6.4 Non-camp: rural resident populations

Almost by definition, programmes for resident populations take place in a situation of less acute emergency than programmes for displaced populations who tend to move as a last resort when all coping strategies have been exhausted. Furthermore, the displacement often increases the nutritional and health risk as populations are forced into camp situations where provision for basic need may not have been properly established.

Nevertheless, the nutritional and health condition of in situ populations can still be very serious, with emergency feeding programmes being implemented in a context of severe food shortage. Emergency SFPs for resident populations therefore take place in widely different contexts, ranging from situations where there is a risk of nutritional decline, although none has yet taken place, to a scenario where several years of crop failure and erosion of livelihood have brought the population to the brink of famine and forced migration.

Agencies faced by these diverse situations and aware of the need for some form of emergency feeding intervention frequently face the difficult choice of deciding where to locate emergency SFPs. The choice may be between a village-based programme, a health centre-based programme, or at some intermediate level, e.g. sub-clinics or rapidly assembled feeding centres serving many villages. There are advantages and disadvantages in operating through each type of infrastructure, yet many agencies repeatedly seem not to anticipate the disadvantages while failing fully to capitalise on the advantages. It is clearly important that the pros and cons are considered before deciding on the programme type, and that certain practices are avoided or followed once the infrastructure through which to operate the programmes has been selected.

Village-based programmes

The selection of villages in which to establish emergency SFPs can be a major difficulty, especially where there is a large geographic area affected by the food crisis so that many villages may need to be targeted. In this type of situation there is no tried and tested way to identify needy villages. Nutritional surveys are very time-consuming and will probably give results which are not statistically valid, as numbers of children in each village may be small so that results cannot be compared. Even short-cut methods such as village conglomerate surveys, whereby a central village in a geographical location is surveyed using MUAC measurement and the results are extrapolated to surrounding villages, can be very time-consuming and expensive. There is also the added difficulty of knowing what cut off points or trigger levels to use as a basis for including villages in the programme. Villages may be at different stages of food insecurity. Thus, the population in one village with low rates of wasting may be about to run out of food completely but have managed relatively well until the point of the survey, while another village population with higher rates of wasting may have been under stress for a long time but have evolved coping strategies which have stabilised their situation. Furthermore, as argued elsewhere in this report, nutritional status may be affected by disease patterns and constraints on parental care, so that high rates of wasting may indicate that a greater priority should be given to health and income support than to emergency feeding. It is therefore vital that anthropometric data be supplemented by contextual data which allow better interpretation of the nutritional data with regard to the need for supplementary feeding.

This type of contextual data can best be described as socio-economic. In other words data that describe the social and economic circumstances of the population, e.g. resources, access to income-earning opportunities, economic and physical access to markets, etc., so that need for extra food can be identified. However, it is no easy matter to obtain socio-economic data. Methods are poorly developed compared with nutritional surveys, and results are subject to gross inaccuracies and bias, e.g. under-representation of resources, cultural misunderstanding. Many methods have been tried by agencies, e.g. rapid rural appraisals using local information sources and key informants or large household budget and expenditure surveys. It is, however, probably true to say that, with some notable exceptions, much of the information has proved unusable for targeting purposes because of obvious inaccuracies and failure to develop methodologies for interpreting the data in advance of the survey/assessment.

Recent experience of attempting inter-village targeting of SFPs raises a number of pointers to good or better practice.

1. anthropometric data must be complemented by socio-economic data

2. socio-economic data collection can be very problematic and resource-consuming, so that attempting to assess socio-economic conditions without prior experience of an area, or without using established information sources/networks, may be justified only where the data are also to be used to inform decisions about targeting greater programme resources, such as in a general ration programme.

Given these two provisoes agencies may need to assess critically why inter-village targeting may be necessary. Usual justifications include lack of resources to cover all villages and fear of the over-supplying of some villages leading to agricultural and economic disincentives. If neither condition really applies then it may be more sensible to include all the villages in a food emergency-affected area in the SFP. This conclusion is reinforced by the added difficulty that can arise when there is some subsequent change in food security, e.g. a partial harvest, so that the original targeting assessment has to be completely revised. A further complication of inter-village targeting is that the resulting logistical programme can quickly assume nightmare proportions as single villages separated by large distances and very poor roads are identified for inclusion in the programme. Distributing small quantities of supplementary foods to disparate villages may not be a very cost-effective use of resources.

Monitoring. Monitoring village-based programmes can also be highly problematic due to logistical constraints, and can consume vast agency resources. Recent experiences have taught us a number of lessons here as well.

Box 24 Difficulties of monitoring village-based SFPs: Kosti Province, Sudan A NGO operating a village-based emergency SFP in Kosti Province in Sudan in response to the 1990/91 drought eventually targeted 250 villages out of a possible 650 villages. Selection was based upon MUAC survey results and area coordinators carrying out poorly developed socio-economic assessment procedures. Retrospective evaluation of the programme established that the MUAC surveys were very time-consuming and poorly implemented, that the socio-economic assessments were grossly inaccurate with little standardisation amongst the area coordinators, and that political factors inevitably played some role in the final choice of village. Furthermore, the data collection took so much time that villages could only be phased into the programme over a period of five months as surveys were gradually implemented. Finally, with the arrival of a variable harvest in the province, the vulnerability of villages changed drastically, yet the implementing agency had neither the resources nor the 'motivation' to undertake a new assessment in order to re-target the programme.

Given that a primary aim of emergency SFPs is to ensure that vulnerable groups receive a supplement and, where the general ration is poor, to influence intra-household targeting decisions so that the target groups' consumption is protected, it is important to monitor whether beneficiary households are complying with this aim. It is also important to monitor the regular delivery of foods by contractors and to ensure that there is no 'leakage' away from targeted villages. Monitoring must therefore be regular and take the form of site visits, checks on stores to determine that planned quantities are delivered, and assessments to determine that offtake from the village stores correlates with the number of identified beneficiaries in the village, e.g. to ensure that other individuals are not being supplied. This workload can be enormous where villages or feeding points are separated by large distances and can lead to a situation where either the majority of agency resources are literally expended in these activities or the monitoring is so poor that serious problems remain unsolved for long periods.

An important point about monitoring is that agencies need to take care that monitoring does not turn into policing. An increasingly frequent scenario is that where donors provide sufficient cereals for an emergency general ration but only small quantities of legumes and oil. As a consequence, agencies may decide to allocate the beans and oil through a village-based dry take-home SFP. However, the lack of these commodities in the households basic diet may determine that many non-eligible families will be given beans and oil by village allocation committees on the grounds that they are also poor and in desperate need and that eligible families do not in any case target the beans and oil on the agreed target groups. While an agency is entitled to try to encourage households and village committees to conform with the aims of the SFP in this type of situation, it is important that the policy does not become coercive, e.g. by punishing villages which abuse the system. Ultimately, once open discussions have taken place, intra-village and intra-household targeting decisions must be respected by agencies, so that vast resources do not need to be expended on 'checking up' and penalising beneficiary villages.

Box 25 Monitoring difficulties in Kordofan Province, Sudan A NGO operating an emergency SFP through 60 widely dispersed health centres in rural Kordofan in Western Sudan as a result of the 1991/2 drought took several months to find out that food deliveries were not reaching many feeding points and that this resulted from the transport contractors' reluctance to undertake long journeys in order to distribute small quantities of food. The large distances involved and the poor roads meant that it was virtually impossible for the implementing agency to keep a close eye on the intervention. The programme was eventually suspended as a result and redesigned to include a much smaller number (18) of needy villages.

Data collection. Attempts to introduce data collection at village level in the context of an emergency SFP have often proved unsuccessful. Experience of setting up a growth-monitoring capacity, even in its simplest form, has not been good. There are many reasons for this, including the difficulty of training illiterate village people, the poor motivation of data collectors who are unpaid, lack of transport to visit satellite villages away from the feeding centre, lack of equipment and insufficient back-up field visits from agency staff. The lessons from this experience are that there should be no attempt to set up growth monitoring from scratch in village-based programmes in the teeth of an emergency. Once the acute emergency phase is over or the programme is running effectively and the implementing agency is not overstretched, and if it is intended to continue the SFP, then it may be possible to establish simple forms of growth monitoring. However, one type of data collection and monitoring that may be more feasible in a village-based SFP than a health centre-based SFP is the identification of defaulters and subsequent follow-up to determine the cause.

Box 26 Difficulties of monitoring village-based SFPs: Southern Zimbabwe An NGO operating a village based emergency SFP through 1,600 village feeding points in 2 provinces in Southern Zimbabwe trained village people in weight monitoring. Villagers were only asked to record weight of children (height and age were not recorded). Even with this simplified type of measurement, it still proved extremely difficult to get villagers to record weight regularly and accurately. Scales went missing and registration books contained long columns where data were not entered. Furthermore, the difficulty of monitoring over 1600 dispersed feeding points meant that it was only towards the end of the feeding programme that it became apparent that data collection was poor and the resulting data of limited use. It is worth noting that this situation occurred in spite of the fact that road infrastructure in Southern Zimbabwe compares favourably with many other African countries in the region.

Another weakness of village-based SFPs is that these cannot easily be implemented in conjunction with certain types of health input which require specialised and trained health staff. Consequently, if the food emergency becomes severe and some individuals become severely malnourished, then these cases will need to be referred to the nearest health centre. Furthermore, in a village-based SFP it may be far harder to identify all such cases. Similarly, if the food emergency occurs in an area where vitamin A deficiency is endemic and likely to be exacerbated by the food shortage or some other micro-nutrient deficiency is likely to occur, then diagnosis and treatment may be far harder in a village-level SFP. It may therefore be advisable to try to predict (however inaccurately) which infrastructure to utilise in advance of deciding, the likely nutritional impact of the emergency on the prevalence of severe malnutrition and the micro-nutrient status of the population in order to determine whether a village- or health centre-based intervention may be most appropriate.

Health centre-based programmes

The decision to implement emergency SFPs through health centres may be based largely on convenience as health centres tend to have good service infrastructure and to be located where population density is greatest. Furthermore, existing staff can treat serious cases of malnutrition and relatively easily administer the complementary medical activities and growth monitoring necessary as part of a SFP. The main disadvantages of operating through existing health centres are that centres may not be located where the need is greatest (in fact health centres are often not located in the poorest rural areas), and that outreach will be less than in village-based programmes. Furthermore, such programmes will take up more beneficiary time as most participants will need to travel greater distances to the feeding programme.

Recent experiences show that there are a number of important considerations with health centre-based programmes which are often ignored.

One important consideration is that in many developing countries Mother and Child Health (MCH) programmes at health centres routinely conduct growth monitoring of children under five, and that in many cases this information is collated and analysed at district, provincial and national level. These data are subsequently published and provide baseline levels of malnutrition at different administrative levels. They also show trends in patterns of malnutrition, e.g. seasonal and drought-related. The information can then be used for targeting development initiatives and in some cases for early warning of food crisis. As these are clinic-based data they are obviously biased, as the poorest sections of the population may not participate in the MCH programme. Nonetheless, it is believed that they allow useful comparisons between areas and useful trend analysis. In many countries this information resource has been built up over many years and has become a useful operational tool for policy and planning in development and emergency relief.

However, this growth monitoring is usually based upon weight-for-age measurements, which, as discussed earlier, is a measure of past as well as present nutritional status. Thus, children with low weight-for-age may be short (stunted) but not thin (wasted). They therefore have a low weight-for-age due to a past episode of malnutrition. Consequently, there may be limited benefit in enroling such children in emergency SFPs. The current view is that stunted children can benefit from additional (supplementary) feeding up to the age of two, i.e. catch-up growth is possible. However, the morbidity and mortality risk amongst stunted children is far less than amongst wasted children.

In most rural communities levels of malnutrition as defined by low weight-for-age are much higher than levels of malnutrition as measured by low weight-for-height (wasting). Thus, any attempt to operate an emergency SFP utilising weight-for-age measurements will initially lead to the enrolment of far greater numbers than if weight-for-height measurements were used. In fact, the optimal practice in such a situation would be to enrol all malnourished under-five children less than 80% weight-for-age (third percentile growth curve) and to follow their growth for two to three months. Any children over two years of age who follow the growth curve but remain under 80% could then be discharged on the basis that they are currently growing normally and not at heightened risk and that there is limited benefit in their inclusion in a SFP.

However, the potential problem of being overwhelmed by numbers in the early stages still remains. Also, numbers enrolled in the programme even after a few months will still be greater than if weight-for-height measurements were used, as stunted children under two will be included.

Clearly, in most situations it would not be advisable to change the system of growth monitoring to weight-for-height measurements as this would necessitate a large amount of retraining of staff and purchasing of new equipment. It would also radically change the baseline data of the national growth-monitoring system. However, in some situations it may be feasible, e.g. where the agency is working through a small number of health centres.

Another difficulty that is rarely anticipated is the effect on attendance of distributing emergency SFP rations through an existing MCH programme structure. The inevitable response to this type of programme is that more individuals attend the health centre in order to obtain the SFP food ration. The more acute the food stress in the area or the larger and more diverse the supplement, the greater the pull of the feeding programme. Numbers attending MCH programmes have been known to quadruple with the introduction of an emergency supplementary ration.

There can be several effects of such an increase in numbers. MCH staff work loads will increase substantially, especially where they have responsibility for storing, allocating and accounting for the food rations. Great care must therefore be taken to ensure that this extra workload does not interfere with their normal health programme activities. Where such a conflict does arise it is important for implementing agencies to consider employing other individuals to take on some of the extra responsibilities arising out of operating the emergency SFP.

Another consideration, and one which is often overlooked, is the potential effect of the increase in attendance at the MCH programme on the existing data base. A large increase in attendance once feeding is introduced usually indicates that households that would not normally participate in the MCH programme because they may live further away or be poorer so that, previously, the opportunity cost of participation in the MCH programme was too high, are now attending. As a consequence, the nutritional condition of this section of the population may be much poorer than that of those who normally attend the MCH clinic. Experience shows that this is often the case, so that when numbers increase, the overall levels of malnutrition, as indicated by the growth monitoring at the MCH programme, also increase significantly. These higher levels of malnutrition seen at the health centres can then be maintained throughout the emergency SFP and may even continue when the SFP has been phased out. As a consequence, it may appear that the emergency SFP has been associated with an increase in levels of malnutrition. Furthermore, the increased levels of malnutrition which continue to be seen amongst those attending the MCH programme at the end of the SFP, make redundant much of the baseline data collected in previous years which may have been used for targeting and early warning purposes.

Box 27 Changing anthropometric measurement methods: Angola and Malawi One agency working out of a small number of health centres in conflict besieged towns of Angola switched measurements from weight for age to weight for height as the centres were admitting too many unnecessary cases and it was fairly easy to train existing staff to do this. Furthermore, the growth monitoring data were not being used as part of a national nutritional surveillance system. Another agency working through five MoH staffed feeding centres in Dedza in Malawi also changed measurements during the programme. Once again these data were not part of an existing nutritional surveillance system and the limited number of centres determined that the change-over was relatively easily achieved and supervised by the agency. In both country cases one of the aims was achieved in mat the number of admissions dropped dramatically improving the efficiency of the programmes and ensuring better supervision and monitoring of those admitted to the programme.

It is important to be aware of this phenomenon for several reasons:

First, it is important to make some attempt at protecting the data base. This may be done by separating out new attenders from old attenders once the feeding programme begins. The feasibility of this will depend upon the way data are recorded and collated at clinic level. Second, the new population effect must be taken into account in interpreting the higher levels of malnutrition. Thus, increased levels of malnutrition do not necessarily indicate an ineffective SFP or a rapidly deteriorating food security situation. Also, it may not be advisable to wait for levels of malnutrition to revert to pre-SFP levels before ending the programme.

Finally, it is important for agencies to pre-plan for increasing attendance at MCH programmes so that health inputs can be maximised. This will necessitate working closely with the MoH and supporting agencies such as Unicef at district, provincial and national level. Depending on the cause, food emergencies are usually associated with increased prevalence of certain diseases, e.g. diarrhoea, scabies, and micro-nutrient deficiency, and increased risk due to certain conditions, e.g. measles. It is therefore vital that agencies help the MoH pre-plan potential drug and vaccine needs once the SFP is operating. The likely increase in attendance is the perfect opportunity to fulfil EPI goals better. All too often health centres run out of the necessary drugs and vaccines once emergency SFPs are implemented. Agencies will therefore need to think through the likely demand for MCH services with district MoH staff. These calculations will need to be based on assessments of the population of health centre catchment area and, where applicable, the previous experiences of emergency SFPs in the area.

Box 28 The influence of attendance rates on growth monitoring: Southern Zambia MCH growth-monitoring data from two districts in southern Zambia did not indicate a deteriorating nutritional situation when the decision to implement an emergency feeding programme following crop failure in 1992 was taken. At this time levels of malnutrition amongst those seen at the MCH programme were less than 20%. With the introduction of an emergency SFP ration at the health centre, attendance dramatically increased, especially following the addition of oil to the ration. This coincided with increasing levels of malnutrition as determined by the percentage of children who were measured as malnourished on presentation at the MCH programme. When the programme started to be phased out following the next good harvest, levels of malnutrition at the health centres were in excess of 30%, reflecting the type of beneficiary participating in the MCH programme.

Given the considerable agency resources required to establish a health centre-based emergency SFP (e.g. logistics, setting up storage, monitoring, etc.) and the limited resources finally allocated, e.g. a supplementary ration barely provides for 10% of household caloric needs, it is almost axiomatic that the provision of complementary health inputs should be given equal priority to the provision of the supplement. It therefore seems reasonable to argue that any evaluation of the emergency SFP at health-centre level should include evaluating the goals of increased vaccination and provision of drugs.