Nutrition causal analysis: planning and credible advocacy
By Paul Rees-Thomas
Based primarily in Eastern Europe and the Horn of Africa, Paul Rees- Thomas worked for five years with Action Contre Le Faim (ACF), latterly in the food security department at the Paris headquarters. Since then, he has worked for Medecins sans Frontieres (MSF) in Kenya.
The contributions of MSF Spain and Manuel Duce in preparing this article are gratefully acknowledged.
This article outlines some of the key components of nutrition casual analysis, and describes how this assessment method was successfully used to provide a multi-sectoral overview of factors affecting nutritional status within an urban community in Kenya.
Since 1993, various sections of MSF have been engaged in the region of Mandera, north-eastern Kenya, which has played host for up to 60,000 Somali refugees displaced from the civil war raging in their own country. The district of Mandera has been described as suffering from 'chronic poverty compounded by successive environmental pressures.'1
In July 1996, MSF-Spain responded to the needs of a primarily local population affected by drought, by establishing therapeutic and supplementary feeding centres, and general food distributions. With few exceptions, nutritional surveillance since then has demonstrated how the 'usual' rate of malnutrition within Mandera district has consistently remained between 20 and 30% Global Acute Malnutrition (GAM2) (see graph 1).
The MSF-Spain programme continued through 1997 due to persistent drought, and into the main part of 1998 due to floods and heavy rain brought on by 'El Niño'. Although the programme was scaled down and eventually closed in 1998 (GAM around 20%), a survey in May 1999 found that the prevalence of GAM had risen to a new high of 39.2%, with 6.9% severe malnutrition. In response, selective feeding programmes were re-opened by MSF and continued until May 2001, when a cluster survey demonstrated that GAM rates had again fallen to 20%.
In March 2002, a MSF nutrition survey, conducted in the urban area of Mandera Central, showed a significant decline in the nutritional situation3. Similarly, an Oxfam-Quebec survey found high levels of malnutrition in the eastern flank of the district4. In light of these results and a subsequent influx of Somali refugees in mid April 2002 (recent surveys had shown high rates of malnutrition)5, MSF re-introduced both therapeutic and supplementary feeding programmes.
Mandera district currently endures significant environmental degradation, worsening pasture coverage and declining quality of livestock, as well as an increasing number of urban pastoral destitute. This group is composed predominantly of pastoralists who have lost their entire herd and is characterised by the households' almost complete dependence upon 'casual labour' in the urban vicinity. As a result, the level of outright poverty within the division of Mandera Central continues to increase. The increasingly competitive manual labour market has heightened the levels of vulnerability for much of this urban destitute group.
In this context of successive extended dry seasons in an area of widespread chronic poverty, many actors have found it increasingly difficult to justify emergency responses (involving selective feeding) following acute shocks, e.g. drought or flood. Many of these issues were more recently highlighted and discussed during a multi-sectoral assessment conducted in the last quarter of 2001. The findings of the assessment, which was overseen by the District Steering Group (DSG) and conducted by several organisations, formed the basis of the District Strategic Development Plan for Mandera District. A causal analysis has previously been conducted in Mandera District6. However, it was considered important to conduct such an assessment specifically for Mandera Central, in order to gain the population's perspective of the current causes of malnutrition within this urban setting and to generate a baseline advocacy document.
Basis of casual analysis
A causal analysis investigates and presents a 'multi-sectoral' overview of the contributing factors affecting nutritional status within a given community. Causal analysis first aims to establish the relative importance, or the perceived weight of contribution, of the underlying 'spheres' or factors that influence nutritional status (see diagrams 1 and 2). Secondly, and perhaps more importantly, it investigates the relationships between these factors.
While individual sector reports provide vital information and recommendations, causal analysis provides a greater insight through cross-sectoral mapping and by illustrating how the inter-connected nature of these factors contributes to malnutrition. Having established the 'relative importance', the type of relationships, and hence the associated factors, a more integrated approach to project planning and implementation is feasible.
Causal analysis framework
Goats being watered in Mandera, Kenya. June 2002
The causal analysis methodology used was qualitative and participatory, involving a number of rapid assessment techniques and based upon the 'framework of causal analysis for malnutrition' (see diagram 1). The first vital step of this analysis was to identify the most recent and important 'secondary' documentation relating to the area (e.g. reports of previous assessments and analysis in Mandera). Ideally, these reports would form the background to the subsequent investigation, and provide baseline information with which to confirm, elaborate or even adapt assessment findings.
The participatory data collection and analysis entailed two activities, household investigations followed by workshops. Household investigations were carried out using semi-directive interviews rather than set questionnaires. This method allowed those being interviewed to identify and prioritise the issues that they themselves felt were the most pressing problems currently being faced in the community. The technique relied on posing open questions, with direction only given when detail and elaboration were required on issues that had already been highlighted. Households were purposively selected to represent the two previously identified livelihood economies in the district, i.e. 'pastoral' and 'riverine' households who practice agriculture. Geographical variations, as well as poorer and wealthier households, were also taken into account. Any further distinction or categorisation of wealth was deferred to the workshops. Essentially, households visits continued until the information collected became repetitive, and nothing significantly new was being established or expressed.
The workshops were typically comprised of five or six individuals drawn from various 'groups', such as mothers, teachers, traders, pastoralists and farmers, as well as the MSF mobile team. The overall purpose of the workshop was to cross-reference and, where possible, elaborate further upon the identified causes. The workshops also attempted for the first time, as far as possible, to quantify the findings to date.
Relative importance of causal spheres
During the workshops, participants were initially asked to assign a percentage to their 'perceived relative importance' of the spheres representing underlying causes of malnutrition in the 'causal framework' (see diagram 1). Only three 'groups' were content to quantify importance of the spheres in terms of percentage. Another three groups were only prepared to 'rank' the underlying causes. However, taken together, the results provided our first key finding - confirmation that household food security was the most significant factor contributing to malnutrition.
Other tools, such as mapping, timelines and agricultural calendars, further helped discussion about the type of relationships between the spheres and how they had changed (primarily over the previous three months). Household information was not presented to the workshops but was referred to, to encourage elaboration and clarification.
It also proved possible to include previous workshop results in order to facilitate and provoke discussion. The results of the 'wealth classification' exercise (diagram 3), that provided a socio-economic categorisation of both poverty and wealth through the communities' eyes, were presented within the final report.
Process of wealth classification
The wealth classification exercise, outlined in diagram 3, provided our second and vital finding. This was related to the continuously increasing urban destitute caseload in Mandera Central. The various workshops almost unanimously agreed that fifty to sixty five percent of the urban population was presently made-up of this 'urban destitute' group. Amongst these, vulnerability was linked to the insecurity and irregularity of low-paid work that forced households to purchase food daily at higher retail prices.
The three key data sources (key informants, households and workshops) helped to triangulate information, thereby solidifying priorities, identifying trends and establishing connections between different sectoral needs and expenditures. For example, these three data sources helped build a considerable understanding of expenditure on medication and health services. It was found that the price of medication for 75ml of cough syrup (250 shillings) or multi-vitamins (300 shillings) equated to 10 to 15 days of the adult food basket. There was strong evidence pointing to a reduced availability of basic medication within government structures, forcing those in need to approach and spend available cash in private pharmacies.
Wherever possible, the exercise endeavoured to include the food equivalents of basic expenditures, as well as the food equivalents of casual wage labour. This illustrated potential food gaps from irregular casual labour for a range of smaller or larger households. The analysis also determined that more and more individuals were being forced into daily casual labour, allowing less time to be spent supervising younger children. Also, seasonal water price changes had forced vulnerable and remote households to draw water from the river, a source shared with livestock.
Advocacy role
Undertaken correctly, qualitative and participatory assessments have been increasingly accepted in decision-making fora. Improved credibility has given advocates greater confidence in approaching various bodies, fuelled by a higher chance of being given time to present findings.
The strength of this type of assessment lies in complementing, not replacing, existing forms or channels of advocacy. It can provide additional information and 'capital' for debate and discussion, as well as reinforcing more technical/ quantitative survey findings and improving their credibility. In this sense, causal analysis assists in ensuring a more profound discussion with regard to targeting and programme priorities.
Clearly, there is a time limit as to how long any particular causal analysis study remains credible and 'active' for advocacy purposes. At the same time, a causal analysis may provide the first step towards the inclusion of additional and more regular data collection and analysis within national Early Warning Systems (EWS).
One of the main aims of conducting the causal analysis in Mandera was to provide a basis of understanding to use for advocacy purposes. Subsequently, MSF-Spain intends to become more involved in the EWS, primarily in the areas of health and nutrition, and investigate further which civil society actors could act as partners in these activities.
Under-pinning the entire advocacy potential generated from the causal analysis, is the primary aim of assisting the local communities and civil society, wherever and whenever possible, to advocate for themselves. From the outset, participatory methodologies aim to include the community and civil society actors in the entire process, to ensure that their opinions are heard and correctly noted. These voices are central to the decision making process involved in combating the issues and problems facing their community. Subsequently, whatever lobbying activities are undertaken, efforts should be made to allow these local partners to benefit and become actively involved in lobbying networks, which are often only open to larger (and frequently international) organisations.
By developing a picture of the multiple challenges facing a given community, causal analysis can assist organisations and the communities with whom they work, to identify and articulate why certain conditions are not improving or, in fact, are deteriorating. Emergency orientated organisations can sometimes find themselves dealing with protracted emergencies or addressing acute shocks within an area experiencing chronic poverty. Causal analysis provides important information and opinions to assist these organisations to either plan or advocate for appropriate medium term, higher impact interventions aimed at reducing vulnerability.
For further information, contact Paul Rees-Thomas at email: rees-thomas@tinyworld.co.uk
1Alistair Blair, Health Assessment of Mandera District, MSFSpain, 2001
2Global acute and severe acute malnutrition rates measured using weight-for-height z scores
3MSF-Spain nutrition survey, Mandera Central: 26.7% GAM, 4.7% SAM (March 2002).
4Oxfam-Quebec nutrition survey, Eastern Mandera: 33.3% GAM, 5.3% SAM (March 2002).
5FSAU Nutrition Up-date December 2001. FSAU led survey in Belet Hawa, Gedo Region, Somalia. Conducted with UNICEF, Care and Gedo Health Consortium. The results found a prevalence of 37.2% Global Acute Malnutrition (Dec 2001).
6Causal Analysis for Mandera District, by Abagail Montani, Action Against Hunger.
7Adapted from an Action Against Hunger version of the UNICEF original framework.
Imported from FEX website