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close this bookNutrition Guidelines (MSF, 1995, 191 p.)
close this folderPart I: Nutrition Strategies in Emergency Situations
View the document1. Food crises
View the document2. Assessment of the nutritional situation
View the document3. Interventions: ensuring adequate general food availability and accessibility
View the document4. Interventions: selective feeding programmes
View the document5. Evaluation

1. Food crises

Introduction

In emergency situations, food security is often severely threatened causing increased risk of malnutrition, disease and death.

Emergency health workers/organizations have the responsibility to try to cure the malnourished, prevent malnutrition amongst the vulnerable and promote adequate distribution of food to allow a healthy existence.

The complexity of food and nutrition as an issue means that the best response to a situation depends on the context.

Part I attempts to define emergency nutrition needs (Chapter 1), to outline the information needs critical for decision making (Chapter 2), and some of the essential tools for assessing nutrition problems (Chapter 3). A range of potential interventions for alleviation of nutritional emergencies is then discussed (Chapters 4 and 5). The final Chapter deals with the necessity of evaluation as a means to manage programmes, monitor population needs and adapt programmes over time (Chapter 6).

Malnutrition, food insecurity and famine

Household <<food security>> is a concept that refers to the ability of a household to feed its members, enabling them to live full and active lives.

Inadequate household food security for a population, on short or long term basis may lead to different forms of chronic and or acute malnutrition.

While malnutrition is a disease of the individual, the causes of malnutrition are often complex and multi-sectoral, and are linked to different social and economic factors (see Figure 1).

Action to improve household food security (improve availability and access to food) may need to cover a broad range of sectors (agricultural, land ownership, price supports, inflation, taxation, etc.).

In emergency contexts, there is often a sudden and massive reduction in food availability (drought, conflict, isolation, siege, transport problems) or reduction in food accessibility to some sections of the community (displacement, reduced purchasing power, increased prices). The result is often acute and severe food insecurity, which may lead to high levels of malnutrition and mortality.

In acute food crises the extent of global acute malnutrition means that nutrition becomes an emergency health issue.

However, even in emergencies, nutrition and food accessibility is a complex social issue and population groups may envolve complex coping strategies to deal with reduced availability/access to food.


FIGURE

A complete breakdown in food security systems leads to acute food shortages which may lead to famine (a time of destitution and increased mortality).

The process of food shortage leading to famine has been described in different phases:

1. Change of behavior to cope with hard times (rationing of food, sale of excess cattle, etc.).

2. Sale of capital and income earning assets - which means future prospects are damaged (loans, sale of essential tools, land or cattle).

3. Break down of established life patterns and destitution (distress migrations, reliance on aid, etc.).

4. Starvation and death - famine.

Emergency food interventions

Under emergency conditions, General Food Distributions (GFD) aim to bring the nutritional value of the diet, for the whole population, up to a "sufficient" level for survival.

GFDs are often insufficient to meet the needs of all members of the population and/or distribution of food is unfair, so that certain vulnerable groups (growing children, pregnant and lactating women, elderly, handicapped) are at particular risk of becoming malnourished.

Different types of selective feeding programmes aim to cover special needs of certain vulnerable groups:

· Blanket supplementary feeding provides a quality or energy supplement in addition to the normal ration which is distributed to all members of identified vulnerable groups to reduce risk (preventive).

· Targeted supplementary feeding provides energy or quality dietary supplements and basic health screening to those that are already moderately malnourished to prevent them from becoming severely malnourished and improve their nutritional status (curative).

· Therapeutic feeding provides a carefully balanced and intensively managed dietary regimen with intensive medical attention, to rehabilitate the severely malnourished (curative) and reduce excess mortality.

Thus, the range of nutritional interventions vary from population based GFD to intensive, highly managed, curative, individual level interventions (intensive therapeutic feeding).

Health organizations working in food crisis situations have an obvious responsibility towards the curative rehabilitation of acutely malnourished individuals. However, the rehabilitation of malnourished individuals can become a pointless and frustrating task in a situation where the population simply cannot get sufficient quantities or quality of food.

Thus, emergency health workers also have a very great responsibility to promote the nutritional welfare of populations by advocating adequate GFD and other complementary interventions (see Figure 2).


FIGURE

2. Assessment of the nutritional situation

What do we need to know?

Information collected in order to take a decision, and to implement, alter, or stop programmes must be as clear and precise as possible.

· General information:

- Identify the origin of the problem (harvest failure, increased prices, population movements).
- Identify the population that is effected (number, ethnic groups, displaced, villages, camps).
- Identify other factors that may alter needs for intervention (other organizations, timing of harvests, national strategies).
- Realise the logistic constraints.

· Basic health information to be gathered must include (see Ref. 12, Annex 1):

- Mortality rates (crude and under five mortality rates);
- Major infectious diseases (measles, diarrhoea);
- Nutritional status of the people;
- Water availability (number of litres/person/day);
- Number of persons per latrine;
- Shelter;
- Amount of food available (Kcal/person/day).

Where do we find the information? (see Ref. 10 and 13)

· Capital Level Visit

- To collect all available information on relevant health, population and food/agriculture issues.
- To contact other organizations and find out their knowledge and plans to work in the affected area.
- To establish a realistic understanding with the authorities.

· Visits to the Field

- Talk to representatives of the population, or those with special knowledge (chiefs, health workers, agricultural extension agents, spiritual leaders, etc.).

- Talk to the affected people, in order to assess their ability to cope with the situation and their prioritization of needs.

- Observation (geographical area, water resources, shelter, adequacy of the food system).

The initial evaluation is extremely important and needs to be global, brief, concise and fast in order to allow an appropriate intervention as quickly as possible (see Annex 1). However, if a high level of precision is required for decision making, it is necessary to use a structured survey methodology.

The feasibility and usefulness of the information will depend on if the situation is <<simple>> or <<complex>>. A <<simple>> situation (like a well established camp) is where the population is:

- almost totally dependent on external food aid,
- population figures are well known,
- the population is easily accessible.

A more "complex" situation (like an open area) has many different food sources and the population is very spread out and inaccessible.

Measuring Malnutrition

There are 3 major clinical forms of severe protein energy malnutrition - marasmus, kwashiorkor and marasmic kwashiorkor. There are various clinical signs useful for diagnosis, but most obviously a marasmic child is extremely emaciated and a child with kwashiorkor has bilateral oedema (see Ref. 1 and 3). However, clinical assessment is not practical for managing nutritional programmes and monitoring and comparing large scale food crises.

Most standardized indicators of malnutrition in children are based on measurements of the body to see if growth has been adequate (anthropometry; see Ref. 14, 15, 18, 20).

· Height for age (H/A), is an indicator of chronic malnutrition. A child exposed to inadequate nutrition for a long period of time will have a reduced growth - and therefore a lower height- compared to other children of the same age (stunting).

· Weight for age (W/A), is a composite indicator of both long-term malnutrition (deficit in height/"stunting") and current malnutrition (deficit in weight/ "wasting").

· Weight for height (W/H), is an indicator of acute malnutrition that tells us if a child is too thin for a given height (wasting).

For all 3 indicators (W/H, W/A, H/A), we compare individual measurements to international reference values for a healthy population (NCHS/WHO/CDC reference values).(Annex 13).

In emergencies, W/H is the best indicator as:

- it reflects the present situation;
- it is sensitive to rapid changes (problems and recovery);
- it is a good predictor of immediate mortality risk;
- it can be used to monitor the evolution of the nutritional status of the population.

· Bilateral oedema is an indicator of Kwashiorkor. All children with oedema are regarded as being severely acutely malnourished, irrespective of their W/H.

Therefore, it is essential to assess W/H and the presence of bilateral oedema to define acute malnutrition.

· Middle upper arm circumference (MUAC), is another anthropometric indicator. MUAC is simple, fast and is a good predictor of immediate risk of death, and can be used to measure acute malnutrition from 6 months to 59 months (although it overestimates rates in the 6-12 month age groups).

However, the risk of measurement error is very high, therefore MUAC is only used for quick screening and rapid assessments of the nutritional situation of the population to determine the need for a proper W/H random survey (see Annex 2).

(For the assessment of adult and adolescent malnutrition, see Annex 3.)

Measuring the Nutritional Status of a Population

Anthropometric surveys allow us to quantify the severity of the nutritional situation at one point in time, which is essential to help plan and initiate an appropriate response.

The prevalence of malnutrition in the 6 - 59 month age group is used as an indicator for nutritional status of the entire population, because:

- this sub-group is more sensitive to nutritional stress,
- interventions are usually targeted to this group.

In order to ensure that the estimate will be representative of the whole population, random, systematic or cluster sampling procedures must be used (see Part II).

During the survey, the nutritional status of individual children is assessed, prevalence of malnutrition is then expressed as the percentage of children moderately and severely acutely malnourished. It is very important to mention:

- the indicator (W/H, OEDEMA, MUAC),
- the method of statistical description (% of the Median, Z-Score),
- the cut-off points used.

Results should always be expressed as the percentage of children < -2 Z- Scores and < -3 Z Scores and/or oedema, to allow international comparisons as well as for statistical reasons.

However, it might also be necessary to express the results using a different classification system, if that is the method generally used in the area that you are working in.

The cut-off points most often used to define acute malnutrition for the different indicators during nutritional emergencies are:


FIGURE

WHEN TO CONDUCT A NUTRITION SURVEY

Ideally, an anthropometric survey should be part of the initial assessment in every emergency situation. The malnutrition rate can be used:

- to establish the degree of emergency for the delivery of food aid;
- to plan complementary interventions;
- as baseline information to monitor the progression of the situation over time.

Survey information might be useful under certain circumstances. For example:

· Camp formation is usually sufficient evidence of problems with food supply, and an anthropometric survey is an essential part of the initial needs assessment.

· Health information systems or famine early warning systems indicate a deteriorating nutritional situation.

· Health organizations often have a good field presence and close contact with the population. When secondary information or field experience (from contact with health workers, local chiefs, extension workers, other NGO/government workers) indicates a major nutritional problem, an anthropometric survey should also be considered. Nevertheless, conducting a survey is expensive and consumes time and energy. You must consider the following aspects before actually starting a survey:

1) Will results of the survey be crucial to decision making?

If the needs are obvious, a survey may not be needed to mobilize full scale action and will only waste time.

Secondly, one should be prepared to act after identifying a problem, directly or indirectly. If this is not possible and the information will not affect anyone's decision, do not do a survey.

2) Is a survey feasible?

Risks from insecurity, and logistic and team capacity should be considered.

3) Is an anthropometric survey the only option?

In stable environments, it may be better to establish a system of data collection that helps track trends in the nutritional status of a population over time. Only when there are dramatic changes (i.e. deterioration of the nutrition situation, influx of people, natural disaster, epidemics) might there be a need for further anthropometric surveys to determine the absolute levels of acute malnutrition.

4) Are you able to get access to all of your population of interest?

It is essential to make a clear definition of the population of interest (political/ administrative boundaries, geographical regions, etc.), from which to draw a representative sample. If all sections of the population of interest are not reachable, * may not be worth doing a survey.

WHEN TO REPEAT A SURVEY

There are no hard and fast rules about the required frequency of anthropometric surveys.

In a simple situation:

In the emergency phase, surveys should be repeated quite often (i.e. every 3 months) as food supply systems are often weak, there may be considerable influxes of people, a greater risk of epidemics and elevated mortality rates.

Once the situation has stabilized and mortality rates have declined, the frequency of anthropometric surveys can be decreased.

In complex situations:

Organizing a survey in insecure regions or where the population is spread out is logistically more difficult and results are harder to interpret. A good anthropometric survey may provide critical information, but the frequency and regularity with which they are conducted should depend on priorities and the capacity of the team to implement the surveys.

A compromise may be to do an initial survey, then collect other data in order to monitor the situation (i.e. OPD data, hospital admissions, food availability and prices). Extreme caution is needed in interpreting this kind of non-representative data over time. If the groups measured are well known and the data shows consistent trends over time, then they may be a very useful source of information.

When trends indicate a rapidly worsening situation and there is a need for more precise estimation of the severity of the problem, then another survey should be conducted.

· An anthropometric survey should be part of the initial assessment of an emergency situation. Discuss beforehand how the results of the survey will influence decision making.
· When feasible and useful, anthropometric surveys should be repeated regularly.
· In more volatile situations, repetition of surveys may not be possible on a regular and frequent basis. An initial survey can be complemented with the collection of other data to monitor trends over time - a deterioration in the situation can prompt another survey.

HOW TO INTERPRET THE SURVEY

There are crucial survey figures, that will be used for decision making and reporting:

· global acute malnutrition rate
· severe acute malnutrition rate

In addition to describing and quantifying the severity of the situation, one must also have information on:

- Factors that might bias the estimate of severity.
- The distribution of malnutrition in the population.
- Context factors that will influence interpretation.

Factors that might bias the estimation of rates of malnutrition

· Excess mortality of the most vulnerable might result in an underestimation of the true malnutrition problem (see Annex 9: <<gaps>> in the sample's age/height groups may show an under-representation of an age group or a sex group which might indicate elevated mortality).

· Timing or seasonality might make comparison of results from different periods hard to interpret.

· When malnutrition is mainly a problem in age groups other than the under 5 years (rare), survey results might underestimate the problem.

· Migration or absence of the worst effected families will tend to reduce the significance of malnutrition rates.

· Inadequate population data or access to certain segments of the population may mean that certain groups are left out of the estimation of malnutrition rates.

Distribution of Malnutrition within the population

The identification of population groups most affected can help target programmes more effectively. Sub-analyses of the anthropometric data may help suggest target groups:

· Malnutrition rates per age/sex group (Annex 9).
· Malnutrition rates by population group (displaced/residents, ethnic groups, etc.).
· Malnutrition rates per geographic area.

Contextual factors in the interpretation of anthropometric surveys

The interpretation of anthropometric surveys must take into account the context.

a) Interpretation in simple situations

Interpretation of anthropometric survey results should take into account 3 main aggravating factors:

· Mortality figures (see Annex 1 for <<acceptable>> mortality figures);
· General food rations (Chapter 3);
· Major epidemic outbreaks (measles, Shigella and other diarrhoeal diseases,...).

b) Interpretation in complex situations

In complex situations, both food availability and accessibility can be at the base of the nutritional problem.

Figure 3 outlines various factors that can influence food availability and/or accessibility and therefore may have an impact on nutritional status.

In complex situations, an anthropometric survey may not provide sufficient information with which to make informed decisions. In these conditions, other information (existing, information collected by rapid assessments or additional information collected during the anthropometric survey) will be needed to characterize the situation.


FIGURE

The survey data may therefore need to be complemented with the following additional information:

* Market prices of important cereals and livestock
* Information on access and availability of food
* Price and availability of seeds and tools
* Rainfall, pests and other agricultural information
* Major events with respect to mortality and morbidity
* Specific nutritional deficiencies (e.g. scurvy, pellagra,...)
* Food intoxication cases (rare)
*Information from health centres or clinics.

The interpretation of these data types will depend on an understanding of the normal circumstances, and what a change in the indicator actually means.

Often an important factor to consider is seasonality. The timing of harvests and hunger periods explains much of the yearly variation in the nutritional status of some populations. Some communities live constantly on the edge, due to poverty and seasonal food shortage.

HOW TO USE SURVEY RESULTS

· Context

In simple situations it is possible to use survey results to make straight forward decisions and implement standard programmes. In more complex situations it is important not to encourage camp formation through our nutritional interventions. In complex situations, it is essential to adapt standard strategies to support local coping strategies and reflect social and demographic patterns in the population.

· Survey timeliness

As stressed earlier, nutrition surveys are only useful if they inform decision making. Surveys should be conducted so that the results are ready in time for important decisions that need to be made. Survey results should also be shared with other organizations, to help them make more informed decisions.

· Causes

The causes of the nutritional problem may greatly effect the choices to be made in designing a nutritional programme. You may have an idea of the causes, as this knowledge may have prompted the survey (i.e. inadequate food rations for an extended period of time, crop failure). However, it may be necessary to investigate causes by asking community leaders about the problems or by asking the mothers of the malnourished.

· Logistics survey

Survey results may imply a certain intervention strategy, but programmes must be designed to reflect the logistical realities and the team capacities.

When conducting a nutrition survey, the various teams will travel extensively through the area of interest, they will have opportunities to talk to representatives of many communities and observe some of the constraints faced by the population.

The survey team should take advantage of the field experience to collect information useful for interventions:

· Teams can be asked to map out their paths to villages and report on broken bridges, impassable rivers, etc.

· Teams can report on the spread of the population in various areas.

· Teams can report on the availability of water and cooking fuel for the population.

- Surveys are expensive and time consuming so one should take full advantage of the opportunity to collect relevant information when conducting a survey.

- One should never ask too many questions.

- However, key information can help make the analysis of the nutritional situation and associated factors much stronger.

SUCH INFORMATION MUST BE IDENTIFIED BEFORE THE SURVEY - it is impossible to go back and ask the questions later.

· It is useful to consider more than just the traditional rates of malnutrition for decision making.

· Additional information collected and special sub-analyses of the data will allow speculation about causes and identification of most effected groups - thus enabling better design and targeting of the programme.

· The experience gained while conducting the survey can provide important additional information for practical considerations in programme planning.

The feasibility, reliability and usefulness of an anthropometric survey depends on the resources of the organization and the level of complexity of the situation.

In "simple" situations where food systems are controlled, the population is well monitored, anthropometric surveys are relatively easy to plan, conduct and interpret - interpretation must take into account the adequacy of food rations, mortality and epidemics.

· In more "complex" situations, anthropometric surveys are difficult to perform adequately and results are often insufficient to characterize a situation and make decisions - other critical information must also be collected to help interpretation.

3. Interventions: ensuring adequate general food availability and accessibility

Meeting basic food needs for all

In certain emergency situations the self-reliance of the population is reduced to such an extent that they may become totally dependent on the international community for their livelihood.

The classical intervention to meet basic food needs of refugees, the displaced and destitute is a General Food Distribution (GFD). Emergency health organizations prefer to concentrate on their areas of expertise and leave GFD to organizations with more specific experience. Nevertheless, the emergency health organizations have a tremendous responsibility to monitor the quality, quantity and equity of distribution.

In international refugee camps, UNHCR and WFP will agree on their responsibilities to ensure the food supply to the affected population. WFP will supply the basic commodities of the general food ration and the funds for transport and handling of these commodities. UNHCR should provide refugees with complementary food items where necessary: fresh vegetables, fish or meat, spices. UNHCR also coordinates the transport and distribution of the food, which may be sub-contracted to other agencies. UNHCR will also often take responsibility for the supply of food items to supplementary feeding programs (see Annex 4).

QUANTITY OF GENERAL FOOD RATIONS

It is impossible to tailor the food basket to individual needs - so an average general ration has been proposed, designed to meet minimum nutritional needs.

Different guidelines exist between different agencies defining what level of ration is "adequate":

WFP: minimum of 1900 Kcal/person/day.

ICRC: 2,400 Kcal/person/day.

MSF: 2,100 Kcal/person/day.

Although WFP and UNHCR are currently working on new guidelines for a more accurate assessment of population food needs and will not work with a set target ration in the future.

The overall ration (average Nº Kcals) received is not the only factor of importance

- food must be provided regularly to ensure a constant flow of food to families to avoid hunger and must be of sufficient quality (protein, fats, minerals and vitamins) to promote a healthy existence.

Most health organizations believe that the 1900 Kcal/person/day ration is insufficient (when there are no other sources of food).

Generally speaking, the minimum ration should aim to provide 2100 Kcal/ person/day (of which, at least 10% of energy should be from protein and 10% from fat. See Annex 6 and 7). The provision of an adequate food ration has been clearly shown to have a critically important effect on the recovery and maintenance of a satisfactory health status in camp populations (Ref. 4 and 2)

The classic full food basket contains 6 basic commodities; a cereal, a pulse, oil/fat, possibly a fortified cereal blend, sugar and salt and occasionally may include some canned fish or meat.


FIGURE

(See Annexes 5 & 6 for guidelines on the calculation of the caloric content of alternative food baskets).

Factors that require an increase in the general ration:

· Age and sex composition of the population: an excess of male adults or pregnant women calls for higher rations per capita.

· Bad general health and nutrition status: widespread illness, epidemics, general undernutrition or a crude mortality rate >1/10,000/day, implies the need for an increased ration.

· Activity level: during periods of increased activity (intense agricultural labour, specific infrastructure works or other labour intensive activities - pounding/milling cereals supplied, fetching water and firewood from great distances), the energy component of the ration should be increased.

· Low temperatures: a drop in temperature will increase metabolic energy expenditure and thus dietary needs. The cold or wet season (cold nights), lack of shelter, blankets and clothing should be taken into account when calculating ration levels. An additional 100 Kcal/person/day should be added to the ration for every 5ºC that the environment temperature drops below an average of 20ºC.

Factors that might alter the need for food aid:

· Activities that provide a direct (i.e. farming, foraging) or indirect (income generating) supply of food to the household. When income generation and other coping strategies are inhibited for large segments of the population, the general ration should cover all of the nutritional requirements. If the population is still able to participate in some (but insufficient) economic and food producing activities, general rations may only need to cover some of the nutritional needs.

· Those severely affected by emergencies have many needs other than their dietary requirements. If other requirements (i.e. shelter, fuel or firewood, water, transport costs, health services and social functions) are not met by other agencies or individual income, part of the general ration will be bartered or sold in exchange for these commodities or services.

· Acceptability and familiarity of the food items: it is a misconception that people will eat anything if <<really>> hungry. Some taboos, impala/ability or lack of knowledge/tools for food preparation might reduce the real intake of the food supplied - implying the need for other commodities to be distributed.

· The diet provided is very monotonous and may be culturally unacceptable. If there are preferred food items available through market systems, part of the general ration will be bartered or sold in order to buy preferred goods (tea, herbs, local staples, vegetables). Bartering distributed food items on the market is often an essential survival technique and should not be regarded as an indicator that the population gets too much food and no longer requires the same levels of GFD.

· Processing, storage of food and other wastage in the chain, from household receipt of food to consumption: through specific milling, storage and cooking procedures, food can loose part of its nutritional value; the micronutrients are especially vulnerable to destruction or deactivation.

Distribution system losses

· Losses in the transportation, storage, processing and distribution of food from the donor to the individual can often account for a large proportion of the food aid.

· Losses, due to bad management or corruption, can hide food needs, as overall food input to a country/region may seem adequate to meet calculated theoretical food needs, without reaching many of the needy. Thus, the calculated theoretical ration is often different from that actually received by individuals.

QUALITY OF THE GENERAL FOOD RATION

Ration composition is often calculated with insufficient attention paid to the nutrient content. Consequently, refugees and displaced often suffer from micronutrient deficiencies.

Complementary food items, supplied with the basic ration, may not contribute significantly to overall energy intake, but are often crucial for increasing the acceptability, palatability and quality of the food ration (i.e. protein, micronutrients). Unfortunately, food basket commodities and ration levels are often determined by what surpluses donor governments wish to dispose of. Due to the donor driven supply of food aid and the logistical difficulties with food distributions, food baskets seldom contain 6 items and are rarely upto standards in terms of energy content, micronutrient content or acceptability.

The risk of specific nutrient deficiencies can be estimated from the composition of the general food ration. The following table gives you some clues as to which deficiencies might be expected according to the composition of the food ration.


FIGURE

(A description of the major clinical symptoms of micronutrient deficiencies is given in Annex 7).

The role of health organizations

In the absence of an adequate general ration, selective feeding programs and other dietary supplementation will have limited or zero impact.

The relevance and effectiveness of specific feeding programmes should always be evaluated as complementary to an adequate general food ration.

It is the duty and responsibility of emergency health organizations to monitor the regularity and adequacy of the general food ration supplied to the beneficiaries. As emergency health organizations are often the only operatives with a full time field presence, they may be the only witnesses available. The general health and nutrition status of the population in need and the impact of selective feeding programmes depend on it.

Monitoring implies an active collection of relevant data, and targeted reporting of information to the authorities and agencies concerned to influence distribution activities as needed (see Annex 8).

Advocacy can be cooperative or adversarial, it is always better to try and cooperate with food distributing bodies. However, sometimes the political aspects or corruption involved in food distribution become overwhelming and distributors are unwilling to try to alter practices. In these instances, advocacy becomes adversarial and media and political channels must be used to expose distributors and hold them accountable.

FOOD SYSTEM MONITORING

It is crucial to have information on the actual amount and quality of food that reaches the family or beneficiary. There can be substantial differences between what is actually received per capita and the theoretical general food ration (GFR). Furthermore, there may be considerable variation in the levels of access to food rations by individuals between/within populations.

It is useful to discern several levels within the food distribution system (see Figure 4).


FIGURE

Between steps 1 and 3 there may be several organizations involved, with different constraints and capacities. It is necessary to understand the chain of responsibilities and locate where responsibilities are not being met. Information from various sources should be collected and investigated, to get as close as possible to the real situation:

- Theoretical GFR:

· Relief coordinating agency (UNHCR, government department, etc.)

· Donor agency (WFP, EEC, USAID, etc.)

- Generalfood ration reaching the distribution spot:

Implementing agency (Red Cross/Crescent, Care, relief committee, etc.). There may be several implementing agencies for different steps in the chain or covering different geographic areas - it is necessary to delineate their individual responsibilities and follow their individual actions to establish where changes need to be made.

Information can be collected from stock management reports, distribution reports, presentations at coordination meetings or personal contacts.

- Generalfood distribution actually distributed:

· Implementing agency

· Beneficiary or community representatives

· Independent observers

Information can be collected and compiled from distribution reports, feed-back from beneficiaries and observation near distribution points. At the distribution point, a more formal investigation is possible (i.e. food basket monitoring - the regular weighing of allocated rations to randomly selected beneficiaries just after distribution).

Food basket monitoring implies the regular investigation of the quantity and quality of food items which are received at the household level. UNHCR is now actively seeking partners in the field, to monitor distributions it is responsible for, in order to increase accountability to donors and improve management of food distribution systems and refugee crisis situations (see Annex 8).

- Food ration reaching the home:

· Beneficiary and community representatives

· Independent observers

Information can be collected and compiled from talks with families and household food availability surveys (i.e. formal weighing of available items in chosen shelters, to calculate the food availability per person till the next planned distribution).

- Food actually consumed:

· Household food consumption surveys (difficult and time consuming - consult headquarters before considering this option).

Alternatives to general food distribution

In certain rare situations, the mass preparation of cooked meals is the only way to ensure access to food for the population, due to insecurity (Somalia 1992) or lack of ability to prepare foods (i.e. lack of firewood in Ethiopia in 1985). It is important not to under-estimate the logistical requirements of preparing food for large numbers of people. More importantly, these programmes should only be a temporary last resort, as the negative psychosocial consequences of mass feeding compound the distress of the affected population.

In some cases in which financial access to basic food items is the main problem, subsidy of food items or even cash distribution can alleviate the problems. These kinds of interventions require a thorough analysis of the situation and the legal/ administrative implications require specialised advice.

In camp situations or areas of high population concentration (displaced settlement zones), there may be programmes to promote income generation and to grow certain nutrient rich foodstuffs (i.e. vegetables). Well implemented vegetable gardens have proven to be a valuable contribution to dietary balance and a means for income generation.

For a population group dependent on external aid, a general food ration should:

· provide an average minimum ration of 2,100 Kcal/person/day; 10% of the energy should be in the form of protein and 10% in the form of fat; provide a balanced and sufficient intake of essential vitamins and minerals;
· contain items that are acceptable/familiar to the beneficiaries;
· be adapted to the particular circumstances that alter individual nutrition and food requirements. Emergency health organizations do not usually participate in GFD, but they should assume responsibility for:

· food basket monitoring (overall quantities, quality, regularity and equality of access);
· attentiveness towards other, varied information on the circumstances and the impact of GFD;
· advocacy to specific targeted decision makers;
· coordination with other agencies responsible for supply and logistics of food aid.

4. Interventions: selective feeding programmes

Even if the overall food needs of a population are adequately met there may be inequities in the distribution system, disease and other social factors causing degrees of malnutrition in certain vulnerable groups

Vulnerable groups may be targeted to receive a food supplement in order to upgrade their diet to a level that responds to their increased needs.

Those that are already acutely malnourished must receive medical and nutritional attention in order to rehabilitate them to a healthy state.

The following decision tree can be used to help interpret the seriousness of the situation but should not be interpreted as a set of rules.


FIGURE

Figure 5: General guidelines to assist in decisions to implement nutrition programmes

(*) Aggravating factors to consider are:

- Mortality: Crude Mortality Rate (CMR) > 1 /10.000/day;
- Inadequate general food ration
- Epidemic of measles, shigella or other important communicable diseases
- Severe cold and inadequate shelter

Objectives of selective feeding programmes

The general objective of a therapeutic feeding programme (TFP) is to reduce mortality by taking care of those vulnerable groups at greatest risk of dying from causes related to malnutrition. Generally the target group is children less than 5 years with severe acute malnutrition.

The general objective of a targeted supplementary feeding programme (SFP) is to prevent the moderately malnourished becoming severely malnourished and thereby reduce the prevalence of severe acute malnutrition and associated mortality.

In a situation of a grossly inadequate general food supply, it may be necessary to organise a Blanket Supplementary Feeding Programme for all members of the vulnerable groups (for a short period of time). The objectives of this programme are to prevent widespread malnutrition and mortality. In this case the programme may include up to 40% of the total population ! In such a situation, however, first priority should be given to restoring the general food supply.


FIGURE

Other factors like general food supply, water and sanitation and general health services also have a major impact on the pattern of mortality, disease and malnutrition.

Objectives of feeding programmes should be specified to be realistic and feasible, and must therefore take into account the local conditions and project capacity.

Example 1:

In a displaced population, a nutrition survey among 6 - 59 month old children indicates 15% acute malnutrition (Confidence Interval 15 + 3%) (<-2 Z-Scores W/H and/or oedema) and 3-5% acute severe malnutrition (<-3 Z-Scores W/H and/or oedema). Mortality surveillance shows a crude mortality rate of 2/10,000/day and an under-five mortality rate of 4/10,000/day.

It is necessary to implement a TFP, targeting the severely acutely malnourished and a targeted SFP for the moderately acutely malnourished.

The target population (50,000) is settled in two camps, with well established health services in each camp, which are easily accessible for the entire population.

Therefore, it seems realistic to set the objectives of the TFP and SFP to: - a coverage of 90% of severely malnourished children,

- a coverage of 80% of moderately malnourished children,
- a recovery of 80% of children admitted to the TFP and 70% to SFP,
- a reduction of the mortality among severely malnourished children admitted to the TFP to below 5% and the reduction of the under 5 mortality rate to < 2/10,000/day,
- a reduction in the prevalence of severe acute malnutrition to < 2% (<-3 Z-Scores W/H +/or oedema).

All objectives should be reached within 3 months.

Example 2:

In another, newly displaced population, a nutrition survey also indicates 15% global acute malnutrition and 3% severe acute malnutrition in under-fives. As the accessibility of the feeding programme will be limited, because the people live in scattered small settlements and often at large distances (> 2 hours walking) from the health services, the programme objective of a reduction of the severe malnutrition rate to below 2% has been set for within 6 months, and coverage objectives are re-set.

Example 3:

Because of a crop failure last year, there is a severe food shortage in a rural population, while the next harvest (which is expected to be normal) is still 3 months away. The global acute malnutrition rate among under-fives, which at this moment is 9%, will increase rapidly if nothing is done.

A blanket supplementary feeding programme will be implemented for all children under 5 years, for a period of 4 months (until after the next harvest) with the objective of stopping any further deterioration in nutritional status until the harvest.

5. Evaluation

The collection of information for monitoring and evaluation should be an integral part of all nutrition programmes. Evaluation is a learning process involving continuous collection of information to monitor the progress in achieving set goals and to suggest adaptations to the progamme, or closure with time.

Monitoring and evaluation will involve the planned and regular collection and analysis of:

· PROCESS INDICATORS to evaluate the progress in implementation and the trends in programme needs over time (i.e. attendance rates, coverage, recovery rates).

· IMPACT INDICATORS to evaluate the effect the programme is having/had on the population, and to summarize the total efficacy of the programme (malnutrition prevalence, mortality figures, numbers served).

Assessment of impact is extremely difficult as analysis of trends in health indicators does not prove that the programme has caused the change. However, a well collected data set can be used to argue for an association of the programme with the change in overall health status.

It makes little sense to only look at indicators of IMPACT for evaluating a nutritional programme. First it is necessary to know that the programme serves a useful purpose and is running well. PROCESS information will allow you to see how well the programme is functioning and adapt programme emphasis and design over time. PROCESS Indicators should be thoroughly analyzed and Interpreted (see Chapter 8, Part III).

The collection of information for evaluation needs to be planned during initial programme design. If information is not collected in a regular and systematic fashion, quality and relevance of the programme cannot be assessed while giving services.

It is the responsibility of coordinators and the team to implement the collection of process evaluation data systems and compile and analyze the data. Coordinators and their teams should be prepared to act to change programme design and management procedures based on feedback received through regular evaluation (see Chapter 8, Part III).

In camps, IMPACT indicators may be collected along with malnutrition prevalence rates, mortality rates, etc., and interpreted as a function of nutritional programme efficacy in conjunction with other relief activities.