World Health Organisation

By Jeremy Shoham, ENN

Zita on a WHO field trip

The ENN interviewed Zita Weise Prinzo, who works in the Nutrition in Emergencies (NIE) programme of the WHO's Nutrition for Health and Development Department (NHD), for this issue's agency profile slot. Zita has been a focal point for WHO's emergency nutrition work for many years now. Her first work for WHO was in Nepal between 1992-5, where she worked as an APO, effectively seconded to the Ministry of Health (MoH) nutrition unit. In 1995 she took on the first of a series of short term assignments in the nutrition department of WHO in Geneva and has remained at head office since then. Zita's professional background includes a Masters in Science and Food Technology and a further Masters in Nutrition at LSHTM (1990-1).

WHOs interest and involvement in nutrition emerged at the First Health Assembly in 1948, where nutrition was included as one of six WHO priorities. In the early years, WHO nutrition work was mainly focussed on nutrition in development contexts. Early emergency related work included provision of technical support to WFP through the food aid programme (FAP) situated in WHO. FAP provided technical appraisals of WFP programmes and participated in joint interagency evaluation missions. However, the programme was mostly involved in 'developmental' programming, like school feeding and food aid for Maternal and Child Health (MCH) programmes, and had a limited emergency role. During the 1990s, WHO always had at least one nutritionist working at headquarters on NIE issues. However, it was not until 2005 that the WHO nutrition department formally instituted a nutrition in emergencies programme. The NIE programme was one of seven programmes being implemented within the Nutrition for Health and Development Department in WHO. The other programmes were growth assessment and surveillance, micronutrients, nutrition policies and programmes, infant and young child nutrition, obesity, and HIV and nutrition.

During the 1970s and 80s, WHO's nutrition department produced a number of key guidelines and management tools, some of which were specifically for the NIE sector, e.g. Seaman and Goyet's Nutrition in Emergencies handbook. However, more recently, the scope of WHO involvement in NIE has increased substantially. In addition to development of guidelines and tools for managing nutrition programmes, capacity development at national level, as a component of preparedness and recovery and operational support during emergencies, is now a key element of the NIE programme.

The capacity development work has mainly focussed upon regional and in-country training for the management of severe malnutrition. WHO have worked, and continue to work closely with, UNICEF in this area. In the 1990s, WHO undertook a series of regional trainings in the management of severe malnutrition. Capacity development involving the training of national staff has included curricula on infant and young child feeding and Nutrition and HIV. The NIE programme works closely with the HAC department in WHO by, for example, feeding into the HAC pre-deployment training of staff.

Provision of operational support in acute emergencies is perhaps the newest element of NIE work. Zita feels that, in some ways, WHO are not currently well set up to undertake this kind of work in nutrition. In the past, WHO sent out HQ staff to assist government or WHO country offices when requested to do so following the onset of an emergency. However, this did not have a sustainable impact at the country level. Zita explained "there was not a great deal of sense in suddenly getting involved in nutrition when there had been no previous involvement or presence on the ground". It was recognised that WHO needed to build up a network of nutritionists at country and regional level in advance of an emergency, in order to be able to provide operational support adequately. This would allow more appropriate responses as in situ staff "would be building upon ongoing partnerships when an emergency struck". The NIE programme has now put together a proposal that would fund nutritionists at country level. This was completed at the end of 2007 but there has, so far, been little interest from donors. Zita fears that this may partly be due to competing demands of the UNICEFled Interagency Standing Committee (IASC) Nutrition Cluster and the perception amongst donors that this should be a Nutrition Cluster rather than a WHO role - thus failing to see the complementary role of the agencies.

Zita on a WHO drought survey

Zita reflected that, in the past, WHO have put out guidelines and management tools as WHO documents but have learnt that they need to work more inclusively with other agencies in order to get comprehensive buy in. The current development of tools on the integrated management of severe malnutrition (community-based and hospital based approaches) follows this model, with other non-governmental organisations being involved in developing the guidelines. Zita and her colleagues are also aware that in the past some guidelines and tools have simply gathered dust as dissemination and roll out has been poorly planned. "To be effectively used, these finely honed documents need to be disseminated through mechanisms based on long-term relationships between WHO and governments and other local agencies".

Zita sounded a little downbeat in response to my question about NIE funding. In short she said that it was a continual struggle. Certainly, the advent of the Nutrition Cluster with UNICEF as the lead has not helped the NIE programme cause. There are also battles to be won in house, as some NIE funding traditionally comes through HAC, and there are staff at the country-level that in turn have questioned whether certain NIE activities fall more within the domain of UNICEF. At the moment there are 25 staff in the WHO nutrition department, three of who work in the NIE programme (Zita and Chantal Gegout on the technical side and one support staff).

Zita was far more upbeat about NIE plans for the future. Work in a number of key areas is planned including;

• Updating the WHO training for hospital based management of malnutrition
• Reviewing the implications of new growth standards for operational practice
• Producing policy guidance on integrated management of malnutrition
• Reviewing and providing guidance on management of moderate malnutrition through supplementary feeding programmes and dietary counselling
• Reaching greater clarity on preventing and controlling micronutrient deficiencies in emergencies, e.g. use of iron in malaria endemic countries
• Infant and Young Child Feeding in Emergencies (IFE)
• Improving maternal nutrition in emergencies.

Zita on a WHO field trip

I left the most controversial questions until the end. I couldn't finish the interview without asking about WHO and UNICEF's relationship and any problems therein. Zita was surprisingly frank in stating that things can get a "little competitive," especially at country level, and that the outcome (good or bad) depends very much on personalities involved and level of resources available. I also asked her about the view that WHO take 'forever and a day' to produce guidelines and manuals and that by the time these eventually come out, knowledge and practice have moved on. Again Zita held her hand up on behalf of WHO, saying that the length of time it can take is unacceptable but that delays also included late inputs from stakeholders and Member States on certain standardsetting work. She did, however, say that WHO are now producing fact sheets as a way of getting information out more quickly. She observed that delays are not just due to the technical discussions but also that fact that documents have to be cleared by so many stakeholders and parties within the organisaorganisation. Apparently WHO now have guidelines on how to develop guidelines.

Zita on well-earned R and R!

A final question for Zita was how she saw WHO's NIE programme fitting into the sector. She quickly identified the fact that it's location, i.e. within a health organisation, allows for integration of nutrition with health and vice versa in all activities. She also believes that the NIE programme has the potential of doing excellent work in providing an evidence base for the management of nutrition in emergencies, as well as supporting and developing the capacity of member countries to undertake this management.

An overriding and familiar impression from the interview was that, as seems to occur in so many agencies, nutrition and therefore NIE, has to continually fight its corner to survive. In Zita it is clear that WHO and the nutrition community have an individual who is more than able to go the 10 rounds.