Emergency Supplementary Feeding

Supplementary Feeding Programmes (SFPs) are amongst the oldest and most common type of nutritional intervention in developing countries. The main aim of SFPs in both emergency and non-emergency situations is to prevent mortality due to malnutrition amongst groups who are considered to be most at risk. These groups normally include children under five years of age, pregnant and lactating women, and the infirm. Children under five usually make up the largest group in SFPs. Where resources allow, socially vulnerable groups with decreased access to food may also be targeted. Programmes either target mild and moderately malnourished individuals with a view to restoring adequate nutritional status (targeted programmes) or all those in a group thought to be at nutritional risk in order to prevent nutritional deterioration (preventive or blanket programmes). The rationale behind a targeted SFP is that it provides a supplement to the general ration which although adequate for most of the population does not provide enough food for certain groups with additional needs. The malnourished and ill require additional food for catch up growth. The rationale behind a preventive supplementary feeding programme is that it provides additional foods to groups who are believed to be most at risk due to lack of food, e.g. if the general ration is inadequate. Preventive SFPs are usually only considered to be appropriate as a stop gap measure until better general ration provision can be secured. The supplement for both types of programme can either be given out as a dry take home ration or prepared daily at a feeding centre and given as an on-site feed.

There has been a lot of controversy about emergency supplementary feeding programmes in recent years. Some agencies have maintained the view that SFPs have no role in emergency programmes and that all nutritional requirements (including those for catch up growth) should be catered for in the general ration. Others have advocated setting up this type of programme whenever levels of malnutrition reach a certain point.

Another continuing debate has revolved around whether emergency SFPs should be implemented when the general ration available to households is inadequate so that all demographic groups are likely to receive less food than they need. As can be seen from the RNIS data, this is not an unusual occurrence during emergencies. The argument here is that if the general ration is inadequate then the SFP ration may not provide enough of a supplement to allow restoration of nutritional status or may not have much impact in preventing weight loss in the vulnerable group. This is because much of the supplementary ration will be shared with other family members or merely substitute for a meal that would have been eaten at home Also, setting up this type of programme may remove pressure on agencies to improve general ration provision as the worst effects of food shortage are being prevented in the short-term. Supporters of 'preventive' SFPs argue that this type of programme acts as a holding operation preventing mortality until better general rations can be provided for the whole household. A question that then arises is whether this type of programme should be classified as a SFP as it is not supplementing an adequate general ration but attempting to make up for its inadequacies. Other questions are raised by this type of programme like what are appropriate objectives and evaluation criteria and whether the same programme outcomes could be achieved through a less costly intervention, e.g. strengthening general ration provision. There is a contradictory dynamic here in that agencies often support the use of preventive SFPs at some stage of the emergency cycle where general rations are inadequate yet questions are continually being raised, often by the same agencies, about the wisdom of implementing SFPs in the absence of adequate general rations.

There is also the issue of whether SFPs should be run as on-site or take home feeding. While it is impossible to generalise about all situations, consensus, as expressed in agency guidelines, seems to have largely been reached in recent years. The predominant view is that in most situations the advantages of take home feeding out weigh those of on-site feeding. However, there have been very few studies looking at the comparative effectiveness of both types of programme design. On-site feeding is only considered to be appropriate in very specific circumstances, e.g., in insecure areas or where households lack fuel. Yet in spite of this consensus, many emergency SFPs are still implemented as on- site feeding and justified by beneficiaries and programme implementors for a variety of reasons. This may be partly explained by the fact that guidelines have still not taken into account all the factors and circumstances which affect decisions about most appropriate programme design. Some agencies are now advocating a two tier system whereby both types of feeding are made available to beneficiaries who can then choose between one or the other.

There is also some controversy about choice of target group. Though it is recognised that children under five are more vulnerable to malnutrition and associated mortality than other demographic groups, their proportional increase in vulnerability in certain emergency circumstances may not be as great as that which occurs in other groups. Also, there are specific emergency situations where it has been shown that other demographic groups are at greater risk of mortality than under-fives. This has led to some discussion as to whether in certain situations it becomes justifiable to include several target groups in emergency SFPs and whether this then starts to make the size of programme logistically and financially less viable. In this case it may be more appropriate to allocate the supplementary food through the general ration rather than have a separate distribution system.

There is also a lot of discussion about the most appropriate type of supplementary foods to give. Recent research suggests that certain types of diet may promote far quicker weight gain than foods that have been traditionally used in SFPs (see Food for the treatment of malnutriton).

Then there is the debate about how best to monitor and evaluate the effectiveness of SFPs. Traditionally, we monitor indicators like rates of weight gain, mortality, discharge, and default. Many people are now advocating an expanded set of indicators including rates of re-admissions and some measure of cost-effectiveness. There is also a sense that we do not know enough about, and are therefore not in a position to set, appropriate target levels for the indicators used in assessing the performance of programmes and that these target levels will in any case need to be flexible based on different emergency situations.

Clearly, many of the controversies and uncertainties about emergency SFPs will be around for some time to come. At the recent inter-agency meeting on Selective Feeding, held in Dublin and reported on in the last edition of Field Exchange, it was recognised that much invaluable work is carried out in what are called SFPs. At the same time it was recognised that the types of programme that are carried out under the name of supplementary feeding are changing all the time. However, many of these programmes may not fit well under the heading of supplementary feeding and lack clarity in terms of objectives. This makes it difficult to evaluate programme success. An example of a supplementary feeding programme which may not fit into the traditional mould is 'prison feeding' (see Selective Feeding Programme for Detainees in Rwanda - page 4). One of the problems with endeavouring to classify newly emerging programme types as some form of supplementary feeding programmes is the resulting expectations and constraints this imposes when it comes to justifying and evaluating the intervention. At the recent Dublin meeting an attempt was made to begin the construction of a typology of the wide array of programmes that are classified as SFPs, setting out good practice, objectives and evaluation criteria. We can report that work is continuing amongst the workshop participants in developing this typology and that Field Exchange will report on progress in this area.

Editors.