Advocacy from Eritrea: working with WFP

By Hassan Taifour

Hassan Taifour is the Emergency Response Nutritionist for SC(UK). He graduated from the Faculty of Agriculture, University of Khartoum in 1985 and completed his nutrition Masters in LSHTM in 1991. Hassan worked for NGOs, UNICEF and the Sudanese Ministry of Health. He has worked in emergency situations in Sudan, Ethiopia and Eritrea. This article arises from experiences with Save the Children UK in Eritrea.

Child being weighed during a nutrition survey. Gash barka region Eritrea Dec.2001

Save the Children UK have worked in Eritrea since 1957 and in 1992 a country office was established. Between 1992-98 SC UK were involved in a wide variety of activities focusing on primary health-care supply and support, emergency drug supply, immunisation and malaria control.

When war broke out on May 12, 2000 all routine SC UK programmes were suspended so that resources could be focused on the more acute nutritional needs of displaced women and children. The majority of IDP camps which emerged in Gash Barka and Debub regions in Eritrea were formed after the outbreak of fighting in May 2000, although a few had already sprung up between 1998-1999.

In response to the emergency, nine feeding centres were established by SC UK in six of the Gash Barka IDP camps.

By June 2001 the number of malnourished children had fallen to less than 30 children per feeding centre. As a result the camp feeding programmes were closed and the focus switched to nutritional surveillance of the returning population. Three anthropometric nutrition surveys were carried out between July and December 2001. In addition morbidity, nutrition surveillance (weight and height of children under 110 cm were measured on a monthly basis by the ministry of health clinic staff) and daily energy intake data¹ were collected for the same period as part of the ongoing SC UK nutritional surveillance system.

Although monthly growth monitoring data were available, these were considered unreliable because the coverage was too low to provide a representative picture for the under five population. Before the outbreak of conflict in May 2000, growth monitoring data were collected (weight for height) in conjunction with distribution of a supplementary ration in the IDP camps. After May the distribution ceased and attendance for monthly nutrition surveillance fell to less than 20%.

Major finding of nutritional surveys and nutritional surveillance

The nutrition surveys of the returning population revealed a marked deterioration in the nutritional status of children under five years. The prevalence of global acute malnutrition significantly increased from 8% in August to 14% in December. The increase appeared to be associated with inadequate caloric intake and high morbidity rates (fever (26%) and ARI (26%)).

Daily energy intake and morbidity data based on monthly nutritional surveillance

Community areas included in SC UK surveillance were divided into a series of sub-zones. SC UK nutrition surveillance teams visited at least three villages in each sub-zone on a monthly basis. Five families were interviewed to obtain energy consumption data for the previous two weeks. The calorific value of all food consumed (including the WFP ration) was then calculated resulting in an estimate of average caloric intake for each family. From the average of the five families a village average value was generated. Results were then extrapolated to the whole sub-zone.

The tables on the left summarise monthly nutritional surveillance data collected in the IDP camps and sub-zones by SC UK.

In all three sub-zones, caloric intake steadily fell throughout the pre-harvest period between July and October. During this time, calorific consumption never reached the recommended minimum of 2100 calories/person/day. In October (the peak of the hunger period), energy consumption declined to the lowest level, with average intake ranging between 1451 - 1654 calories per person per day. In terms of morbidity, prevalence of fever and acute respiratory infections peaked in October as the night temperatures usually drop significantly during this time and there were also 'pockets' of malaria.

Advocacy

"SC UK nutrition surveillance teams visited at least three villages in each subzone monthly"

An inadequate general food ration and high morbidity rates for fevers and ARI were considered by SC UK to be the main contributing factors to this decline in nutritional status of the returning population.

Following the October survey findings, SC UK convened a co-ordination meeting which included all NGOs operating in the nutrition and food sector, UN agencies (WFP, UNICEF, OCHA) the Ministry of Health and the Eritrean Relief and Rehabilitation Commission. The main issue raised at the meeting was the perceived inadequacy of the WFP ration. The WFP general ration had been reduced from 100% to 60% in June 2001, in anticipation of a good harvest. However most crops 'dried out' and produced very little. Increased morbidity, rather than ration size, was initially suggested by WFP as the more likely reason for the observed decline in nutritional status. However, SC UK used the nutrition surveillance data to demonstrate the inadequate average daily energy intake and advocated for a return to a full general ration of 2100 Kcal per person/day. After a number of meetings and consultations, WFP were satisfied with the evidence from the data and agreed to increase the general ration to 100% from December 2001.

Current situation

Gash Barka region,Eritrea Dec 2001

Currently, WFP is maintaining a 100% general ration while mobile clinics are covering almost all sub-zone villages without health stations. Access to health care has now increased from 78.6% in October to 99.8% in December. It is hoped that this level of programming will help prevent a further decline in nutritional status.

Based on more recent findings in the December nutrition survey, SC UK has made a number of additional recommendations in its most recent report. These include:

• WFP/ERREC should resume the distribution of dry supplementary rations of blended food to all children under five in the area.
• An NGO with sufficient capacity should implement a targeted supplementary feeding programme for all malnourished individuals (children and women).
• Nutritional surveys should continue to be implemented at three monthly intervals to monitor the nutritional status of the underfive population and to inform any nutrition interventions. As SC UK has closed their programme in Eritrea, this should become the responsibility of the MoH with assistance from UN and other voluntary agencies.
• Full general ration distributions (2100 Kcal/person /day) should continue at least until the harvest of the following year (November/ December 2002).
• Ensure that there is good access to health care for all villagers by providing mobile clinics for villages that do not have health facilities.
• A food security monitoring system should be established. Ideally, this should be a joint initiative involving donors, UN agencies, NGOs and governmental departments (e.g. Ministry of Health and Ministry of Agriculture).

Conclusion

This experience has demonstrated that the provision of timely, reliable, and accurate field data can be used to advocate for programme change. In this instance an effective and trusting working relationship was established with WFP. A key element of effective advocacy is the field presence of experienced and dedicated staff who can make, and support clear recommendations.

For further information contact Hassan Taifour at: htaifour@hotmail.com

Below are comments on the above article from Salem Elhadji and Jennifer Bitonde, WFP Eritrea

The nutrition surveys conducted by SCFUK and MOH (Ministry of Health) in 2001, have been useful in getting an overview of the nutrition status in the surveyed sub-regions in Gash Barka region.

Based on WFP experiences in the Eritrea we would like to make the following comments about the article.

Findings

In assessing the current situation, the SC-UK article emphasizes inadequate general rations and high levels of morbidity as the main contributory factors to the decline in nutritional status of the returning population but leaves out other factors such as access to water, which are mentioned in the main nutrition survey report of December 2001.

A recent rapid assessment of the main causes of malnutrition in Asmat and Hagaz sub-regions in Anseba conducted by MOH, ERREC (Eritrean Relief and Refugee Commission) and WFP identified the following contributory factors to high levels of malnutrition.

• Lack of diversified food and the fact that the majority of caretakers are not aware of the importance of diversifying the meals.
• Health and hygiene factors and access to clean and safe water: At the household level, water was not kept safely and none of the respondents boiled water for drinking. Sanitary facilities were lacking and the majority of children defecated in the compound and/or open field, which in most cases exposed them to infections and diarrhoea.
• Social and care environment: Prolonged exclusive breast-feeding without complimentary food and poor feeding practices had links to the nutrition status of the children. Most caretakers with malnourished children did not participate in the childcare education provided at the health facilities and as a result many were unaware of the best feeding practices for their children. The assessment also found that food was not shared equally at the household level. The male head of household received the best food (in quality and quantity) at the expense of the children. The lack of basic literacy levels among caretakers was an impediment to accessing information.

A nutrition survey conducted by COSV in Mensura, Agordat and Logo Anseba sub-regions in Gash Barka in December 2001,showed a prevalence global malnutrition of 12.8%. The report identifies morbidity and water usage as factors that need to be addressed to improve the nutrition status of the target population. COSV survey report also recommends targeted supplementary feeding programme, improvement and provision of clean and safe water and promotion of intensive growth monitoring activities at the village level.

Recommendations

The SCF nutrition report confirmed that all 590 out of 591 household surveyed received WFP general rations. The nutritional survey data that are described in the SC-UK article do not justify the need for a blanket supplementary feeding programme. Blanket supplementary feeding is recommended when global malnutrition prevalence exceeds 15% or where the general food rations are grossly inadequate, i.e. less than 1500 kcal/person/day. It is more appropriate to recommend a targeted supplementary feeding programme for malnourished children under 5 years old linked with growth monitoring promotion.

The SC UK advocacy article omits mention of a number of other factors which contribute to malnutrition in Eritrea. For instance, the SC UK nutrition survey (December 2001) reports that global and severe malnutrition are higher amongst children of 2 and 3 years because this is the time when they are introduced to weaning food and are at greater risk of infections. The report further mentions that the percentage of malnourished children within female headed households was slightly higher possibly due to the fact that the mothers do not have enough time to look after their children as they are involved in public work to support their families. Hence there is limited health and social care. The report recommends strengthening nutrition and health knowledge of mothers and caretakers through training the MOH staff, providing sufficient water and a full general ration.

Current situation

WFP provides a full general ration (2100 kcals) to the in-camp population because this group has no other source of food/income. The 'out of camp' population (host communities) receive a 60% ration because they have access to food through farming, and other source of income. WFP has been and is still providing food to 81% of the total 'out of camp' population in the three sub-regions surveyed by SC-UK. Based on recommendations from WFP field offices, agricultural crop production data from MOA and nutrition surveys undertaken by different NGOs in Gash Barka and Anseba, WFP provided full general ration to the drought affected vulnerable groups, returnees, and host communities in December 01 and January 02.

Field Exchange would like to point out that at the end of the draft article submitted initially by Hassan Talfour there were a number of additional recommendations, two of which related to the above comments in the post-script. A number of these recommendations were edited out (with the permission of the author) in order to keep the focus of the article on food security and advocacy. The two recommendations relevant to the above postscript were:

• Provide sufficient water: at least 15 litres/person/day, (Sphere minimum standard) and distribute water containers so that every household has enough water storage equipment.
• Strengthen nutrition and health knowledge by training the MoH staff as trainers on simple practices who in turn will then train the mothers and carers of their villages. (Eds.)

¹While it is best practice to calculate energy intake based on a 24 hour recall, we found through field work that it was easier to find out the quantities of food that were purchased / consumed by a household over a two week period.We recognise that this will not be accurate intake data for individuals but would argue that it provides an indication of sources and access to food over the period in question.