Reflections on food and nutrition interventions in Huambo

By Lola Goselow

This article is based on a field trip made by Lola Gostelow (SCF HQ emergency advisor) to the SCF programme in Huambo province, Angola in November 1999. The aim of the visit was to review activities and future plans as well as work with the team on technical aspects of the food and nutrition programme. The article provides a snapshot description of SCF's emergency food and Nutrition intervention at the time. It also shows how mid-term programme reviews can strengthen interventions.

Angola has been at war for almost 3 decades. This has had a profound influence at all levels of the country's infrastructure: economic, social, public, commercial, political and military. There had been massive inflation of consumer prices, averaging over 1000% in the period 1994-98.1 Almost half the country's 11 million population live in urban centres, partly to avoid insecurity in rural areas.

Fighting had resumed in December 1998, and was concentrated in the central Planalto region of the country, in and around Huambo Province. The resulting displacement, together with the economic impact of the unrest led to the current emergency programme.

The scale of SCF's emergency operation in Huambo had increased markedly since December 1998, mostly as a result of concerns about the food and nutritional situation of the town's inhabitants - displaced and latterly residents. The IDPs fell into two broad groups: camp residents (about 30,000) and those dispersed in the local bairos (about 100,000).

SCF's emergency operations included:

1. a General Food Distribution Programme, and
2. a Supplementary Feeding Programme

General Ration Programme

SCF were an implementing partner of WFP for the general ration programme. At the time of my visit the programme was undergoing several changes linked to servicing the expanded case-load of residents and non-camp IDPs. WFP had finally acceded to repeated SCF requests to expand food aid support.

In the period June 1999 to January 2000 the total distribution by ICRC and WFP/SCF amounted to 14% of estimated food requirements.2 The November nutrition survey in Huambo had indicated a global malnutrition rate of 13.8%.

On arrival it appeared that coordination of the food aid programme had been weak. One manifestation of this was the discrepancy between ICRC and WFP approaches. ICRC gave a ration of 6kg of maize per person whereas WFP provided anything up to a full ration of 12kg maize, 1.8kg beans, 0.75 Kg oil and 0.15kg salt. In contrast to WFP, ICRC did not employ targeting criteria in the belief that everybody had been equally affected by the conflict. This served to confuse relations with Government authorities, through whom all agencies worked to ensure a co-ordinated, planned response to the population's food needs. Although geographical areas of responsibility were clearly demarcated between ICRC and SCF, the rationale for ration variations was not clear.

WFP planned a monthly food distribution of 1,500MT of food aid involving food for work, general ration distributions and supplementary feeding programmes in Huambo Municipality. In contrast ICRC had a monthly programme of 3,000MT food, distributed entirely through general rations, for people living outside Huambo Municipality, plus 3 bairos in Huambo (Aviacao, Fatima and San Luis).

One serious limitation of WFP's operation in Huambo had been the lack of forward planning; all activities were carved out in one-month chunks, with little analysis of needs/responses beyond that. Undoubtedly, this was partly a result of pipeline constraints, but more transparency as to these constraints would have eased rapport with the other agencies. It meant that SCF could not guarantee beneficiaries rations beyond a month or inform them in sufficient time about what their ration entitlement was going to be. But perhaps even worse was the fact that this lack of information undermined relations with the secretaries and communities of the various bairos.

At the time of my visit WFP appeared to be revising their activities largely sparked by a mission from Rome which revealed problems in the food distribution programme.

Targeting rations when the need for food aid support is ubiquitous

SCF's registration procedure for the general ration programme in October employed two broad criteria for exclusion from non-camp distributions: salaried employment (including army, police, civil security forces, government workers etc.) and evidence of commercial activity (business people rather than petty traders). As some households were therefore not eligible, disputes emerged and grievances were often directed at SCF. At the time of my visit the decision had been taken to postpone future distributions until the Government had formally agreed to the criteria proposed and communicated this agreement to all bairo administrators.

WFP Huambo subsequently criticised these criteria as too broad. A meeting was convened in November to review the criteria used and plan for a re-registration exercise. WFP tabled a list, on which criteria could be based. The list included:

• elderly (>55 years) head of households
• disabled head of households
• salaried workers
• family income (the idea of a 45 million Kwz poverty line was discussed)
• nutritional status
• agricultural activity and farm income

Lengthy discussions ensued amongst the agencies, during which it was agreed that there was a need for realism about the sorts of information that it would be possible to collect with some confidence, or which could be verified independently of interviews. The final outcome of the meeting was that three sets of criteria for exclusion from non-camp distributions were to be considered in making a decision about eligibility for a food ration and that background information on the beneficiaries should also be collected (see table).

It was anticipated that the background information would be useful for the general monitoring of the situation in Huambo and for getting a basic profile of the population for use in future non-emergency programme planning.

Thus, the decisions making process regarding receipt of a food ration would be as follows:

There was a great deal of discussion and unease about these criteria, not least because it could be expected that the vast majority of households would have some 'other income' apart from a salary. Indeed, those with no other income would arguably have died by now, since the general ration would not have met all nutritional needs. However, there was quite a lot of pressure from WFP to 'tighten' the criteria used, as they felt it was unacceptable to see well-dressed people arrive for food at a distribution; they wanted to exclude the 'obvious' cases of inappropriate registration. The point was made that while the revised criteria might reduce inappropriate registrations, it would also markedly increase the likelihood of missing people who truly needed support. WFP maintained that we should progress with these 'new' criteria, and review the programme in January 2000.

In January another SCF advisor visited Huambo to conduct a brief appraisal of food security in Huambo. He concluded that the total food supply to the city was less, probably very substantially less, than was required by the population for adequate subsistence (the November nutrition survey in Huambo had indicated a global malnutrition rate of 13.8%). In addition there was no evidence for any easily identified household characteristic, other than possession of an affluent residence in the concrete city, which allowed discrimination between those who were in need of food distribution and those who were not. In other words the proportion of the general population who were able to meet their food needs from their own economic activities was so small as to negate any advantage from targeting. Following these recommendations WFP reinstated a general untargeted food distribution which was finally running smoothly in April 2000. The general food distribution ceased for all non-IDPs in May as a result of the WFP/FAO Crop assessment which concluded that the recent harvest would meet people's food needs for two months. Preliminary results from the May survey showed global levels of malnutrition to be 10%.

The discussions, disagreements and arrival at consensus over targeting, registration and management of the distribution system took almost 6 months. We have to ask ourselves at what cost?

The Supplementary feeding programme

There were a total of 13 supplementary (8 SCF, 2 Concern, 3 ADDRA) and 6 therapeutic feeding centres. Entry criteria for all SFCs were similar: children up to 12 years of age, below minus two standard deviations (equivalent to approximately 80%) of the median weight-for-height (WFH). SCF centres had used low MUAC as an alternative entry criterion to admit cases who were not below the WFH cut off but looked malnourished. It was however agreed that this practice would be stopped. This would help more rigorous monitoring as only WFH is used after admission to evaluate progress and decide on discharge.

Supplementary feeding in the context of the overall general ration.

Registration records in some centres showed that those attending were coming from nearby bairos rather than the immediate vicinity: For example, approximately 65% of the caseload in the Aviacao centre come from Kalamanda, where SCF had only made one general distribution in the past. The ration given at the centres was 1,400kcal per child or carer per day (two porridge meals were provided at around 9.30am and 1.30pm). This was quite generous and reflected the concern about the lack of general ration at the time the programme was established. It was decided that the ration could be reduced for children aged below three years. Thus, instead of the 200ml porridge, the under three year olds would receive 150ml, or approximately 1050 kcal per day. Also, no second helpings would be given to older children. In this way, it was hoped that the 'supplementary' aspect of the feeding programme could be strengthened so that children would realise that they also needed to eat outside the feeding centre.

In addition, out of the 4,000 or so registered in the SCF feeding programme, about one third were carers accompanying children below 2 years of age that were travelling long distances to come to the centre. The carers received the same ration as the children. We discussed the possibility of reducing their allocation to one meal.

The feeding programme team were planning a rapid assessment to examine the proportion of children attending the feeding centres whose families had received a general ration in the last two months. This enquiry was intended to help guide any future decisions about the size of the ration for children and carers. It was also hoped that it would shed light on whether those children who had been attending for several months came from families who received no other food aid.

Attendance Issues

Data from feeding centres were showing a clear pattern of non-attendance for about two weeks following a food distribution. But, once the food at home ran out, children would return for feeding. A corollary was that there were a significant number of children who had been attending the programme for several months but who had yet to recover. Two additional staff were recruited in each of the centres in order to trace children. With these additional staff, it was hoped that families could be encouraged/supported to continue sending their children for feeding in order to ensure full and speedy recovery. It was also hoped that such contact would help provide information about some of the constraints that families were facing with regard to participating in the feeding programme and the decision-making processes they go through.

There were regular weighing days (2 per week per centre) with the bulk of admissions and discharges occurring on these days. It was therefore of little surprise that attendance on weighing days had been dropping as children sought to avoid discharge! Consequently, it was agreed that the weighing days would be varied, and any children who missed the weighing day would be monitored on their first day of return.

Improving Psychological Care

Another new cadre of staff employed were play organisers (two per centre), to promote mental stimulation and developmental activities with the children as a complement to the physical care they were receiving. Such activities are an important aspect of the success of a feeding programme, and there is evidence that length of stay is reduced when play and other activities are combined with the feeding. These new staff were about to be trained by a church group on techniques to care for children who had been psychologically injured.

Lessons Learnt

Although not explored in detail during my visit, a key issue which emerged and that would hopefully be taken forward by the team, was the need to improve the quality of documentation of our programmes. With this in mind, it was recommended that all teams compile key documentation relevant to their programme: lessons learned, monitoring formats, staffing issues, guidelines on approaches or protocols, rationale for any major decisions made, etc. These needed to be compiled on paper and disk, and stored in a clear, accessible location (in Huambo, Luanda and London).

For example:

• In the general ration programme, there were important experiences of targeting, ration selection, timing, distribution methodologies, monitoring etc. which needed to be captured for future reference.
• In the nutrition programme, lessons about information for registration, the need for individual record cards for each child, formats for reporting the monitoring statistics, the final protocols etc. constituted important experiences which would help inform the implementation of any future feeding interventions.

It was vital that we should not have to begin again from scratch (as was the case for this programme).