is mainly used for initial rapid assessments (IRA) This tool assist
with a multi-agency (involves several agencies) and multisectoral (involves several technical
sectors) approach, ensuring that the inter-linked health and nutrition needs of emergency-affected
people are met through an integrated analysis and response.

Key health information to be assessed

Key assessment information includes health status, capacity of existing health services and wider
information, such as the water, sanitation and shelter needs, all of which will have an impact on
health and nutrition status. Caring practices, such as infant and young child feeding (IYCF)
should also be considered. Assessing health status involves analyzing the available information
on morbidity and mortality.

Some of the indicator to monitor are;-

Crude mortality rate (CMR) – this is the rate of death of the entire population, including both
sexes and all ages. A CMR of double the normal rate or above 1 death per 10,000 per day
indicates an emergency situation.

Under five mortality rate (UCMR)-The mortality rate for children under five years of age is
calculated as a rate of the number of deaths of children under age five of the total number of
children under five years of age. The aim should be to maintain the rate at or below 2 deaths per
10,000 per day (or double the normal rate).

Methods of obtaining nutrition information

There is no single prescribed method for obtaining nutrition information. A variety of nutrition
information sources are used depending on the context, what is appropriate, available and
feasible. It is best to use representative data collected from the population.

The following are the main methods for obtaining nutrition information;
 Rapid nutrition assessments that involve rapid screening based on mid-upper arm
circumference (MUAC).
 Large scale national surveys and repeated small scale surveys. Surveys are good sources
of nutrition status data, morbidity and mortality and food security data. In most cases
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o Clinic-based monitoring E
o Sentinel site surveillance \*
 Early warning systems -Many early warningM systems (EWS) have been set up at national
ER
and regional levels. These have become increasingly sophisticated and no longer rely
solely on food production information. GEWS now incorporate information on access to
food as well as availability like marketsEF
and coping strategies. Systems which have been
O
operating for a number of years in famine-prone countries have built up baseline
R
information and an understanding of trends so that alerts to pending emergencies are
M
produced in a timely manner.
AT
 Monthly and annual reports -These are monthly bulletins generated on monthly bases on
1
food security status
 Secondary data-Data from health facilities can be used to inform the action to be taken.
For example immunization data, prevalence of a certain disease or sschool census data.

Indicators commonly used

In emergencies, acute malnutrition, especially wasting, among children 6 to 59 months is usually
taken as a proxy indicator for the general health and well being of the entire community.
However, in certain contexts information on the nutritional status of adolescents, adults or the
elderly may also be valuable.

A number of standard indicators are used to assess the nutritional status of the population and the
underlying causes of malnutrition. These include:
 Anthropometric measurements
 Clinical and biochemical indicators of micronutrient deficiency diseases
 Indicators to assess the underlying causes of malnutrition such as care practices, health
status, water and sanitation, and food security

Information on other indicators may also be relevant such as mortality (death), population
displacement numbers and shelter conditions.

Uses of the information in emergency

a. Used in identification and prioritization of interventions.
b. Used for monitoring and evaluation.
c. For nutrition programming
d. For decision making.
e. Used for planning purposes
f. During the targeting beneficiaries
g. For preparation of budgets
h. In gaps Identification

Data collection and analysis

Data should be accurately and frequently collected. The analysis process should be intensive to
lead to an appropriate action. There are a variety of computer programmes that can be used to
analyze nutrition and related data. These include Nutri-survey software Epi-Info and SMART for
ENA. The quality of data needs to be maintained at a high level in order for it to be credible.
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Interpretation of data \*
The following should be taken into account when M interpreting data:
1. Rates of acute malnutrition in relation ER to thresholds for response. A number of
classification systems have been developed G around which particular emergency
interventions should be initiated. In addition,
EF more specific nutrition ‘decision trees’ have
been developed to indicate when selective O feeding programmes should be started.
According to WHO, cut off points by useR of MUAC for children are as follows;
M
Table 5: Cut off points for MUAC among childrenAT
Nutrition implication
1
>13.5 cm Normal
>12.5 – 13.5 At risk
11.0 to 12.5 cm Moderate
< 11. 0 cm Severe
< 12.5 cm GAM

2. Trends over time and seasonality. Nutrition data must be interpreted in relation to pre-
emergency levels of malnutrition and normal seasonal patterns.

3. Underlying causes of malnutrition. The relative importance of food, health and care as
nutritional risk factors need to be identified so that appropriate responses can be
prioritized.

4. Relationship between malnutrition and mortality. The relationship between mortality

and nutritional status is not clearly defined. In some cases it is strong and in others it is
weaker.

INTERVENTIONS

FOOD AID
Food aid refers to the forms of assistance given directly in form of food. Food aid remains the
dominant form of response to nutrition-related problems in emergencies. For standardization of
ration, the United Nations has introduced standards for emergency food rations. An adequate
basic ration should provide an intake of up to 2100 kilocalories of energy per person per day and
include a range of foods that are acceptable and broadly familiar to the population and fit for
human consumption.

The underlying purpose of food aid is based on the needs of the affected population. These are;
 To provide a short-term income transfer or income substitution to people to allow
household resources to be invested in recovery and long term development.
 To provide sufficient food resources to eliminate the need for survival strategies, that
may result in long-term negative consequences for human dignity, household viability,
livelihood security and the environment.
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 To sustain life by ensuring adequate availability
\* and access to food by people affected by
disaster. M
Methods for distributing food aid ER
There are four systems for distributing food aid to
G populations:
 General Food Distribution (GFD) EF
 Food-for-work (FFW) O
R
GENERAL FOOD DISTRIBUTION M
GFD is the main mechanism used to distribute AT food aid to a population during emergencies.
GFDs target households rather than individuals.1General food distribution (GFD) is when a food
ration is given out to selected households affected by an emergency. The food ration will consist
of a number of items. The minimum three are cereal, pulses and oil, but items can be added, such
as salt, sugar, fresh vegetables, tinned meat or fish. The general ration is normally delivered as
dry items.

The main objectives of a GFD at the outset of an emergency are to save lives and to protect the
nutritional status of the population. As the situation improves, GFD objectives can broaden to
include the protection of livelihoods. GFD has frequently been implemented in response to acute
food insecurity.

Nutrition content of food rations

A well-balanced ration should provide a suitable combination of macronutrients and
micronutrients. Cereals make up the bulk of the food ration and provide most of the energy, a
large part of the protein and significant amounts of micronutrients. Pulses and oil seeds are an
important source of protein and provide a range of micronutrients. Blended foods are a processed
mixture of cereals and other ingredients and are fortified with vitamins and minerals.
Unfortunately, even a full ration is frequently lacking in some micronutrients. Ration planning
for GFD
There are two stages for calculating food aid requirements. The first stage is to establish the
energy requirements and the second stage is to select the quantity and type of food commodities.

Stage 1: Calculate energy needs

The planning figure of 2100 kilocalories is multiplied by the population size to establish the
overall energy requirements for a population. The planning figure of 2100 kilocalories may be
adjusted for the following reasons;

 Age and structure of the population. Women and children require less energy than
men.
 Nutrition and health status of the population. Malnourished children require extra
food for catch-up growth. Physical activity levels- those with high physical activity
require more energyEnvironmental temperature- For every 5 oC drop below 20oC, an
additional 100 kcal/day/person should be provided.
 Access to alternative food sources
 Provision of milled or un-milled cereal. The volume of milled cereal is 20 per cent less
than whole cereal.
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\*
Stage 2: Selection of type and quantities of foods
M the commodities for the food ration.
The following should be considered when selecting
ER
 Nutritional and dietary considerations- Foods supplied in the ration must be
nutritionally complementary to the foodsGpeople obtain for themselves.
 Risk of micronutrient deficiency diseases EF (MDDs)
 Acceptability and familiarity of the foodOitems
R
 Storage, quality control and specifications- All foods distributed must be fit for human
M
consumption and meet certain quality specifications.
AT
 Food processing and preparation-Food 1 commodities should be easy and quick to
prepare and cook.
 Availability and substitution of food items- Ration items that are unavailable can be
replaced by available food items to maintain the nutritional balance of the ration.
 Ration cost and resale value -The most cost-effective ration is based on a combination
of cereals, legumes and oil. The inclusion of high re-sale commodities in the GFD allows
beneficiaries to purchase other essential food and non-food items.

Factors to ensure successful GFD

1. Context awareness- It is important to be aware of the social and political divisions within
the area and whether GFDs may increase local tensions.
2. Management and coordination-All those involved in planning and implementing a GFD
must, as far as possible, be neutral, impartial and willing to be accountable and transparent.
Roles and responsibilities should be clarified at the onset to ensure effective coordination
among the key players.
3. Training and support for the implementation process. Sufficient support and capacity
building must be given to newly formed GFD committees.
4. Decentralized GFD system- When distributing food aid to dispersed and mobile populations
a decentralized system will help to increase the coverage rate and help to reduce the
exclusion rate.
5. Timing of the GFD- GFD implemented before mass migration, adoption of long-term
negative coping strategies and increased rates of severe malnutrition and mortality will be
more cost-effective than GFD implemented later. The potential impact of GFD on food
production should also be considered.
6. Women-There is a view that women are more likely to ensure that food aid resources are
consumed by household members. Targeting food assistance to women is a requirement of
the World Food Programme.
7. Cost to the recipients-When planning a GFD system it is important to consider the cost
(opportunity) to the recipient.
8. GFD mechanisms-A GFD programme may use a combination of existing structures and
newly established structures for implementation. Implementation includes registration of
recipients, developing ration cards or recipient lists, designing scoops of specific sizes to
apportion food, establishing distribution cycles, identifying distribution points and employing
an appropriate mix of staff.

FOOD FOR WORK

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In some cases the food distribution is undertaken
\* in form of food for work. The vulnerable
households are identified for the program. Development
M work within the community is also
identified. In the identified households, able members
ER are identified to undertake he task. The
work done is compensated in form of food. G
Examples of development work that can be doneEFin a community are;
 Road construction O
 Clearing road sides R
 Dams construction M
 Public works like construction of schools AT
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SUPPLEMENTARY FEEDING PROGRAM
Emergency supplementary feeding programmes (ESFPs) provide nutritious supplementary foods
to vulnerable groups in emergencies. Programmes aim to rehabilitate mild or moderately
malnourished individuals or to prevent a deterioration of the nutritional status of those most at
risk by meeting their additional needs, focusing particularly (but not exclusively) on young
children, pregnant women and breastfeeding mothers. ESFPs are generally perceived as short-
term measures to compensate for an inadequate general food distribution (GFD).

In this program you target moderately malnourished under five, pregnant and lactating mothers.
SFP is normally started when global acute malnutrition (GAM) is between 10-14 %.

It can either be given as dry ration where the beneficiaries are given a take home ration
fortnightly or as wet feeding where the beneficiary assemble at a feeding center daily to feed
from there. SFP should be started during the onset of an emergency and when GFR are still in
place.

The inclusion criteria-

 Under five children MUAC < 12.5-11cm or 70-80% weight for height
 Pregnant mothers and lactating mothers MUAC< 22 or BMI of 16-18.5

The food commodities usually given in an SFP are,

 Unimix or Corn soy blend (CSB)
 Vegetable oil
 Sugar
 High energy biscuits

Types of Emergency supplementary feeding programmes

There are two types of Emergency supplementary feeding programmes;
1. Targeted – This targets identified individuals who are severely malnourished. Targeted
Emergency supplementary feeding programmes should be run in conjunction with a GFD
that provides for all the nutritional needs of the population except particular groups.
Groups that might require Emergency supplementary feeding programmes are: the
malnourished, who have additional nutritional requirements for catch-up growth; the
medically ill, who have additional nutritional requirements for tissue repair; and certain
socio-economic groups, who have restricted access to the GFD
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\*
2. Blanket – gives food to all individualsM within a specified group. Blanket ESFPs aim
primarily to prevent deterioration in the ER
nutritional status of at-risk groups in a population
and to reduce the prevalence of acute malnutrition
G in children under age five. Blanket
ESFPs may be set up at the onset of an emergency
EF when GFD systems are not adequately
in place and/or rates of acute malnutrition
O are high (e.g., more than 15 per cent), an
increase in rates of malnutrition is anticipated
R due to seasonally induced epidemics or in
case micronutrient deficiency disease outbreaks.
M
AT
Modes of feeding 1
There are two modes of feeding;
1. Wet feeding
2. Dry feeding

Wet feeding
Supplementary food can be distributed as onsite feeding or wet rations. Wet rations is where
beneficiaries are given daily cooked food at feeding centres
Onsite feeding should provide from 500 to 700 kilocalories (500 kilocalories recommended but
up to 700 kilocalories to account for sharing with siblings at the centre) of energy per person per
day, including 15 to 25 grams of protein. Two meals are needed for children given their small
stomach size. Food is also needed for caregivers.

Dry feeding is when beneficiaries are given take-home dry rations through the regular
(weekly or fortnightly) distribution of food in dry forms that should be prepared at home.
Take-home rations should provide from 1000 to 1200 kilocalories per person per day and
35 to 45 grams of protein in order to account for sharing at home and should be provided
in the form of a pre-mix. Women need an additional 350 kilocalories /day from the third
month of pregnancy and 550 kilocalories per day for breastfeeding.

Take-home rations should always be considered first as these programmes require fewer
resources and there is no evidence to demonstrate that onsite ESFPs are more effective. Other
advantages of dry ration feeding include less risk of cross-infection in overcrowded feeding
centres and lower demands on mothers and caretakers who only have to attend every week or
fortnight. Onsite feeding may be justified when food supply in the household is extremely
limited, firewood and cooking utensils are in short supply and the security situation is poor
placing beneficiaries at risk when returning home carrying weekly food supplies.

Admission, discharge criteria in ESFPs

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Targeted ESFPs should be implemented when \* there are large numbers of malnourished
individuals (e.g., prevalence (rate) of 10 to 14 per
M cent acute malnutrition and/or when rates are
between 5 to 9 per cent but there are aggravatingER factors such as high rates of disease). Criteria
for admission and discharge to programmes are G based upon different degrees of malnutrition
using weight-for-height as the measurement forEF children under age five and body mass index for
adults. O
R
Guidelines tend to prioritize target groups as Mfollows: malnourished children under age five
including those discharged from therapeutic feeding
AT programmes, followed by malnourished
children over age five, then selected pregnant and1 breastfeeding women, and, finally, individuals
with social and medical problems such as twins, orphans, the disabled and elderly people. It is a
typical practice to close down a programme when there are less than 30 patients. New cases
should then be referred to health centres or hospitals.

Food commodities for ESFPs

Supplementary foods must be
1. Energy-dense and rich in micronutrients,
2. Culturally appropriate,
3. Easily digestible and palatable.

Examples of ESFPs
1. Blended foods, such as corn soy blend
2. Vegetable oil
3. Sugar
4. High energy biscuits (HEB)

OUT-PATIENT FEEDING PROGRAM

Selective feeding programmes have been revolutionized by the development of ready-to-use-
therapeutic-foods (RUTF). Home-based therapy using RUTF has reduced the need for feeding
centres thereby allowing children to be treated in the community. This has led to far greater
coverage and has prevented overcrowding in centres where the risk of epidemics is high.

Objectives of therapeutic care

The main objective of therapeutic care is to save the lives of individuals with severe acute
malnutrition (SAM). Severe acute malnutrition is a complex medical condition that needs
specialized care to save the patient’s life. It can be identified using anthropometry (body
measurements). Therapeutic care programmes can obtain very high recovery rates (above 80 or
90 per cent) and reach most malnourished individuals in the community.

Components of OTP
Acutely malnourished children are identified in the community or directly in a health facility.
Three forms of treatment are provided according to the severity of the child’s condition;

1. Individuals with moderate acute malnutrition and no medical complications are supported in
a supplementary feeding programme (SFP) that provides dry take-home rations and standard
medicines. The objectives of SFP programmes are to decrease the incidence of severe acute
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malnutrition and treat moderate acute malnutrition.
\* Technically, this is not therapeutic care,
but SFPs are usually linked to therapeutic care
M during emergencies.
2. Individuals with SAM with no medical complications
ER are treated in outpatient care sites
(health centres or posts), with RUTF and routine
G medicines. These are taken at home, and the
child attends the outpatient care site weekly EF
or biweekly.
O
Admission criteria R
Several admission criteria are currently used for M deciding which children should be admitted to
therapeutic care. All are based on the useAT of weight-for-height and/or mid-upper arm
circumference (MUAC) and presence of bilateral1 oedema.

Treatment protocols
Routine medicines are given on admission. Vitamin A and folic acid are recommended only for
children with marasmus presenting specific deficiency symptoms, or when there is high risk of
deficiency (e.g., during an outbreak of measles).

Routine antibiotics are given to all children, given the high prevalence of silent infection in cases
of severe malnutrition. A curative course of anti-malarials is often included in areas of high
malaria prevalence. Children over nine months are usually vaccinated against measles.

Medical treatment
Routine medical treatments for those admitted to ESFP are recommended. Patients referred from
a therapeutic care programmes will already have received treatment. Usual treatments include:
1. Supplementation with vitamin A on admission
2. Treatment of all children for worm infections
3. Measles vaccination for all children between 9 months and 15 years of age
4. Supplementation of iron and folic acid on admission and then administered weekly

STABILIZATION CENTER
Inpatient care is provided for the treatment of cases with medical complications or infants or for
those that cannot participate in outpatient care (e.g., where outpatient care is not available). It can
be organized as residential care (with the patients staying overnight) or, less often, as day care
(with the patients returning to their homes for the night). It can be established as an attachment to
an existing hospital or health centre, or as an independent structure. Patients usually stay a
maximum of 10 days in inpatient care before they can be referred to outpatient care to complete
treatment at home. Medical treatment and therapeutic feeding are given according to the
principles of WHO guidelines. Inpatient care facilities should be staffed with nurses and with
physicians (at least part-time and reachable 24 hours a day), feeding assistants (1 assistant for 10
patients), cleaners and kitchen staff. One supervisor (usually a clinician) is needed for each
inpatient feeding facility.

Inpatient and outpatient care are different components of the same programme. Even if
implemented by different agencies, the programmes need to be integrated and coordinated to be
effective. Overall supervision of the three programme components is required.
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 Bilateral oedema \*
 Anorexia (lack of appetite) M
 Severe oedema ER
 Marasmus with any level of oedema G
 The presence of associated medical complications
EF
O
R malnutrition are always admitted to inpatient
Infants below six months of age with severe acute
care with their mother or caretaker. M
AT
1
Individuals with SAM who have medical complications or infants (below six months of age)
with SAM need to be treated in inpatient care until they are well enough to continue being
treated in outpatient care.

Feeding protocols
 Patients with complicated SAM should be admitted to an inpatient facility for the
stabilization phase. This is achieved with F75 therapeutic milk and specific medical
treatment. Meals are given six to eight times per 24 hours (throughout the day and night).
The patient should not receive any other food during this period.

 When appetite returns and oedema is reduced, the patient is ready for the transition phase
of inpatient care. During the transition phase the patient is supposed to receive an
increased amount of energy, but still needs careful monitoring. If it is possible to admit
the patient for outpatient care, RUTF should be given. If the patient does not take enough
RUTF or has difficulties swallowing, a replacement feed (F100, a specialized therapeutic
milk to promote weight gain) is given. As soon as the child starts gaining weight without
developing complications he or she is upgraded to the rehabilitation phase, which ideally
should be implemented in outpatient care. When this is not possible, the patient should
stay in inpatient for the remainder of treatment with F100.

 Patients in the rehabilitation phase have either passed through stabilization and transition
phases or have a good appetite and no complications from the start and have been
admitted directly into the rehabilitation phase as outpatients. RUTF, a paste or crushable
biscuit that has the same composition of F100, is the therapeutic food used in outpatient
care. Specific amounts are given for the week, according to the child’s weight. The
objective is to maintain weight gain. It is important to train mothers or caretakers during
the rehabilitation period on how to feed their child with available local foods.

 Throughout treatment, it is important to promote emotional and physical stimulation of

the child, to prevent developmental delays and mental disorders. Special programmes for
this should be organized in all centres.

 During outpatient care, the patient visits outpatient facilities every week or every two
weeks for follow-up treatment and receives routine drugs and RUTF. During these visits,
health and nutritional education, with an emphasis on appropriate infant and young child
feeding practices, should be given. If the patient is not recovering at home, or if
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E by a clinician and referred to inpatient care if
complications occur, the patient is assessed
necessary. During treatment, the patient \* is monitored through a patient’s card where
weight, MUAC, clinical assessments andMtreatment received are noted.
ER
 Infants below six months of age (or belowG 3 kg of weight) are treated with a different
EF
protocol aimed at reinstating breastfeeding, when this is appropriate for the mother or
O by a method called supplementary suckling
another female caregiver. This is achieved
R
where the infant is fed diluted F100 through a tube attached to the mother's nipple
M
thereby stimulating milk production at the same time as being fed.
AT
1
 HIV-infected malnourished patients can recover their nutritional status with these
protocols although minor modifications may need to be made to the antibiotics given. To
prevent toxicity, antiretroviral drugs are started only when nutritional status improves and
any metabolic disturbances have been corrected.

 Patients are discharged from outpatient care when they meet target weight-for-height or
MUAC, and have good weight gain with no signs of oedema for two weeks. Patients
discharged from therapeutic care are then followed up at an SFP for a period of four
months.

LIVELIHOODS SUPPORT
These are broad-based approaches to address malnutrition and prevent death. These approaches
are more sustainable. The protection and promotion of people’s livelihoods in emergencies is
essential for safeguarding food and income security which in turn determine nutritional status.
Livelihoods programmes are relatively cost-effective compared to other responses like food aid.

There are a large variety of livelihoods interventions that can be implemented in emergencies.
These can be categorized under
 Income and employment
 Market support
 Production support.
Objectives of livelihood support
These include:
 Preventing the sale of, or maintaining, essential assets such as livestock or farm land
 Providing essential assets or providing households with the means to acquire them
 Supporting livelihoods strategies, such as livestock production, agriculture, small
businesses or enterprises
 Diversifying livelihoods
 Improving access to markets
 Improving the capacity of local institutions and Governments to respond to crises and to
improve livelihood security

The main aim in highly unstable situations is livelihood protection and saving lives. In more
stable contexts, programs may be able to build or recover assets and protect existing ones.
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INCOME AND EMPLOYMENT SUPPORT\*
The main form of income and employment is the M cash transfer interventions. Cash distributions
are often more cost-efficient when compared to ER food aid and can also be faster to implement.
Cash can be easily invested in livelihoods as wellG as improve the status of marginalized groups.
Cash is appropriate when food and essential EFnon-food items are available and markets are
functioning. O
R
Cash transfer interventions are mainly done soMas to provide cash for use in purchase of food
items that are not being supplied. It also assistsATthe affected population towards attaining assets
and meets needs in education and medication. 1

In theory, cash grants are quicker and can be applied on a larger scale in acute emergencies. Cash
or commodity vouchers can also be exchanged either with traders and retailers in shops or with
traders or producers in local markets, distribution outlets, fairs and other events organized
specifically for the programme. Voucher programmes are most commonly used for seed or
livestock fairs.

Criteria for selecting cash transfer beneficiaries;

 Pension approach by targeting the elderly
 Dependency ratio where the number of dependants in a household is considered
 Vulnerability where the most vulnerable members of the community are targeted.
An outline of the process of implementing cash transfer program
 The donor, implementing agencies and monitoring and evaluation organizations come
design the program
 The targeting criteria is determined
 Social Rights Committee are established
 The beneficiaries are identified
 The amount to be provided per person is determined
 Agents are identified mainly shopkeepers in the affected regions
 Sensitization of involved parties
 Registration process of beneficiaries
 Communication on release of funds
 Withdrawal and use of money
 Monitoring and evaluation of the program

Challenges
 Security concerns for staff or recipients
 Price distortion (e.g., inflation) within the local market.
 The risk of taxation or diversion by local authorities or elites, as well as the risk of
theft before and after delivery.
 Limited communication

MARKET SUPPORT
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Developing market access interventions is \* critical in promoting livelihoods of affected
populations. The aim of market support programmes
M in emergencies is generally to ensure that
people’s access to basic goods is maintained. ER
G
Market support interventions can take many forms:
EF
 Cash and voucher programmes O
 Support programmes to market infrastructure
R
 Maintenance of food prices in markets through
M the provision of subsidized foods.
 Assisting producers to access markets. AT
1
Simple market analysis tool are available which can assist in determining whether an increase in
demand for basic goods, created by cash distributions, can be met through the market.

PRODUCTION SUPPORT
Production support includes crop production, livestock and fishing support. These can take a
variety of forms, depending on the stage and type of emergency and the livelihoods affected.

Emergency crop production programmes are generally part of a rehabilitation programme, and
most commonly comprise seeds and tool distribution often implemented in conjunction with
general food distribution to ensure that seeds are not eaten or sold for food.

there are other types of responses or support given to individuals who meets certain criteria.
MONITORING AND EVALUATION OF NUTRITION RESPONSES

PROGRAMME MONITORING

Monitoring is an ongoing review of program indicators to assess the process of achievement of

the goals. It is an appraisal of programme activities towards achieving its activities. Monitoring
can also be referred to as periodic oversight of the implementation of an activity which seeks to
establish the extent to which input deliveries, work schedules,

Types of monitoring

There are broadly two types of monitoring;

 Process monitoring is about monitoring programme delivery. For example, in the case of
general food distribution key process indicators are food pipeline flows, food management
and coverage.
 Impact monitoring assesses how food security, nutrition status, mortality rates and micro-
nutrient deficiencies have changed as a result of the intervention at population level. For
example, in the case of therapeutic care, the numbers of children treated and cured,
numbers defaulting and dying are monitored.
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Reasons for Monitoring \*
M
1. For decision making on the continued interventions
ER
2. To show programme strengths and weaknesses
G
3. To assess whether programme resourcesEF are being put into right use
4. Used to measure programme inputs O
5. To review strategies R
6. To observe the trends of the programme M
7. It is a management tool that helps the ATstakeholders to improve their effectiveness and
efficiency in addressing the problems in emergency
1
8. It is helps the affected people in an emergency to increase awareness and understanding
of` various factors affecting their lives.
9. To provide useful information to stakeholders. It enables the implementing agency and
the affected community to check on any processes and impact of the programme / check
on achievement of the objectives
10. It identifies or anticipates problems in the programme so that solution can be sought
11. It forms the basis for evaluation. It is almost impossible to evaluate a programme that was
not monitored
12. For future programming where the experience acquired will help in planning for future
similar programmes
13. To identify the gaps and areas for adjustments
14. For accountability especially by donors whose continued support depend assurance that
the intervention are within the plan and area geared towards meeting the objectives.

PROGRAM EVALUATION
Evaluation is the assessment of the overall program performance mostly done at the end of the
program. Evaluation is the process of determining the relevance, effectiveness, efficiency and
impact of activities in light of specified objectives. It is a learning and action-oriented
management tool and a process for improving current activities and future planning,
programming and decision-making. This is an appraisal of programme achievements against the
expected and set objectives outcomes. Evaluation should begin at the planning stage and extend
through the implementation stage to the end of the programme. It involves in-depth
comprehensive analysis of an intervention and its operations with the objectives. It questions the
relevance of the initial choices and looks at their performance.

Types of Evaluation
1. Context evaluation: Context evaluation is concerned with the assessment of existing
information of the funding agency, the target group and the general programme
environment.
2. Formative evaluation: This is the day to day running of the programme towards
acquisition of short term objectives therefore assess programme input, output or services
and the general events in the programme environment
3. Impact evaluation: Determine the ultimate effect on the beneficiaries in the long term. It
is concerned with ultimate programme indicators.
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Reasons for evaluation \*
1. Provide useful information for other ongoing
M or future programme in the community
2. To provide useful information to stakeholders
ER
3. To determine whether the programme was G successful or not
EF
Evaluation indicators should be specific, independent
O and valid. The evaluators are either
insiders who implemented, took part in theR planning of the programme and are more
knowledgeable about the programme or external M people who did not take part in the planning
and implementation of the programme. The external
AT people are more objective than insiders.
1
Factors that contribute to programme failure
1. Poor programme coverage or targeting
2. Due to cost sharing policy where beneficiaries are needed to contribute some resources
and they are unable.
3. Poor programme planning especially where community is not involved
4. Failure to monitor and evaluate the programme
5. poor utilization on programme resources
6. Failure of community to participate in the programme

The following are areas normally included during nutrition intervention;

 Effectiveness: (achieving objectives – doing the thing right, including cost-effectiveness)
 Efficiency: (doing it right, with as few resources as possible; effort, time, money, people,
material)
 Relevance /Appropriateness (doing the right thing in the right way at the right time)
 Impact (doing the right thing, changing the situation more profoundly and in the longer-
term)
 Coverage (the extent to which the interventions reach the intended target population-
linked to effectiveness)
 Timeliness (as well as appropriateness). In emergencies there are different responses at
different points in the emergency. These are generally expressed as: (immediate) response
and rescue; recovery (short to medium term); rehabilitation (medium to long term).
Interventions should be tailored to the phases.
 Connectedness (and coordination). In order for a complete service to be offered to
vulnerable individuals and households, agencies need to ensure that they coordinate
effectively.
 Coherence. For nutrition interventions in emergencies to be coherent they need to provide
a minimum package for beneficiaries and, as far as possible, fit into the medium and long
term plans of the host government.
 Preparedness. Verify whether preparedness activities took place (for example, pre-
positioning of therapeutic foods) and the effectiveness of the activities undertaken.

Monitoring indicators
Each intervention program has specific indicators for evaluation.

Indicators for evaluation of SFP and OTP programs

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Recovery rate - >75% of total program
\* exits
Death rate - <3% of total program
M exits
Defaulter rate - <15% of total program
ER exits
Attendance rate - >75% G
Programme Coverage - 60% EF
O
Sources of Information for Monitoring and Evaluation
R of a Programme
1. Reports from staff, nutrition survey, monthly
M weekly/annual reports
2. Minutes of meeting AT
3. Staff members 1
4. Other agencies
5. Community interviews
6. Local administration/ leaders
7. Documents receipts and letters etc.

CHALLENGES IN MONITORING AND EVALUATION

There are a number of major challenges for monitoring and evaluation:
 Lack of standardization of methodologies and indicators
 Lack of time for establishing a baseline making it difficult to measure change (impact)
 Monitoring and evaluation systems are often established in a rapidly changing
environment (for example, changes in the people affected and population movement)
 Lack of an agency with a mandate to act upon findings from nutrition evaluations
 Lack of information on the cost effectiveness of nutrition intervention

HUMANITARIAN ASSISTANCE
Humanitarian assistance is the help provided to the affected populations in an emergency. The
international humanitarian system includes a wide range of organizations that have a role in
alleviating human suffering arising from emergencies. Included are; the United Nations agencies,
the Red Cross movement, non-governmental organizations (NGOs) and Donor agencies.

Humanitarian coordination is coming up together by all the humanitarian agencies to plan and
harmonize the process such that the assistance is delivered in a cohesive and effective manner in
order to save lives and reduce suffering among those affected.

Humanitarian coordination
Humanitarian coordination is essential because a coherent cooperative response to an emergency
by all agencies will maximize the benefits and minimize errors in the response. This must be
achieved by delivering the right assistance, to the right place, and at the right time – enabling
those affected by conflict and disasters to achieve their rights to protection and assistance.

This has been through technical clusters so that during an emergency, all agencies working in a
particular technical area coordinate their activities. The nutrition cluster aims to improve
nutrition coordination, capacity building, emergency preparedness, assessment, monitoring and
 PA Nutrition in emergencies
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surveillance. Currently (2005-2010), there is \*a nutrition cluster with 35 agency members,
including United Nations agencies, non-governmental
M organizations and the Red Cross
Movement. UNICEF is the lead agency. ER
G
COMPONENTS OF HUMANITARIAN SYSTEM EF
There are several components of the humanitarian O system. Each component supports a range of
nutrition-related activities in emergencies. ManyR of them have memorandum of understanding to
guide and help coordinate their roles and responsibilities
M with respect to nutrition-related
activities. AT
1
These are;
 United Nations humanitarian system
 Donor agencies
 International Red Cross and Red Crescent Movement
 Non-governmental organizations
 Military
United Nations humanitarian system
The United Nations humanitarian system is composed of six key actors:
1. United Nations High Commissioner for Refugees (UNHCR)
2. World Food Programme (WFP)
3. United Nations Children’s Fund (UNICEF)
4. World Health Organization (WHO)
5. Food and Agriculture Organization (FAO)
6. United Nations Development Fund (UNDP)

In the 1990s a number of new mandated bodies were created to strengthen the United Nation’s
response to both complex emergencies and natural disasters. Among these is the Inter-Agency
Standing Committee (IASC), a forum for coordination, policy development and decision making.

The IASC includes;

 United Nations agencies
 The International Committee of the Red Cross
 Three NGO umbrella groups (Inter-Action for NGOs based in the United States, the
Steering Committee for Humanitarian Response and the International Council of
Voluntary Agencies).

The Office for Coordination of Humanitarian Affairs (OCHA) has responsibility for coordinating
the United Nation’s response to complex emergencies and natural disasters, including soliciting
donor support through the consolidated appeals process (CAP) and issuing emergency appeals on
behalf of countries affected by disasters.
Donor agencies
Foreign governments either provide aid bilaterally (government to government) or channel
assistance through United Nations agencies, the Red Cross and NGOs in support of a
humanitarian response. For example, the European Community Humanitarian Organization
(ECHO) is the humanitarian arm of the European Commission. The European Union’s mandate
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to ECHO is to provide emergency assistance \* and relief to the victims of natural disasters or
armed conflict outside the European Union. ECHOsM grants cover emergency aid, food aid and
aid to refugees and displaced persons. The routeER of assistance depends on the nature of the
emergency and on political and logistical factors.G
International Red Cross and Red Crescent Movement
EF
The International Committee of the Red Cross O(ICRC) and the International Federation of Red
Cross (IFRC) which includes National Red Cross R and Red Crescent Societies is known as The
Red Cross Movement. The ICRC is mandated by M the international community to be the guardian
and promoter of international humanitarian law AT and provides assistance to people affected by
armed conflict and other situations of violence. 1 The IFRC is the largest humanitarian
organization and carries out relief operations in non-conflict areas.
Non-governmental organizations
Large-scale emergencies are characterized by the mobilization of local and international civil
society organizations. These range in size, capacities and quality of response. The largest global
non-governmental humanitarian organizations are represented by the Steering Committee for
Humanitarian Response. NGOs undertake many different activities in nutritional crises but
usually on a relatively small scale.
Military
Military is deployed, usually on peacekeeping or peace enforcement missions. Military carry out
projects that would normally be regarded as the business of humanitarian or aid agencies.

STANDARDS AND ACCOUNTABILITY

One of the fundamental issues with the delivery of quality humanitarian assistance is
coordination among the members of the international community. Thus, there must be standards
and accountability in humanitarian response. Standards refer to desired levels of programme
delivery and impact in terms of quality. Accountability refers to the means by which individuals
and organizations report to a recognized authority (or authorities) and are held responsible for
their actions.

There are two initiatives to improve standards and accountability;

1. Code of Conduct
2. Sphere Project
The Code of Conduct
The Code of Conduct was drawn up in 1992 to set ethical standards for organizations involved in
humanitarian work. It consists of a number of humanitarian principles that include:

 Humanity. Prevent and alleviate human suffering wherever it may be found. Protect life
and health and ensure respect for the human being.
 Impartiality. There is no discrimination on the basis of nationality, race, religious beliefs,
class or political opinions. Relieve the suffering of individuals being guided solely by their
needs and to give priority to the most urgent cases of distress.
 Independence. Maintain autonomy to be able at all times to act in accordance with the
principles.
 Neutrality. Not taking sides in hostilities or engage at any time in controversies of a
 PA Nutrition in emergencies
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political, racial, religious or ideological nature.
\*
The Code aims to provide a practical framework M for accountability by connecting the principles
ER
of humanitarianism to standards of service delivery.
G
The sphere project EF
The Sphere Project was launched in 1997 by a group O of humanitarian NGOs and the Red Cross.
R
It aims to improve the quality of assistance to people affected by disaster and improve the
accountability of states and humanitarian agencies M to their constituents, donors and the affected
AT
populations. There is a handbook: Sphere Humanitarian Charter and Minimum Standards in
1
Disaster Response. This describes the rights of people affected by disasters and includes a set of
standards for humanitarian response by sector. There is a chapter on food security, nutrition and
food aid.

Sphere minimum standards in food security, nutrition and food aid

Minimum standards in food security, nutrition and food aid are qualitative neutral statements that
are meant to be universal. They specify the minimum levels to be attained in humanitarian
response. They are complemented by key indicators which are ‘signals’ that show whether the
standard has been attained, by measuring the impact or result of programmes as well as the
process and methods used. Guidance notes in the handbook provide specific points to consider
when applying the standards and indicators in different situations, guidance on tackling practical
difficulties and advice on priority issues. They may also describe dilemmas, controversies or
gaps in current knowledge. In addition to these standards, there are standards from other sectors
which are directly related to the underlying causes of malnutrition. These relate to water,
sanitation and hygiene promotion; shelter, settlement, non-food items and health services.

Sphere is frequently used as a tool in evaluations of humanitarian response and can be used to
highlight the gaps in high quality services to populations in stable situations. There are certain
emergency situations where standards and key indicators cannot be met. These include the
presence of constraining factors include:
 Insecurity or denial of access
 Displacement
 Lack of staff
 Cultural factors
 Bureaucracy
 Logistical constraints
 Livelihood patterns

Where key indicators are not met, it is essential to identify and understand the reasons why they
have not been met and to consider alternative strategies, which may facilitate meeting the key
indicators.

While the standards promoted by Sphere may be universal, the specific indicators used to
determine attainment of those standards need adjustment on an emergency-specific basis. It is
recognized that too great an emphasis on meeting key indicators can have unintended detrimental
side effects and decisions should be based on a context by context basis.
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\*
Three principals of humanitarian chatter in emergency
M
There are three main principles that govern operations
ER in an emergency. They are stipulated in
the sphere book. G
EF
 All the affected populations are entitled
O to a decent life and dignity. That means that
despite the fact that one is compromised
R by a disaster, he/she is entitled to normal life
and should receive quality service. M
 The rule of non-refoulement. This states
AT that a refugee / asylum seeker or a displaced
1 country or place of origin except in situations
person should not be forced back to his
when such persons consent.
 Entitlement to immunity for both combatants and non-combatants – this states that all
the parties in an emergency are entitled to protection. These are those being afflicted,
those causing the conflict and those offering humanitarian assistance.

Limitations of the quality and accountability initiatives

There a number of unresolved issues in relation to standards and accountability in nutrition in
emergencies: These include;

 There is no body with overall responsibility for the creation, adherence to, and
improvement of technical standards in nutrition in emergency response.
 There is a need to update universally applicable standards for response to meet changing
demands and practices in the field of nutrition in emergencies.
 The application of minimum standards can create differences in the standards of living
between emergency-affected and surrounding populations.
 Lack of funds restricts delivery of humanitarian assistance.

CHALLENGES IN NUTRITION IN EMERGENCIES

A number of challenges face nutrition in emergencies. These are mainly operational and result
from the political and institutional factors that have a major influence on the outcomes of
response to emergencies. They are:

 Impartiality in responding to nutrition emergencies

 Dominance of food aid
 Constraints of the operational environment
 HIV and AIDs related issues
 Lack of an evidence base for interventions
 Lack of skills and expertise in nutrition in emergencies
Impartiality in responding to nutrition emergencies
There is no agreed upon classification system for declaring a nutrition emergency or triggering
particular responses. Areas with high rates of malnutrition are not necessarily recognized as
nutrition emergencies and may not receive emergency international aid.

Dominance of food aid

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The needs in emergencies are both in food and \* non food interventions. Food aid is the dominant
form of aid in emergencies. Donors rarely provideM support for non-food interventions. There are
a limited number of international agencies able ER to implement non-food aid interventions in
emergencies due to their lack of experience and/or
G mandate.
EF
Constraints of the operational environment O
Many emergencies occur in extremely hostile and R difficult environments. There are cases where
malnutrition rates are high and it has been veryMdifficult to address the problems purely because
logistical and access problems. Relief operationsATare therefore hampered by;
 Insecurity 1
 Lack of access to the affected population
 Transportation problems
 Lack of infrastructure
In conflict situations, beneficiaries may periodically be prevented from attending feeding centers
while implementing agencies may be unable to deliver food stocks.

HIV and AIDS related issues

Working with HIV and AIDS in emergencies situations has been a challenge. The standard
guidelines around nutrition and HIV and AIDS in emergencies have not yet been developed.
These challenges include;
 Issues of stigma
 Discrimination
 Violence and sexual abuse
 Lack of adequate treatment regimes
 Safe motherhood practices among those affected by HIV and AIDS

Lack of evidence-base for interventions

Due to new emergencies occurring, interventions are rarely piloted and the few that are piloted
are not well monitored and evaluated. This heavily lies on agency experience, resource
availability and in some cases, ideology rather than an evidence base of effectiveness. As a
result, some emergency nutrition interventions are repeatedly introduced without any evidence at
all that they are effective.

Inadequate skills and expertise in nutrition in emergencies

In nutrition, there is no overarching body that can oversee advice on and encourage best practice.
This means that improvements in nutrition field practice often take a long time to be translated
into general practice, because it involves creating awareness among nutritionists as well as
governments and donor agencies.