Selective Feeding in War-Ravaged Northern Uganda

Mothers receiving supplementary ration

By: John Moore and Mara Berkley-Mathews

John Martin Moore completed training as a Registered General Nurse at National University Ireland, Galway in 1999. In 2000 he joined the GOAL team in Angola working in emergency public health programmes. He is currently working as a Public Health Coordinator in Northern Uganda.

Mara Berkley-Mathews trained as a Registered General Nurse in Bristol, qualifying in 1993. She completed a Diploma in Tropical Nursing at London School of Tropical Medicine and Hygiene in 1998 and worked in Guyana, South America in 2001. Since then she has worked for GOAL in Angola, Mozambique and (currently) Uganda.

Thanks to Mark Adams (GOAL Uganda Country Director),Stephanie Frame (GOAL Ireland), John O'Shea (Chief Executive Officer, GOAL).

Implementation of selective feeding programmes in highly insecure environments can throw up a number of difficult operational challenges. In this article GOAL describe specific challenges related to default and programme monitoring and their attempts to address these (Ed)

Since 2002, Agago County in Pader district, Northern Uganda, has been at the centre of the 'world's biggest forgotten emergency'. In 2002 the Ugandan Government's attempt to extinguish the Lord's Resistance Army, 'Operation Iron Fist', precipitated the return of rebel forces into Ugandan territory from Sudan and a wave of killing and displacement that had not subsided by the middle of 2004. As a result, the people of Agago County have suffered two years of intensive, continuous terror and displacement at the hands of rebel forces. Humanitarian needs are immense. The World Food Programme has warned it will soon be unable to cope with the escalating food needs of the displaced population in Northern Uganda, which now numbers at least 1.6 million. Another 200,000 refugees have also been affected by the conflict. OCHA estimates that there are 279,256 people displaced within Pader District.

Nutrition Survey Findings

GOAL has carried out two nutritional and household surveys in the past 12 months (Table 1) and is about to implement a third assessment in the coming weeks.

In the six month period between the August 2003 and February 2004 surveys there was a dramatic decrease, from 83.1% to 19.3%, in the number of households relying on their own crop production as a main food source, while the percentage of households utilizing the market as the primary source of food increased from 13.7% to 71.6%. These trends were reflected in an increase in the market prices of millet, sorghum and beans. The predominant underlying factor behind these findings was the high level of insecurity acting to discourage agricultural production. In excess of 70% of households interviewed by GOAL were registered to receive WFP food rations.

Other key factors adversely affecting nutritional status were found to be poor environment, water, sanitation and public health facilities. The GOAL surveys found that just 17.4% of children over 9 months of age had evidence of any vaccination coverage, almost 30% of households used unprotected water sources, and over 27% of children were weaned onto solid foods inappropriately. Child Mortality Rates in Under 5 year olds were found to be at the threshold of emergency levels (2.1/10,000/day in August 2003, increasing to 2.8/10,000/day in February 2004). These survey findings prompted GOAL to undertake a number of measures in order to meet humanitarian needs.

GOAL's support for Supplementary Feeding Programmes (SFPs) and Therapeutic Feeding Centres (TFCs) in Agago county

In June 2002 GOAL had begun activities within Agago County, providing support to the nutrition unit (TFC and SFP) at the Mission Hospital in Kalongo (the urban centre of Agago County), managed by the Comboni Fathers. This support increased in July 2003 with additional funding from OFDA, and GOAL began to work with the Directorate of District Health Services (DDHS). In May 2004 GOAL also undertook to help set up and monitor SFP activities in six outlying village locations in Agago County.

The six satellite Supplementary Feeding Centres (SFCs) were opened in response to the difficulties reported by mothers travelling with their malnourished children to Kalongo each week. Food is now taken to where the need is, and the mothers do not need to use unsafe roads. The SFCs are all run from existing DDHS health centres in towns, villages and IDP camps under military protection. All SFCs are operational over two days every second week, distributing a two week supplementary ration to beneficiaries.

Child with naso-gastric tube in feeding centre.

The TFC operates over 24 hours despite limited human resources. The programme functions with three trained nurses and additional staffing provided predominantly by unqualified nurse aides. The ratio of staff to patients during the harvest period (November - May) is approximately 1:10. However this ratio can increase to 1:57 during the hunger gap period, as the number of TFC admissions increases and problems with recruitment exacerbate the problem of poor staff to patient ratios. Education and health infrastructures throughout Northern Uganda have been significantly paralyzed as a direct consequence of the conflict. Appropriately qualified staff are therefore in short supply, and agencies experience chronic difficulties in locating and 'coaxing' appropriate staff back into the conflictaffected area.

Data available from Kalongo TFC and SFP records reflect the dramatic upsurge in population displacement and food insecurity as a result of insecurity and the consequent disruption of planting and harvesting activities. Programme attendance increased abruptly, by 255% in the SFC and by 149% in the TFC between 2002 and 2003.

The harvest period for the north of Uganda runs from July/August to November/December with a three month 'hunger gap' between May and July. Admission trends so far for 2004 indicate that the food security and nutritional situation is worsening. The SFP in Kalongo is currently (May 2004) treating the highest number of beneficiaries so far recorded (155 in May 2004), almost three times higher than the numbers for May last year. TFC numbers give a similar picture, with 59 beneficiaries in May 2004, double the number treated in May 2003.

These trends are somewhat reinforced by the bi-annual surveys carried out by GOAL in Kalongo town (Table 1). The first of these was carried out in August of 2003 and the second in February of 2004. Not surprisingly, the GAM and SAM were both worse in 2003 at the end of the hunger period, with GAM at 11.6% (95% CI: 8.6% -14.32%) and SAM at 2.9% (95% CI: 1.6% - 4.2%), as opposed to the end of the harvest period in February 2004 where GAM was 4.7% (95% CI: 3.5-6.4%) and SAM was 0.7% (95% CI: 0.3- 1.5%).

Child with Marasmus in Kalongo, Pader.

In addition, as a result of continued sporadic terrorizing activities of rebel factions in the area, planting and harvesting practices have reduced significantly over the last 18 months to two years. GOAL therefore anticipates an extension of the hunger period in 2004 due to limited crop yields with programme beneficiary numbers to remain higher for longer as more families have less food.

Monitoring of the nutrition programme

The operation, control, support and monitoring of a feeding programme in such an insecure environment presents unique challenges and problems. First, access is severely limited making direct supervision of all the satellite SFCs impossible. Secondly, rebel activities in the area make security a significant obstacle for the local population who risk ambush and abduction if they travel between towns or outside the protected limits of any Government-controlled area. This is identified as a primary explanation for high and unacceptable feeding programme defaulter rates not just for GOAL but for all NGOs working in nutritional support in this region.

Solutions

Solutions to these problems are not easily found. The security situation significantly reduces GOAL's capacity to maintain a physical presence, necessitating 'remote controlled' monitoring of ongoing satellite nutritional programmes and distributions. This creates continuous challenges for maintaining the quality, efficiency and impact of programmes. GOAL's close working relationship with the DDHS and local officials who have been trained in management and support of programme activities, beneficiary criteria, evaluation and analysis of programme data, has been a key strategy in addressing these constraints. GOAL also facilitates a monthly meeting for discussion and training of the satellite programme staff, which enables GOAL to critically review and analyze all data recorded with a view to identifying and ratifying inconsistencies and errors in SFP implementation.

Mother and children in feeding centre.

GOAL has also employed a 'Defaulter Tracer' who works alongside Community Resource Persons in order to identify and locate defaulters from feeding programmes. This strategy has enjoyed considerable success with 90-95 % of defaulters located in Kalongo and returned to the programme.

The six satellite SFP centres were established as a means of increasing accessibility to more families in Agago County as well as reducing defaulter rates. GOAL has also tried to create an incentive for parents to continue to bring vulnerable children to the programme by providing non-food items to all attendees at various stages throughout treatment and upon successful discharge from the programme.

Whether this strategy will have a significant impact remains to be seen. As the situation worsens it is likely that the population will become more needy and defaulter rates may therefore improve automatically. Recent studies carried out by GOAL staff investigating defaulter rates indicated that the main reason for programme defaulting is insecurity. Other explanations included conflicting demands on time - such as families attempting to maintain land and crops, forgetting the appointment, losing their card or an illness within the family. The majority of Kalongo-based women have two households to manage, a daytime residence as well as a nocturnal temporary residence in a more secure location which also needs to be maintained. This unique phenomenon of daily household displacement before dark impedes family routine and restricts their ability to engage in agricultural and income generating activities.

In contrast, current defaulter rates from the TFC are well within accepted levels, indicating that the feeding programmes are valued, trusted and well accepted and that people are willing to bring their children for nutritional and medical treatment when it is necessary.

The Future?

The current political and security dynamics do not suggest that there is likely to be an improvement in the nutritional and food security situation in the county in the near future. GOAL anticipates that it will be engaged in nutritional support programmes throughout Agago County as long as needs exist and security and donor resources allow. The sight of abandoned farm plots from the air tells a chilling story regarding Northern Uganda - there is a war and Ugandans are losing. The organization of teams, the crying and screaming of children suspended from Salter scales and stretched along height boards, the paper chain of surveys and data entries and the tapping of nutritionist's computers in quest of Zscores and global malnutrition rates will be justified here for some time to come. Agago County is a textbook example of war and its effects on civilian populations. The impact of this crisis on nutritional status continues to unfold, presenting GOAL with new challenges. Our greatest challenge is to compliment nutritional activities with provision of adequate shelter, water, sanitation and health - otherwise, our impact will be insignificant, and we owe more than that to the people of Agago County.

For further details, contact Monica Corish at: mcorish@goal.ie

¹UN Emergency Relief Coordinator, Jan Egeland, 10 November 2003.

²OCHA Kampala, Humanitarian Update, May 2004.