Lessons From SC UK Evaluation in DRC

By Anna Taylor, Nutrition Advisor, SC UK

Summary of internal evaluation

Save the Children UK (SC UK) began implementing emergency health and nutrition interventions in eastern Democratic Republic of the Congo (DRC) in 1998, with initial activities in North and South Kivu and North Katanga. The current programme of work began in June 2002, when the geographical focus was confined to a number of health zones in North Kivu. The rationale for this refocusing was to strengthen management of the programme and better monitor its impact. An evaluation was carried out in November 2003 and was conducted as a participatory process involving SC UK's health and nutrition team and government partners. Information was gathered through:

• A review of programme documents
• Key informant interviews
• Group discussions with the health and nutrition programe
• Observation visits and discussions with staff and patients at nine SC UK supported health/nutrition/ cholera facilities, and two other health centres in a total of six health zones
• A review of registers and patient records at each of the feeding centres visited
• Group discussions with community health volunteers involved in cholera prevention work in Kyondo and nutrition activities in Masisi (Kibabi Therapeutic and Supplementary Feeding Centres (TFC/SFC))

A 13 year old boy engaged in co-operative farming in DRC

Key findings

Since June 2002, SC UK's emergency nutrition and health programme in eastern DRC has made considerable progress in implementation of planned activities and delivery of inputs/ outputs. Box 1 details the main project activitiesof the programme.

The programme has contributed to enhanced skills and capacity of government and NGO staff - especially in nutrition and cholera prevention, improved access to basic health and nutrition services, and greater involvement of communities, including children, in health, nutrition and HIV/AIDS interventions. Implementation of the National Nutrition Protocol is well underway. Routine monitoring reports suggest that therapeutic and supplementary feeding centres have achieved Sphere Minimum Standards on several key indicators.

On the other hand, the performance and quality of the work has been constrained by a number of factors, not least the wide geographical spread of the programme, engaged in a diverse range of activities and often lacking in clear focus. Difficulties working at a distance through poorly motivated government partners and the absence of a 'Protocol' (memorandum of understanding) with Provincial/Zonal Health Bureaux to delineate roles and responsibilities between SC UK and government have also hindered progress. Other limitations have included weak logistics support for the programme activities, reported problems with cash flows to carry out the work, and weaknesses in management and administration capacity internally and in government structures. Episodes of insecurity have also hampered activities.

The decision to work through existing structures, in partnership with local government authorities, local NGOs, UN agencies and other international agencies was appropriate for the context of eastern DRC. A significant strength of the programme approach has been the flexibility to switch to and from an emergency mode, while following developmental principles - for example, the flexibility to open and close nutrition centres according to findings of nutrition surveys and local needs in specific localities. The project has adapted to the changing needs and policies of government as the national security and political situation improved. It has also seized opportunities for working with and through local NGOs.

The evaluation highlighted a number of gaps and weaknesses in project design. Key amongst these were the following:

• The large number of activities and wide geographical spread of the programme were ambitious, given SC UK's understanding of the constraints of working through partners in the context of chronic complex emergencies.
• There has been insufficient understanding of the impact of training on the knowledge, skills, attitudes and practice of the health staff and supervisors in the workplace.
• The critical question of the long-term recurrent costs of maintaining and staffing the newly constructed nutrition facilities (e.g. Kitatumba, Bulembo) does not appear to have been considered in the project design.
• The activities selected did not adequately address gender related issues or other non-economic factors affecting decision making processes at household level.
• There has been lack of clarity over whether the intention was to try and reach as many communities and community based organisations (CBOs) as possible, or to use the experience in a few selected areas as a demonstration for advocacy and influencing purposes. Consequently, there is a risk of allowing project staff to initiate activities in more communities than can reasonably be managed.
• The project plan to train families and support staff for integrated livelihood activities calls for a very different set of skills and experience than is usually found in an emergency health and nutrition team.
• The appropriateness of the seeds and tools distribution component in collaboration with the Food and Agricultural Organisation (FAO) is questionable. It appears that no studies were conducted by FAO or others to find out if seeds and tools were needed, if people had land for cultivation, or indeed, if seeds and tools were an appropriate means of reducing the recurrence of malnutrition in the DRC context.

Lessons learned

Amongst the many lessons learnt, the following were key to nutrition programming:

A realistic assessment of the capacity, skills, time and resources required to implement a project in a context such as eastern DRC is essential at the design stage. A programme with a wide geographical spread and many different activities and partners makes heavy demands on management and logistics. Supervision and support carried out at a distance is costly, particularly if it involves travel by air.

The investment in time, skills and resources to ensure a high quality of service at therapeutic and supplementary feeding centres should not be under-estimated, particularly where services are implemented through local partners.

A clear, comprehensive National Nutrition Protocol is an important tool for improving the management of severe malnutrition. However, a system needs to be developed so that TFC staff can provide feedback on the practical lessons, observations and issues from implementation of the Protocol. This information could be used to inform further refinement of the Protocol at national level.

Health officials/hospital directors need to appreciate the importance of ensuring that TFCs are staffed by teams of nutritionists and nurses trained and supervised to implement the National Nutrition Protocol. The practice of rotating new nurses to a centre each month is not an effective strategy. The management of severe malnutrition calls for a combination of nursing and nutrition skills, these skills can only be built over a period of time working in feeding centres.

When planning rehabilitation/construction work for health/nutrition facilities, it is important to consider the full package of requirements to meet international standards for emergencies. If it is not possible for the project to support all aspects of the package (e.g. water and sanitation facilities, incinerators), steps should be taken to try and secure support from government, communities or other agencies.

The recurrent cost implications of constructing new buildings should be careful considered before finalising plans. Temporary structures for feeding centres may be a more cost effective option.

Prompt analysis of nutrition survey data is essential for mounting a timely response to high levels of malnutrition. If there is limited capacity within the government system for this work, SC UK could offer technical support.

For further information, contact Anna Taylor, Nutrition Advisor, SC UK, email: A.Taylor@scuk.org.uk