Nutrition Programming in the Southern Africa Emergency

Summary of unpublished report¹

A review of UNICEF and World Food Programme (WFP) nutrition programming was carried out in six southern African countries (Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe) in the context of recent emergency programming and longer-term nutritional challenges in the region. The overall goal was to enhance appropriate and effective nutrition programming by UNICEF, WFP and their partners in the southern Africa region.

Three main areas were covered:

1. the pre-crisis nutrition context;
2. the emergency nutrition programming undertaken by UNICEF/WFP, both jointly and separately; and
3. the way forward for both agencies.

The focus was on selective feeding (therapeutic and supplementary feeding), HIV/AIDS and nutrition, prevention of maternal to child transmission of the HIV virus (PMTCT), orphans and vulnerable children (OVC), home based care (HBC), nutrition information (surveys and surveillance systems) and on partnership, capacity and resource issues.

The review arose out of an understanding that the southern Africa crisis has long-term dimensions, and that these need to be addressed through increasingly innovative approaches that are appropriate to the complex situation in the region. In addition, there is increasing corporate recognition and support for collaborative programming amongst UN agencies. One manifestation of this is a new Memorandum of Understanding (MoU) being developed between UNICEF and WFP . The review arose out of an understanding that the southern Africa crisis has long-term dimensions, and that these need to be addressed through increasingly innovative approaches that are appropriate to the complex situation in the region.

This summary of the review only deals with emergency related issues. A large section of the review deals with issues and recommendations around longer-term nutrition programming in the region and opportunities for joint agency programming. These findings are not summarised here but can be found in the full report.

The emergency

The emergency followed widespread crop failures and substantial shortfalls in domestic production in the 2001/2 growing season. The situation was exacerbated by a number of country specific institutional and governance factors. Thirteen million people were reported to be facing severe food shortages and, in the absence of a massive humanitarian response, widespread famine was predicted.

Anumber of factors underpinned the focus on food aid distribution and selective feeding that dominated much of the UNICEF and WFP emergency response. Key amongst these was the high level of HIV/AIDS in the region in conjunction with pervasive concerns around the possibility of a 'new variant famine'². Furthermore, the key assessment methodology employed at the outset of the emergency was based on a food deficit model. Although subsequent vulnerability assessments generated substantial data on food access and household vulnerability these data were used almost exclusively to determine allocation of food aid by district. Opportunities for alternative forms of response such as cash transfers, monetisation of food aid, agricultural support programmes, water and sanitation and health care provision were therefore largely missed.

In the event, the anticipated nutrition emergency did not occur. While this may in part be attributed to the substantial food aid response, there are unanswered questions for the future regarding how significant food insecurity in the region can coexist with high levels of HIV/AIDS and low levels of wasting. The need for a more sophisticated evidence-based analysis of the relationship between these factors is crucial.

'There are unanswered questions for the future regarding how significant food insecurity in the region can coexist with high levels of HIV/AIDS and low levels of wasting.'

UNICEF emergency response

UNICEF's country plans include nutrition surveillance, nutrition guidelines for people living with HIV/AIDS, the nutrition elements of prevention of mother-to-child HIV transmission (PMTCT), Orphans and Vulnerable Children (OVC) and home-based care (HBC) programming, the treatment of severe malnutrition and, to a lesser degree, community based or managed nutrition activities.

UNICEF's response to the crisis varied across the region. In some countries, the on-going programme continued with expansion in some key areas. In other countries, there was a rapid scale up of national capacity to provide treatment for the anticipated increase in numbers of severely and moderately malnourished children and in filling the significant nutrition information and coordination gaps that typified the crisis. In general, these activities represented new areas of nutrition programming, placing considerable strain on the agency in terms of external recruitment of emergency nutritionists and in managing the frequently tense engagement with government nutrition departments³.

In general, given the high level of investment, the focus on selective feeding yielded very disappointing results. In particular, the level of demand and uptake of services for therapeutic feeding was grossly overestimated in some countries in the region, and there was insufficient capacity to strengthen national services to address chronic malnutrition. Nonetheless, the opportunity for modifying and strengthening longer-term strategies, capacity and preparedness for selective feeding (both therapeutic care and supplementary feeding) has emerged through the crisis. Similarly, the considerable number of nutrition surveys that UNICEF supported during the emergency, whilst filling a critical information gap, also highlighted the urgent need for more functional national nutrition surveillance systems. This is a priority area that UNICEF must invest in both with regard to it's own human and technical support capacity as well as in helping to strengthen early warning and longer-term nutrition planning in the region.

'The level of demand and uptake of services for therapeutic feeding was grossly overestimated in some countries in the region, and there was insufficient capacity to strengthen national services to address chronic malnutrition.'

The emergency and ensuing increase in resources has led to greater attention on orphans, other vulnerable children and chronically sick adults affected by HIV/AIDS. UNICEF firmly established HIV/AIDS as an organisational priority in 2002 and in some countries UNICEF offices have seized the opportunity to increase the focus on integrated community based approaches to meeting the diverse needs of HIV/AIDS affected groups. These projects, though relatively small-scale, provide considerable scope for replication, dissemination of key findings and, critically, for programme expansion with WFP.

'In some countries UNICEF offices have seized the opportunity to increase the focus on integrated community based approaches to meeting the diverse needs of HIV/AIDS affected groups.'

WFP emergency response

HIV orphans in Jinja District, Eastern Uganda.

Following FAO/WFP Crop and Food Supply Assessment Missions conducted during the main harvest season in April and May 2002, the first Regional Emergency Operation (EMOP) was launched in July 2002. This appealed for assistance for over 10 million people largely through general food distributions. The second regional EMOP by contrast, was more targeted (6.5 million target group) and focused on nutritional well being and livelihood objectives. This re-focus reflects a growing shift in the organisation to diversify modes of emergency intervention and to develop more sophisticated responses. Activities included targeted food distribution and vulnerable group feeding, food for work and food for training, and food provision through nutrition and maternal and child health care facilities. HIV/AIDS programming also expanded and some new areas of programming were developed over the crisis period e.g. HIV sensitisation linked to general ration distributions. Most of WFP's relatively new and more innovative programming, which in large part has an HIV focus, is currently small-scale. Throughout the crisis period, WFP also supported the food security and vulnerability assessments which were instrumental in geographic and temporal targeting and also in generating information on particularly vulnerable population groups.

WFP faces considerable challenges in ensuring that the intended scaling up of projects either under the protracted relief and recovery operation or under country programmes allows for appropriate and more finely tuned targeting as well as integration with non-food responses to maximise the food element and to avoid standalone feeding programmes that have been the hallmark of certain types of WFP feeding programmes in the past. Furthermore, evidenced based programming will be the basis on which WFP is increasingly judged. It is therefore vital that programme objectives are carefully considered, prioritised and made explicit. Effective mechanisms for monitoring and evaluation will be crucial to determine whether objectives are being met, and to ensure that food aid has a positive impact and does not undermine local systems and structures. The importance of drawing on lessons learnt from prior WFP longer-term programming experiences cannot be overstated.

'Evidenced based programming will be the basis on which WFP is increasingly judged. It is therefore vital that programme objectives are care- fully considered, prioritised and made explicit.'

¹Dolan. C and Shoham. J (2004): UNICEF/WFP Nutrition Review. Regional Synthesis Report, July 2004.

²The term 'new variant famine' (NVF) was coined to reflect growing concerns about the impact of HIV/AIDS on food security. The theoretical premise of NVF is that HIV/AIDS increases vulnerability to food insecurity through a number of mechanisms i.e. increasing dependency ratios, increasing household expenditures on health care, loss of economically active adults etc. Hence, when a shock such as drought and crop loss occurs, households are far less able to employ coping strategies. The result, according to NVF theory, is that such shocks will lead to far worse famine than would normally occur. However, the NVF hypothesis is as yet unsubstantiated.

³ Tensions emanated partly from the failure of some newly recruited emergency staff to fully consult with their national counterparts and partly from a reluctance on the part of national nutrition bodies to adopt an emergency approach and therefore neglect regular nutrition programming activities.