Challenges and Opportunities in Integrating CTC and Food Security Programmes in Malawi (Special Supplement 2)

By Jim Goodman (Concern Malawi)

As with the majority of famines and food crises, the 2002-3 Malawi crisis was caused by the interaction of many pre-existing factors of vulnerability that combined to over-stretch fragile coping capacities. The resulting situation demanded both an emergency nutrition intervention and a means of re-establishing food security to, at least, a pre-crisis level.

This article describes experiences from the CTC and food security programmes that Concern Worldwide has been implementing in Dowa district since June 2002. It describes the opportunities that were capitalised upon during the CTC programme, for delivering food security activities through the health service, improved targeting of households to receive direct assistance with agricultural inputs and providing an entry point for longer-term interventions. The main challenges were aligning development and relief approaches, matching the scale of interventions with available resources, and working effectively with Government structures.

Integration in practice - health centres and communities

Achieving sustainable improvements in household nutrition, from a food security angle, demands interventions to improve skills, knowledge and community organisation in the areas of food production, post-harvest food management and food utilisation. The specific challenge for the food security team was to identify interventions that could be implemented effectively in tandem with the OTP programme, taking into account the scale of CTC coverage, its timetable and the resources available.

Food security programme extension staff took advantage of the regular presence of mothers at health centres to distribute agricultural inputs and deliver simple messages on planting and fertilising. Concern also attempted to use the time people spent waiting for distributions constructively, by entertaining mothers through motivational songs about food security issues - these encouraged identification of a group problem as opposed to an individual problem, and helped to create a positive atmosphere. Demonstration gardens, supported by posters, were staged at each OTP distribution point, displaying technologies mothers could adopt at home to diversify diets. Health Surveillance Assistants (HSAs) were trained with simple agricultural skills at the same points on non-distribution days.

The results of these efforts were mixed. The availability of agricultural inputs and training provided an additional incentive for attendance at distributions and probably helped increase admissions. However, the potential for learning at distribution days was constrained by the time available, the frame of mind of attending mothers and the general atmosphere. Mothers were usually tired and focused on their main reason for attendance - access to supplementary food and RUTF. Because of this, messages had to be kept short, and focused on the agricultural inputs provided, simple food processing and hygiene techniques. This left important areas of subject matter uncovered, which had to be addressed with extension work back in communities.

An important question was how practically to deliver extension to OTP mothers who, because of the relatively low prevalence of severe acute malnutrition (1.5%), were thinly dispersed among villages across the District. The chosen solution was to promote OTP households as an important subgroup within existing community groups, in particular Village Health Committees, as opposed to creating separate OTP agricultural support groups. Using existing structures allowed extension staff to reach OTP mothers through their normal extension schedules, increasing the possibility that these groups could continue receiving extra support after the end of the

Concern supported emergency intervention. All that was required was for them to adapt the subject matter, where necessary, to include community nutrition issues of particular relevance to OTP households. The Concern team are now in the process of piloting small programmes aimed at identifying and promoting positive deviant behaviours as an extension methodology which if successful, might improve the focus of this approach and its longer term effectiveness and sustainability.

Issues in targeting the most vulnerable

Food security and nutrition interventions target in very different ways. Food security programmes seek to improve food security at community level, whereas the OTP programme focuses on the individual child and their carer. There are several tensions inherent in this. One is the assumption that households with a malnourished child (OTP/SFP households), are likely to be among the most food insecure. However, in Malawi, nonfood factors, particularly disease and the social care environment, are extremely important determinants of malnutrition. This raises questions about the utility of a food security strategy targeted at only OTP/SFP households. For this reason in Dowa, Concern adopted a community-wide approach that included, but was not restricted to, OTP households. The team also tried to consider food security and nutrition problems holistically and with participatory problem analysis, to address a wider range of causative factors. OTP households were provided with agricultural inputs in an attempt to strengthen their resource base and enable meaningful participation in longer-term food security interventions (e.g. cassava cuttings to enable them to process and store cassava as an alternative to maize).

The Dowa food security intervention also had to address issues surrounding local perceptions of vulnerability. Identification of the OTP/SFP household is relatively fast and easy and ensures that extension staff recognise them, but it does not necessarily ensure acceptance by the community, or action by the extension worker. The notion of 'deservedness' influences both community group dynamics and the attitudes of extension staff. In practice in Dowa, community self-targeting is often biased towards the ability to participate as opposed to objective nutritional status. Mothers with malnourished children may be the least able to participate in community activities, while for both social and economic reasons men tend to capture project benefits. Project staff skilled in these issues needed to devote much time and effort to facilitation between the community and extension staff to increase inclusion of OTP/SFP households. Such facilitation skills are not always well developed and their absence would be an important barrier to success. Participatory discussions and problem analysis did overcome some negative attitudes towards households with malnourished individuals, however more experience and research was needed to determine ways of aligning community priorities and the objective of improving nutrition. This is likely to reinforce the importance of skills in facilitating participatory discussions and problem analysis. This raises another question about whether a Districtwide emergency intervention can devote sufficient resources to exploring and resolving such issues.

Entry and exit points

Seeds distributions can contribute to improved food security.

In Dowa, the team found that an important strength of CTC was that it offered not only immediate action on malnutrition, but also gave the opportunity for better continuity between relief and recovery assistance. CTC's potential to achieve this lay in its focus on working with mothers in their communities. This focus of resources and attention at the community level helped provide an entry point into communities for recovery work, by establishing groups to work with and beginning the process of discussing problems and objectives directly related to improved nutrition with them. CTC also offered an alternative starting point for targeting and promoting other sectoral interventions such as gender awareness, economic empowerment and HIV/AIDS, as components in longer-term food security programming for vulnerable households. This horizontal multisectoral programming is essential in Malawi, where the many problems associated with these issues combine to keep the rate of under five chronic malnutrition above 50%.

Scale and Resources

Defining the scope of the food security intervention in the context of the District-wide CTC programme in Dowa was, in part, a question of resources. A balance between achieving coverage of the needy population and addressing the various aspects of food security for that population in a comprehensive manner, needed to be struck. This balance had to be reached based on the capacity of District Government to take on extra work outside their normal scope of duties.

Concern's response to this was to concentrate selected programme activities in a number of focus villages associated with health centres and specific extension workers. These acted as centres for promoting nutrition as a special topic within the long-term work of government extension staff. Within each focus village, a community volunteer acted as the main contact point for staff and follows up activities between extension staff visits. Government staff were encouraged to replicate successes in other villages. The effectiveness of this pathway depends on staff capacity and attitude; these are factors which themselves are open to development through training, exchange visits to successful sites and participatory meetings. In Malawi, individual extension workers from both Ministries of Health and Agriculture, have been able to address day to day problems outside their normal scope of work. This has enhanced their profile within communities and been a source of motivation. Some individuals, however, are still heavily influenced by the expectation of additional financial gain for participation in new work. Training, meetings and exchange visits, although not necessarily expensive, require funding which, for the foreseeable future, must be provided from non-governmental resources.

Aligning relief and development approaches

An overarching challenge was that different actors involved in programme planning viewed the problem through different 'professional lenses'. Integrating the two required a development perspective to merge with an emergency perspective. This requires resolving differences in the time-scale over which funding is made available, differences in perception of the types of behaviour change which can be tackled over different time scales, and aligning long-term and short-term programme capacity requirements.

Short term impact and long term change

The OTP programme has delivered a set of replicable systems for treatment of malnutrition that will ultimately be managed by the Ministry of Health, and emphasised staff training and logistics management to achieve impact. During the first year of intervention, the participation of mothers in the nutritional rehabilitation of the child was predominantly passive. The short term impact on the patients did not require the carer to understand the reasons for the child's condition or how the treatment works. Selected topics were covered with less intensive staff:mother contact at distribution points (e.g. short demonstrations on a precise topic such as preparation of soya flour), but it is questionable whether these were sufficient to produce lasting behaviour change.

In the same way, a relief programme can successfully use OTP distribution points to distribute familiar agricultural inputs that the recipients know how to use and in so doing, achieve largescale rapid short term impact with minimum follow up. However, this minimalist approach cannot work using inputs that the people are unfamiliar with and cannot hope to influence behaviours and cultivation techniques.

The achievement of longer-term benefits in the Malawian context of chronic food insecurity requires both crop diversity and changes in agricultural, storage and processing practice. These can only be achieved if substantial staff time is spent discussing constraints to production and various preferences with communities, improving crop husbandry skills, exploring new crops and following up on crop development. In Malawi, this is being achieved by a small team of extension staff working in tandem with the larger scale intervention in 30 focus villages across the District, researching and developing activities in these areas. The use of positive deviance as an extension methodology is a key component of this and is one mechanism for improving skills in participatory techniques among programme and government staff. While staff are only able to do comprehensive community nutrition extension in a sample of villages, this provides experience and a model for rolling out the rehabilitation phase of CTC to government staff

Scale

In the direct treatment of clinical malnutrition, staff time is dedicated to ensuring geographically wide coverage; resources are unlikely to be available to provide staff for more developmental work on the same scale. An objective of the posttreatment phase is to increase whole community capacity for involvement in nutrition management. This requires a more developmental perspective, delivering technical training in the context of a broad understanding of the household food security problem and linking of problems.

This approach requires the adaptation of long- term development considerations (inter-alia, sustainability, participation, the adult learning process, group dynamics, community ownership, long-term behaviour change), to an immediate problem. Inevitably availability of resources determines the scale on which this is possible and it is most likely to be on a much smaller scale than treatment. This pathway for programming in overlapping phases (i.e. relief, recovery, development) overcomes some of the differences mentioned above. It requires positive discussion and collaboration between 'relief' and 'development' stakeholders from an early stage.

Working with government

Inter-sectoral programmes are typically slowed down due to confusion over responsibilities. This occurred in Malawi where the pressure for a speedy emergency programme detracted from the process of consultation and discussion with other implementing bodies. In the long run this pressure to achieve results has led to delays (for example in deciding which sector should be responsible for food hygiene or food preparation extension work) that could have been avoided. To minimize these problems future CTC programs should conduct a thorough institutional and capability analysis at the planning stage, even if this slows initial implementation down a little. They should also make more time for on-going discussion and consensus building among managers at District and programme management level during the programme.

In practice, in Malawi despite some initial confusion, the efforts made to develop horizontal links and understanding have borne fruits and an 'inter-sectoral understanding' is evolving as implementation proceeds. At field level, from the outset, staff from the Ministries of Health and Agriculture were encouraged to consider new subject matter, enabling them to recognise and address simple problems not traditionally addressed within their Ministries. This sets up a denser network of extension staff to implement the post-emergency phase. In Dowa, agricultural staff regularly refer mothers to health centres and NRU's and health staff are now able to trouble-shoot agricultural problems. This has been straightforward technically, with staff being eager to acquire new skills to face the problems they meet in everyday community work. At the time of writing, the food security team was training OTP mothers on diarrhoea prevention, while HSAs were distributing indigenous vegetable seeds. This cross sectional cooperation has provided a denser network of extension staff to implement the post-emergency phase improving the impact of both OTP and food security extension activities.

The biggest challenge has been finding space for quality training in the over-stretched and under-resourced schedules of government field staff and avoiding conflict between the programme and District Ministry Offices. Where possible the team tried to design training that was succinct and sometimes conducted outside normal working hours, and generally provided 'take-away' training notes. Some topics were dealt with as part of short planning sessions at health centre level with small groups of staff from both Ministries. Such sessions have also encouraged agriculture and health staff to work together with the same households.

Future Opportunities and Challenges

The work in Malawi has laid the foundations for further work in integrating nutrition, food security and health within the CTC framework. At this phase of the programme Concern are focusing on the development of positive deviance techniques as a community extension tool, organising farmer groups for the local production of RUTF ingredients and developing homebased care for HIV affected households identified through CTC.