Challenges to implementing an integrated emergency public health response

By Dr. Jean Galdwin

Dr Jean Gladwin is a public health nutritionist and researcher with several years work experience in low income countries in emergency and stable settings. She has recently taken up a long-term post in Ethiopia working for the World Food Programme.

Analysis of the underlying causes of malnutrition have shown it to be a complex process, thus interventions in non-emergency situations have attempted integrated responses by focusing on health, food, agriculture, water, economics, religion, traditional beliefs, social practice and welfare systems. The 'Conceptual Model of the Causes of Malnutrition in Emergencies' (The Sphere Project, 2000:76) extends this acknowledged complexity into the emergency arena and has become the basis for action. Oxfam and other agencies seek to provide an integrated approach during assessment, implementation, monitoring and evaluation.

Despite their best intentions agencies cannot always provide the interventions they would like, or deliver to the minimum standards they set themselves. This paper reflects upon some of the challenges encountered whilst delivering an integrated response in Gode Zone, Somali Region in Ethiopia.

Background

Dry supplementary feeding programme distribution by Oxfam. Gode, Ethiopia. July 2000 (Jean Gladwin)

The Somali Region in Ethiopia has had failure of both short and long rains over the past three years. The region is semi-arid and predominantly inhabited by pastoralists and some agro-pastoralists, who, in the main, are dependent upon rain-fed pasture and agriculture for their survival. As the drought period lengthened, their ability to sell or exchange livestock or produce and sell crops became severely affected, and livestock losses increased. The region is one of the poorest in Ethiopia with limited access to basic services and infrastructure such as health, education, water supply, roads and communication. The social aspects of life in the Somali region are complex and, in common with many predominantly pastoralist areas of Africa, have often become associated with inter clan rivalry and political tension. This continues to create conditions of poor security in large parts of the region, and conflict over control of scarce resources.

Oxfam (GB) agreed with the Ethiopian government in early 2000 to provide support in the Somali Region, and this paper will report on their emergency interventions in Gode Zone. It was suggested that Oxfam (GB) meet the needs in Adadle district of Gode Zone (plus one village in Afder Zone) and also provide expert support to the Water Bureau to maintain the water supply over a wider area.

Oxfam (GB) began their interventions in late April, when the most critical obstacles to survival were lack of water and food, high rates of acute global malnutrition, low immunisation coverage, limited access to health care, increased prevalence of disease, and inadequate shelter, cooking utensils and water containers. Extremely high rates of acute global malnutrition were identified by several agencies, and a quick house-to-house mid-upper-arm circumference (MUAC) screening by Oxfam (GB) at the end of May in Bulhagary village indicated an acute global malnutrition rate of over 40%.

Consequently, Oxfam (GB) initially planned to:

• Set up supplementary feeding programmes (SFPs) serving up to 2000 moderately malnourished children and 500 vulnerable adults at any one time;
• Set up a therapeutic feeding programme (TFP) for up to 200 severely malnourished, with referral facilities to Gode Hospital;
• Strengthen the existing facilities at Gode hospital, particularly for the treatment of malnutrition-related medical conditions;
• Support the Zonal Health Department's (ZHD) measles vaccination and vitamin A campaign;
• Strengthen existing local capacity through training of community hygiene promoters;
• Provide treated water to the Oxfam (GB) TFP, villages where the Oxfam (GB) SFPs were sited, Gode hospital and other agencies assisting the affected population;
• Integrate hygiene promotion activities into all aspects of the water and sanitation activities, and in the feeding centres themselves;
• Introduce appropriate sanitation measures (latrines, waste disposal, construction) for the feeding centres and the villages in which these were operating; and
• Carry out community mobilisation activities in support of the interventions.

The decision to conduct these interventions reflected an assessment of need, and the programmes of other agencies and government.

Challenges encountered

SFPs were opened in Bulhagary, Busarado, Derihayo and Liban to serve these four villages and surrounding areas. A fifth was intended in Tordob, but for security reasons was not started. Dry, rather than wet feeding was undertaken, as families had access to fuel, and attendance once a week allowed for the resumption of normal social and economic life. An Oxfam (GB) TFP was opened in Bulhagary. However, the difficulties setting up and operating in Gode Zone were many, some are mentioned below.

Timing of the integrated response

Oxfam water treatment plant. Gode, Ethiopia. August 2000 (Crispin Hughes/Oxfam)

Integrated programmes need to operate at approximately the same time for the greatest impact. Unfortunately this did not always happen in Adadle. Oxfam (GB) decided to deliver feeding programmes in areas where they believed the general population was receiving adequate relief food or had their own resources. In practice the intended 12.5kg of cereal per person per month from the DDP/WFP was probably not delivered. This prompted ICRC to provide a complementary ration of oil and Unimix (a fortified blended food) or sorghum. However, the population in Gode Zone was increasing continually and, as both rations were distributed once per month, people would often arrive in villages where the distribution was not due for several weeks. Consequently many people went hungry or, if they were lucky, shared the meagre resources of others. When there is insufficient food entering the house any SFP food is more likely to be shared by the family rather than consumed by the malnourished individual alone.

As soon as Oxfam (GB) arrived in Gode to implement the programmes they became aware that health care facilities in Adadle were in need of strengthening, particularly where SFPs were located. Minor medical care was available to the malnourished in the SFP, but the general population needed to travel for days to access health care. Two villages had temporary Zonal Health Department (ZHD) health units, but these were inadequately staffed and resourced. No other agency was available to take on the support of the health centres, therefore Oxfam (GB) agreed to support five health centres in villages where the SFPs were located. Unfortunately, this support was not immediately available, and the SFPs operated for many weeks before the general population had improved access to health care.

The provision of treated water to villages where the SFPs were operating went well usually due to the efforts of Oxfam (GB), the Water Bureau, SCF (US) and UNICEF. However, there were times when water was not available and the integrated programme was interrupted. The water was being tankered over great distances to higher than normal concentrations of population. This was quite a logistical feat and there were many occasions when the water tankers broke down or the water supply from Gode town was unavailable.

Oxfam (GB)'s intended integrated programme had a hygiene and health promotion component. Bulhagary and Busarado SFPs began at the same time as the Public Health Specialist was setting up hygiene promotion activities, including the training of community-based health promoters. Unfortunately, the same did not happen in Derihayo and Liban, which interrupted the integrated response. It is particularly important to ensure good hygiene practices in villages where the concentrations of people are high and yet this part of the programme proved very difficult to implement. Moreover, despite the existence of EPI teams at the zonal level the measles immunisation and vitamin A capsule distribution coverage was low until the June/July campaign. Although that campaign did reach over 6000 children under five years old it would have been better if had been initiated earlier as several measles-related deaths were reported in June.

Working with the local community

Providing emergency support to nomadic populations in an area of weak infrastructure is very difficult. Frequent discussions were held with community representatives (men and women) to decide where SFPs should be sited, and the community's needs. However, clan rivalries had to be taken into account when implementing the programme and insecurity curtailed the activities at times.

Balancing community needs and wishes against the resources available and technical knowledge meant that not every one could be catered for. Targeting, rather than equal sharing of resources was difficult for many people to accept. All the villages wanted to have a TFP which led to tension at times, and although the people of Derihayo and Liban were willing to take the severely malnourished children to the existing TFPs none of the severely malnourished children from Busarado were taken. This may have been because the communities were different sub-clans (although an alternative TFP was available) or for other reasons. The women from Busarado said that it would be difficult for them to leave other family members or their temporary shelters. Oxfam (GB) offered to support siblings, but it did appear that there was a lack of a community support network. Without an in-depth investigation it is difficult to know why the children did not go to the TFP, but whatever the reasons the integrated emergency response was again interrupted.

Lack of staff and local implementing partners

Usually Oxfam (GB) prefers not to become fully operational in emergency situations but to work with local implementing partners. If circumstances do not allow this, perhaps due to lack of capacity or conflicting political agendas or insecurity, it is necessary to set up programmes staffed by Oxfam personnel and introduce Oxfam procedures. In Gode Oxfam (GB) became fully operational, and although most of the two hundred staff members employed were from Gode Zone, most of the senior people were not. They included a small number of expatriates and Ethiopians from other parts of the country, who did not have the same cultural background or have extensive knowledge of the area. This is an issue in any programme, but particularly so in Somali Region where the clan system dominates all aspects of social, economic and political life.

Oxfam (GB) arrived in Somali Region at a time when not too many other agencies were setting up programmes. Consequently government employed nursing staff were temporarily seconded, which greatly eased the operation and meant that Oxfam could train such staff to respond to future emergencies. Experienced nutritionists were recruited which no doubt improved the quality of the programmes, especially in comparison to other nutrition programmes in the region that were being operated without nutritionists. However, senior local staff and international staff were very difficult to find and now that many agencies are implementing emergency programmes in other parts of Ethiopia it will become harder to recruit and retain such staff.

Incidence of disease and environmental conditions

Somali Region is a very tough environment in which to work, particularly so after the short rains and due to the constant wind that began in June. The incidence of communicable disease is very high, and Oxfam (GB) staff suffered much illness. MSF (B) estimated the prevalence of TB in parts of Somali Region could be as high as 250:100,000, but the treatment requires a long-term commitment, which is not always possible during an emergency and when funding is precarious. The TB treatment programme, supported by MSF (B) and the ZHD, was confined to Gode town, and did not cover Adadle district unless the person concerned agreed to live in Gode. Consequently few cases were treated, and no doubt the inability to deal with TB and poor environmental conditions reduced the impact of other programmes.

Logistics and bureaucracy

Logistical and bureaucratic problems encountered in attempting an integrated response proved to be very time-consuming. Poor infrastructure, made worse by security problems, rendered parts of Somali Region extremely isolated geographically. During the rainy season (for ten days in late April and early May 2000 Gode Zone received a very heavy rainfall, although it delivered less than normal for the time of year), many villages are inaccessible because most roads are simply dirt tracks. Even the maintained roads in Adadle have broken bridges that are impassable in the rain. The lack of good quality tankers meant there was a constant need for spare parts that had to come from Addis Ababa, often resulting in breaks in water supply. Some of these problems could be overcome by increased funding, but many needed longer-term solutions, or long periods of waiting.

Conclusion

An integrated emergency response is unlikely to be provided by a single agency and consequently a coordinated response is necessary, spearheaded by government. In Gode Zone governmental departments did not have the capacity to co-ordinate an appropriate response, although some departments (such as the ZHD) were better equipped with senior staff than others. Consequently the UN and NGOs supported the Government Task Force and its subcommittees.

Oxfam (GB) is conducting very good programmes in Gode Zone. Lives have been saved and the quality of life improved. This review is intended as a reflection upon the achievements and problems, not as a criticism. The Oxfam (GB) staff are extremely hard working and dedicated. Their programmes are often recommended as role models for other agencies. However, their efforts alone cannot provide all the necessary support for the people in Adadle district.

References

The Sphere Project Humanitarian Charter and Minimum Standards in Disaster Response, published by The Sphere Project, Geneva.

Emergency relief project for the drought affected people in Somali Region, Ethiopia, Oxfam (GB), Addis Ababa April 2000.

General report of Assessment Mission conducted in Shinnile and Jijiga Zones of Somali Region, Ethiopia July 10th - 15th 2000 Oxfam (GB), Addis Ababa, Ethiopia.

Dr Jean Gladwin is currently working in Ethiopia and would welcome visits by other nutritionists. She can be contacted by e-mail: jgladwin_99@yahoo.co.uk