Nutrition coordination in Ukraine: Experiences as a sub-cluster of health

By Anna Ziolkovska

Anna Ziolkovska is the Information Management Officer with the Global Nutrition Cluster Rapid Response Team, UNICEF. She was deployed to Ukraine twice, for a scoping mission in February 2015 and as a Nutrition Sub-Cluster Coordinator in March-May 2015.

The ENN team supporting this work comprised Valerie Gatchell (ENN consultant and project lead), with support from Carmel Dolan and Jeremy Shoham (ENN Technical Directors). Josephine Ippe, Global Nutrition Cluster Coordinator, also provided support.

This article is a summary of a case study produced through a year-long collaboration in 2015 between ENN and the Global Nutrition Cluster (GNC) to capture and disseminate knowledge about the Nutrition Cluster experiences of responding to Level 2 and Level 3 emergencies (available at www.ennonline.net/ourwork/networks/gnckm). The documented findings and recommendations are those of the authors. They do not necessarily represent the views of UNICEF, its Executive Directors or the countries that they represent and should not be attributed to them.

Background

Political unrest began in March 2014 in the Donbas region of eastern Ukraine forcing many people to flee their homes, settling in densely populated urban areas. Violence has escalated significantly since mid-January 2015 with civilian casualities and infrastructure destruction. In August 2015, only MSF was given accredited access by de facto authorities’ - other agency activities were suspended.

It is estimated that more than five million people have been affected since the start of the conflict. Over 1.4 million people are officially registered as internally displaced people (IDPs). Approximately two million people living along the conflict line are reliant on assistance and face persistent threats and insecurity.

Impact of the conflict

In conflict-affected areas, basic services have been disrupted and there is need of medicines, food, basic household items and shelter. Reports indicate that many of those remaining in the conflict zone close to the frontline are living in unhygienic, overcrowded, underground shelters with no WASH (water, sanitation and hygiene) facilities and electricity. Limited access to the population has hampered the movement of humanitarian aid.

In non-government controlled areas (NGCAs), the banking system has collapsed and pensions and social benefits are unavailable. Restriction of movements across the frontline due to the introduction of special permits exacerbates the situation. Many registered IDPs have exhausted their financial resources and face difficulties in paying for accommodation, heating, food and non-food items.

Humanitarian response

The cluster approach was activated on 23 December 2014 and the following clusters were established: Education (led by UNICEF); Emergency Shelter &non-food items (NFIs) (led by UNHCR); Food Security & Nutrition (FS&N), (co-led by WFP and UNICEF); Health (led by WHO); Livelihoods/Early Recovery (led by UNDP); Protection (led by OHCHR/UNHCR); and WASH (led by UNICEF).

A Humanitarian Response Plan (HRP) was developed in November 2014 targeting 900,000 people for humanitarian assistance in the various sectors. Given the deterioration in the situation, numbers were revised in February 2015 to target 3.2 million of the five million estimated to be affected.

Nutrition situation

Based on the available data (mostly 15 years old), pre-crisis stunting and acute malnutrition rates were perceived to be low, while anaemia prevalence was 24.1% nationwide (MoH statistics, 2014).. Poor infant and young child feeding (IYCF) practices existed (MICS 2012), and there are widespread violations of the International Code of Marketing of Breastmilk Substitutes (the Code).

An IYCF-E (Infant and Young Child Feeding in Emergencies) survey conducted by the Centers for Disease Control (CDC) with support from UNICEF¹ in June 2015 found no cases of severe acute malnutrition (as measured by mid-upper arm circumference (MUAC)) and 0.5% moderate acute malnutrition, in under 2’s.

The exclusive breastfeeding rate was low (25.5%), 42.4% of mothers stopped breastfeeding without any specific reasons and 30% stopped due to conflict-related stress. Poor IYCF practices are manifest, with early introduction of non-milk fluids and widespread bottle-feeding practiced by IDPs in eastern Ukraine. Mothers are often told by doctors to give their children water, formula or other complementary foods before six months, with some health providers even offering formula in the birth clinic if the baby cries or is perceived to be hungry. The majority (70.5%) of the families surveyed received baby food in the food basket as part of the humanitarian assistance, while more than half (51.2%) of the families with an infant less than six months received infant formula.

A survey in December 2014 (by People in Need) indicated that 71% of those surveyed regularly face food shortages due to lack of cash to buy food as a result of exhaustion of financial resources, unemployment, lack of access to savings, non-payment of pensions and benefits, increased food prices and rising energy prices. Pensioners, the elderly, the socially vulnerable and people living in active fighting zones and non-government controlled areas (NGCAs) were particularly at risk of food insecurity.

Water supplies are available but are irregular due to the damaged water network. Maintaining water quality is a concern due to lack of access to the main water sources, which are very close to the front line.

Basic health services have been significantly disrupted. At least 32 hospitals in NGCAs are not functioning, while 17 have been shelled and damaged but continue to offer limited care. There are risks of shortages in electricity and water supply in hospitals and lack of fuel for ambulances (ACAPS, 30 January 2015). In addition, between 30 and 70% of health staff have fled the conflict-affected areas of Donetsk and Luhansk oblasts. Low vaccination rates heighten the risk of outbreaks of vaccine-preventable diseases, as evidenced by the outbreak of polio in the west of the country in September 2015.

The drug and medical supply chain have totally collapsed and stocks are depleted. About 71% of people in Donetsk oblast reported having no access to medicine and 85% reported having no access to medical treatment (December 2014, People in Need).

Nutrition sub-cluster coordination

Pre-crisis, the UNICEF programme in Ukraine did not have a strong nutrition component as it was not considered a priority. Health programmes existed but capacity was low. When the cluster approach was activated, the UNICEF Health Specialist assumed the Nutrition Cluster Coordinator (NCC) role but left the position in Jan 2015. To fill the gap in both cluster coordination and technical capacity, the Global Nutrition Cluster (GNC) Coordination Team, in coordination with the Country Office, deployed a Ukrainian-Russian-speaking Rapid Response Team (RTT) member to Ukraine for two weeks (3-14 February) to review the nutrition situation, partner capacity, gaps in response and working arrangements for nutrition coordination (GNC, 2015). Based on the needs identified, the RRT member returned for an additional eight weeks (March to May 2015) to act as the NCC. A Senior Advisor at CDC was also deployed to Ukraine during this time to support design of assessments and providedtechnical assistance to the Nutrition sub-Cluster.

The RRT member provided coordination support for Ukraine while in the country for a total of ten weeks and provided remote support for four weeks from May-June 2015 via Skype meetings and following up with partners on issues raised during the visits. This focused support resulted in active engagement, follow-up on issues and bringing together of partners.

An Information Management Officer (IMO) employed by UNICEF supported nutrition and WASH coordination, as well as the national UNICEF programmes.

Nutrition coordination

Nutrition coordination was initially included as part of the Food Security and Nutrition (FSN) Cluster. During the scoping mission, the RRT member (acting as an NCC) reviewed the effectiveness of nutrition coordination under the FSC and identified other potential mechanisms to improve nutrition coordination. It was agreed that, while there were advantages for the Nutrition Cluster (NC) to continue as part of the FSC (e.g. this promoted closer engagement with partners on complementary and supplementary feeding programmes and ability to monitor more closely violations of the Code in general ration distributions), there could be significant advantages to shifting nutrition coordination to the Health Cluster, such as:

•          Existing systems:the Ministry of Health (MoH) had an existing system/structure and staff that IYCF activities could build on in terms of capacity development.

•          Nutrition expertise:many partners in the Health Cluster have nutrition expertise globally which could allow for greater discussion around nutrition issues.

•          Funding potential:donors are well represented in the Health Cluster meetings, allowing for a higher profile for nutrition.

Based on these arguments, it was agreed in February 2015 that nutrition coordination would best be supported under the Health Cluster with the Nutrition sub-Cluster providing day-to-day management of the nutrition coordination and holding separate nutrition coordination meetings, yet providing updates to the larger Health Cluster in their meetings. The proposed structure was presented to the Emergency Relief Coordinator who formally approved the Health and Nutrition cluster in Ukraine in February. Based on agreement among partners, the scoping mission recommended revisiting the need for a stand-alone nutrition cluster when developing the 2016 HRP.

To support various technical issues and discussions, the Nutrition sub-Cluster established a Complementary Feeding (CF) Task Force in March and an IYCF Advocacy Task Force (TF) in April. The CF TF fulfilled its aim of designing the composition of the complementary feeding ration and has ended. The IYCF Advocacy Task Force continues to develop advocacy documents (as of November 2015).

After the RRT deployment, UNICEF, as the Cluster Lead Agency for Nutrition, tried to maintain both nutrition programmatic and coordination capacities through a series of surge and technical support from UNICEF HQ, other UNICEF offices and CDC. However no dedicated nutrition coordination capacity has been identified (as of November 2015). This has resulted in significant gaps in nutrition coordination and the inability to sustain various efforts of surge staff.

Partners and technical capacity

In addition to the MoH, there are 18 Nutrition sub-Cluster partners including United Nations (UN) agencies (UNICEF, WFP and WHO), nine international non-governmental organisations (NGOs) and five local charity organisations.  None have in-country technical capacity in nutrition. The Ukrainian MoH nutrition capacity is limited to the head of the Maternal and Child Health Department and has limited engagement in cluster discussions. . Nutrition technical support for WFP was initially provided by the Regional Bureau, although it has recently (September) recruited someone based in Ukraine.

Local organisations are playing an important role in the response efforts. Two very large local charities, Akhmetov Foundation (AF) and Alexander Romanovsky Foundation (ARF), are providing significant amounts of food, medical and social support in affected areas, largely funded by private donors and other governments. Both agencies have extensive local volunteer networks (over 1,000 volunteers in ARF) in affected areas and attend Nutrition sub-Cluster meetings. Other local organisations with no technical expertise in nutrition are also involved in food distribution.

Nutrition response

The 2015 Strategic Response plan (SRP) developed in November 2014 had a very limited focus on nutrition. The only nutrition activity listed was “capacity building on food security and nutrition”. Nutrition was not considered a priority due to the lack of acute malnutrition (at a meeting in Dec 2014, UNICEF Health and Nutrition staff informed partners that no severe acute malnutrition had been reported and that individuals have a high coping capacity and resilience). Based on gaps identified in the scoping mission, nutrition activities were expanded in the revised HRP (February 2015) to include needs assessments, IYCF support, complementary food support to young children, capacity development (focused on IYCF), continued monitoring of at-risk groups (children under two years, pregnant and lactating women and older people) and advocacy across sectors for a nutrition-sensitive response. Additionally, various assessments were planned/conducted and mechanisms for surveillance of older people and anaemia were proposed.

Food assistance

General distributions² as well as cash and vouchers are being implemented by several FSN cluster partners. In NGCAs, as of August 2015, WFP was distributing general rations to 200,000 food-insecure individuals for three months. Given that no fresh fruit, vegetables or fortified complementary foods for children are being provided, the Nutrition sub-Cluster has advocated the provision of complementary food baskets to young children. WFP has plans to distribute these complementary feeding baskets to 20,000 children aged 6-23 months for six months once funding and access are secured.

Two large local charities continue to distribute food rations to the affected population, involving sophisticated systems for IDP registration,monitoring of IDPs and targeted commodity distribution using text messages and multiple distribution sites.. Baby-food baskets have been provided as part of their programmes.

A review of the components of the local charity food baskets during the scoping mission highlighted that breast milk substitutes (BMS) were being distributed alongside food baskets to children of all ages. As a result the Nutrition sub-Cluster Complementary Food Task Force, with support from UNICEF headquarters and WFP RO, developed guidance on the composition of complementary food baskets for children aged 6-23 months, with recommendations to separate complementary food baskets for children 6-11 and 12-23 months (Nutrition sub-cluster, 2015). The Nutrition sub-Cluster is advocating with WFP to disaggregate data to facilitate ease of monitoring of the food baskets going to various age groups.

IYCF

Limited cash reserves and lack of availability of BMS in the market, particularly in the NGCAs, has significantly constrained availability of supplies in a population where use is common and access to safe water and fuel for safe preparation of BMS is limited. Based on the Humanitarian System Monitoring report of December 2014, infant formula was the most highly requested food item by the conflict-affected population. Due to shortages, over-diliution of BMS was practised to prolong use.

The IYCF Advocacy Task Force, in collaboration with IFE Core Group at global level, developed a statement on the promotion of safe and appropriate IYCF practices. The statement was signed by the UNICEF Representative (on behalf of Nutrition Sub-Cluster), the WHO Representative (on behalf of the Health and Nutrition Cluster) and the MoH. It was issued in August 2015. A two-day workshop on IYCF was conducted by the Nutrition sub-Cluster with support from UNICEF HQ for partners and government staff in July 2015.

Micronutrient deficiencies (MND)

It was expected that anaemia prevalence in women and children would increase post-crisis and there are anecdotal reports of 60% anaemia in women in some areas, yet reliable data are not available. In March 2015, the Nutrition sub-Cluster proposed a surveillance system to document monthly reported cases of anaemia in pregnant women and infants from randomly selected health facilities in five priority oblasts in both government and NGCA’s. UNICEF field monitors were to collect the data and develop the reports, although the system remains to be established.

Additionally, UNICEF proposed the distribution of multiple micronutrient powders (MMPs) for home fortification in the Nutrition Response Plan; however the product required MoH approval before being imported as it is not registered with MoH. Due to the lengthy process of new product certification in Ukraine, this activity has been dropped.

Nutrition for other vulnerable groups

In addition to children under two years, older people and pregnant women are considered particularly vulnerable groups. The Nutrition Response Plan suggests that some of the needs of these groups might be met through food distribution activities of the FSC and social protection activities. It also recognises that the Nutrition sub-Cluster does not have the capacity to directly assess the nutritional status of older people (noted on pages 11-13), although it aims to review results from the nutrition screening of people over 70 in mobile health units conducted by WHO and develop a response if necessary. Additionally, the plan proposes anaemia surveillance for pregnant women. However neither of these activities have been conducted.

Monitoring and information management

An initial plan for monitoring and information management was established in the Nutrition Response Plan. However, as there have been no nutrition-specific programmes, there has been no programmatic information on which to report. While WFP received money for complementary food distribution and has identified partners, this has been halted due to the lack of access to the NGCAs (since August). The 4W (who, what, where, when) sheet was not updated between May and November 2015 due to the absence of a long-term NCC

The monitoring of Nutrition sub-Cluster Coordination performance is planned through a standard Cluster Coordination Performance Monitoring (CCPM) exercise; however a date for conducting the CCPM has not been established.

Funding

The cost of implementing the Nutrition Sub-Cluster Response Plan (February 2015) was estimated at USD 9.5 million, although this does not include funding secured by local organisations such as private foundations. It was costed in anticipation of capacity materialising where funding was available. By February 2015, the Nutrition component of the Health and Nutrition Cluster HRP was zero per cent funded. The RRT member, providing surge support to Ukraine in February, advocated directly with GNC partner agencies to support a nutrition response, while UNICEF HQ, UNICEF Ukraine, WFP HQ and WFP Regional Bureau advocated for funding with donors directly. As of September 2015, USD 4.01 million (mostly for health) has been received against the overall Health and Nutrition HRP. In addition, DFID has provided 600,000 GBP for nutrition (to UNICEF) and WFP has received limited funding for complementary food  distribution, but it has not started yet (November 2015).

Challenges

Interviews conducted with a number of stakeholders identified the following challenges in effecting a coherent nutrition response to the Ukraine crisis:

• Nutrition has not been a priority for the humanitarian response given the absence of acute malnutrition. Other nutrition issues (such as anaemia and stunting) are widely considered development issues and the responsibility of government in a middle income country. Links between poor IYCF practices and nutrition/outcome are not not clear to donors. A more pressing MoH priority was management of a polio outbreak.
• The areas affected by conflict are on average 9.5 hours (690km) from Kiev, the capital of Ukraine. There is no visible impact on those in the capital and thus it is a relatively ‘silent’ emergency.
• Nutrition coordination has fallen through the cracks. There is no dedicated capacity for coordination or information management, limited partner capacity, low prioritisation and coordination struggles within the HNC and FSC, and weak national UNICEF capacity. The NCC position remains unfilled 11 months after the identified need. Cross-sectoral coordination and engagment with local NGOs (who are many, with massive reach) has also been hampered as a result
• Lack of both technical nutrition capacity on the ground and experienced international agencies in the immediate respnose, coupled with high surge staff turnover, has limited progress on the Nutrition Response Plan.
• Lack of product approval from the government mean that MNPs could not be used to improve dietary quality for children.
• There was no guidance on what to do for non-breastfed/BMS-dependent infants. While all partners recognised this was a large challenge, there was limited leadership and authority on the ground (including agencies' headquarter technical nutrition staff) to make recommendations. This contributed to additional confusion among partners and the wider humanitarian community, including donors, and the population³.

At the time of writing (November 2015), the GNC and the UNICEF Country Office are working together to recruit a NCC as soon as possible; however due to lack of funding for a purely coordination position, a Health and Nutrition Specialist position, which combines coordination with UNICEF programme functions, has been advertised. It is questionable how much time this person will be able to allocate to coordination of the emergency nutrition response. In the interim, short-term support staff are still being deployed to cover basic technical and coordination functions. 

Lessons learned

The scoping visit was a crucial step in understanding the nutrition situation in Ukraine; it raised the profile of the nutrition situation at national and international level and galvanised support for assessments by INGO partners, including CDC.

Absence of acute malnutrition at the onset of the crisis indicated (incorrectly) to many in-country stakeholders that a nutrition response was not necessary. IYCF and complementary feeding issues attracted most attention, but stunting and NCDs did not.

Older people were a crucial vulnerable group in this context but were not included as a group of concern by the Nutrition sub-Cluster, and so were not reflected in the HCT funding and support requirements.

Future situational analyses should review the range of nutrition issues from the outset, including stunting and NCDs, and consider how a deterioration in other sectors will impact all aspects of nutrition, to guide the development of the response. Strong partner technical capacity is crucial. There remains a question as to how emergency response should address a previously existing chronic problem (poor child feeding practices) pre-conflict.

The Ukraine nutrition response (mainly IYCF support) is largely underfunded (97%), according to the HRP; there remains a lack of implementing partners even in the event of funding being secured. This raises the question as to whether funding requirements for a response should be based on assessed needs or on capacity to implement.

Dedicated coordination and information management support for nutrition is crucial, regardless where nutrition coordination sits, and should be prioritised in UNICEF recruitment and funding processes.

For more information, contact: Anna Ziolkovska