Blanket BP5 distribution to under fives in North Darfur

By Hanna Mattinen, ACF

Since 2005, Hanna Mattinen has been Food Aid Advisor at the Action contre la Faim (ACF) headquarters, focusing on policy and operational issues around food assistance and cash-based interventions. Previously she worked with ACF as Food Security coordinator in Guinea, Liberia, Chechnya/ Ingushetia, Nepal and Indonesia.

Many thanks to Philippe Crahay, Hanibal Abiy Worku and Loreto Palmaera (ACF Food Security Coordinators in Darfur), David Mahouy (ACF Food Aid Officer in Darfur), Emilie Crozet (ACF Food Security Expert in Darfur), Sophie Laurence and Aurelie Fournier (ACF Nutrition Coordinators in Darfur), Béatrice Mounier (ACF Nutrition Surveillance Coordinator in Darfur), Dorothy Dickinson (ACF Nutrition Officer in Darfur) and their teams, as well as to Olivia Freire, ACF Nutrition Advisor in Paris, all of whom have been involved in implementing the project and collecting and analysing the data used in this article. Thanks also to Rebecca Brown and Andrew Mitchell for proof reading.

The current conflict in Darfur, Sudan started in 2003. Since then, large-scale violence has decreased but fighting and attacks continue over large parts of the territory despite ongoing peace building efforts. Over 3.5 million people are estimated to be affected by the conflict, with more than 1.8 million people having been displaced from their homes.

Widespread looting and destruction of assets, displacement and restricted movement has had a significant impact on people's lives and livelihoods (farming, livestock herding, trade and migration)¹. The region, which was formerly selfsufficient in food except in unusually bad drought years, became a major recipient of food aid. Most livelihood strategies are now restricted and poorly remunerated, markets and trade are severely disrupted and coercion and exploitation are deep-rooted².

Bags of BP5 packed, ready to distribute

Despite food aid and other external assistance, the prevalence of global acute malnutrition (GAM) in the region is estimated at 16.1%, with the highest rates in North Darfur at 20.5%³. The malnutrition rates are found to fluctuate considerably in time and in space and an overall increase in GAM from 12.9% in 2006 has been n o ted in greater Darfur.

This article focuses on the situation in Abu Shok and As Salaam internally displaced population (IDP) camps in North Darfur State, where Action Contre la Faim (ACF) has implemented nutritional activities since 2004. More specifically, it looks at the impact of a blanket distribution of high energy biscuits to under five year olds, following the detection of extremely high acute malnutrition rates in these camps in June 2007.

Situation in the camps

Abu Shok and As Salaam IDP camps are situated in North Darfur State, 4 km north-west of El Fasher town. Abu Shok camp was opened in April 2004 with 42,000 IDPs registered. As the maximum capacity of Abu Shok was reached, a new camp, As Salaam, was set up within sight of Abu Shok in June 2005. The camps were officially closed to new arrivals in November 2005, but sporadic registrations still take place. The current caseload is approximately 50,000 people in both camps.

General food distributions are implemented by the Sudanese Red Crescent in collaboration with the World Food Programme (WFP), providing the IDPs a full daily ration. WES (Water and Environmental Sanitation)/ Government of Sudan, Unicef and Oxfam are in charge of water and sanitation programmes. Primary health care and kindergartens are also present. ACF's nutritional activities in both camps include supplementary feeding programme (closed in October 2006), a therapeutic feeding programme, involving a therapeutic feeding centre and outpatient therapeutic programme, active case finding and nutritional surveillance⁵.

Malnutrition rates showed an overall declining trend with some seasonal variations⁶, until the GAM peaked in June 2007 at 30.4%⁷, as shown in the Figure 1. This GAM rate is significantly higher than the GAM rate found at the same period during the previous year (22.8%). In addition, over 30% of the children screened during the survey were found to be at risk of malnutrition (80-85% weight/height percentage of the median). There was no statistically significant difference between the severe acute malnutrition (SAM) rates. The extremely high June 2004 malnutrition rates followed a measles outbreak, just after a major population displacement at the beginning of 2004.

Causes of malnutrition

Various causes of the increased GAM rates were identified by staff in the field and corroborated through a Nutritional Causal Analysis conducted by ACF in the camps in November 2007.The following associations suggesting immediate and underlying causes of malnutrition have been identified⁸:

• Malnourished households generally have a lower income than non-malnourished families. Main income sources in the camp include urban casual work in the neighbouring town of El Fasher and to a lesser extent, rural casual work, as well as petty trading and sales of food items from the general food distribution. The income sources are largely similar for both malnourished and non-malnourished households.
• The majority of households with at least one malnourished child were found to have settled in the camp more recently and were more likely not to have a general food distribution card than families without malnour ished members.
• Food diversity in families with a malnourished child is slightly lower, especially in terms of the consumption of lentils, meat and Corn-Soya Blend (CSB) porridge and/or snacks.
• Children in households with at least one malnourished child are more susceptible to diseases than those in families without malnourished children (level of hygiene was found to be lower).
• Mothers with malnourished children have a slightly higher workload than mothers in households without malnourished children.
• A lower proportion of mothers in families with malnourished children attend antenatal or postnatal consultations than mothers in families without malnourished children.
• Families with malnourished children under five years were more likely to leave their children with their older siblings than those with malnourished children.
• Exclusive breastfeeding until 6 months of age is practiced by less than 30% of the households interviewed in all camps⁹. Water and animal milk are introduced early in the diet of an infant (increasing the risk of diarrhoea, particularly if the water is not clean).

In addition to these findings, the quantity of CSB in the general food distribution in Abu Shok and As Salaam was reduced in January 2007. Various reasons were put forward for the decision to cut the ration - restrictions regarding the use of genetically modified maize in the country were under discussion, disruption in the availability of CSB and reports of excessive sales of CSB by the population. The reduction in the CSB ration translated into lower overall energy and micronutrient¹⁰ content of the ration, as well as less availability of food items particularly suitable for feeding children less than five years of age. Focus group discussions with women immediately after the nutritional survey confirmed that they lacked porridge to feed their children after the ration was cut. However of note, the June ACF nutritional survey did take place during the traditional hunger gap and at the peak of preparations for the upcoming agricultural season when the workload of caretakers was particularly high. Younger children were often left in the care of their older siblings. In addition, the survey was conducted during the school holidays and some mothers mentioned that during this period, the morning meal for children was given less importance¹¹.

Women having just received the BP5 ration

Water supply is also an issue of concern in the camps as it depends substantially on hand pumps, with 12 to 15 pumps having run dry or yielding a reduced volume of water over the past 3 years¹². Assessments show that only about half of the water is used for drinking and bathing purposes, whereas the rest is used for brick making and other livelihood activities¹³. However, no particular disease outbreak took place before or during the survey.

Blanket under-5 distribution

Organisation

ACF decided to implement a blanket food distribution to children between 6-59 months as the lack of adequate food for children¹⁴ was identified as one of the key causes for the dramatic increase in the prevalence of acute malnutrition. Infants under 6 months of age were excluded from the distribution to promote exclusive breastfeeding. A preventive approach was favoured as opposed to a curative approach due to the large number of children at risk of malnutrition. Targeted supplementary feeding was hence not an option. SPHERE standards also stipulate blanket supplementary feeding as a response when malnutrition rates are so high that it may be inefficient to target the moderately malnourished and all individuals meeting certain at risk criteria (e.g. those 6-59 months) m a y be eligible¹⁵.

MUAC screening at a distribution site

The blanket distribution was designed to be complementary to the general food distribution, with a ration covering approximately 60% of the energy needs of a child under five years of age¹⁶ until the end of the hunger gap period. Four 15- day distributions were organised between August and October 2007 targeting all the children in the camps. The end of the hunger gap was considered the appropriate moment to end the complementary distributions because traditionally, food availability increases as the harvests start and food prices decline¹⁷. A subsequent nutritional survey was planned after the end of the blanket distribution to measure the impact and the potential need for a follow up intervention. The project was funded by the European Commission Humanitarian Office (ECHO) and cost approximately 1.35 million euros¹⁸.

BP5 biscuits were chosen as the appropriate food item due to their high energy and micronutrient content and the fact that they could easily be used as porridge to feed younger children. Additionally, previous ACF distributions of BP5 in Darfur had demonstrated great acceptability among beneficiaries. The biscuits were crushed and pre-packaged by ACF prior to distributions, in order to limit re-sale and to promote the use of the product as porridge. ACF also considered SP450, but the product could not be sourced in adequate quantities in the required timeframe. Plumpy'nut and Supplementary Plumpy were discarded as options as they were developed for the treatment of malnutrition, not prevention. CSB-oil-sugar mix was not considered satisfactory, given its low acceptability and poor performance in treating malnutrition in ACF supplementary feeding programmes in Darfur¹⁹. ACF staff registered children under five at the outset of the project with the help of local leaders (umdas and sheiks). The height of a child was used as a proxy for their age²⁰. In total, 15,337 children were registered and over 150 MT of BP5 was distributed during the project period. Largescale information and awareness-raising sessions were organised to explain the aim of the project to the population. Special efforts were made to ensure the involvement of umdas and sheiks, who could relay the message to the population, further promoting its acceptance. ACF nutrition screening teams also organised hygiene education sessions, awareness raising on breastfeeding practices and cooking demonstrations, and visited homes in-between the distributions to give further information and assistance.

Impact

Post Distribution Monitoring, organised after each distribution round, showed that the number of meals for children under 5 years increased during the project period and that almost all the BP5 was consumed within the household²¹. Less than 1% of the product was sold or exchanged. Intra-household sharing, as well as using BP5 to feed infants under 6 months of age, which were common during the first round of the distribution, decreased substantially due to additional efforts put into sensitisation (Figures 2 and 3). Education sessions for women waiting in distribution lines and the time given to discuss the use of BP5 were important factors in limiting intrahousehold sharing.

A nutritional survey organised by ACF after the end of the blanket distributions in November 2007 showed a radical improvement in the nutritional status²². The GAM rate in children 6-59 months decreased from 30.4% to 14.3% and the SAM rate decreased from 2.8% to 0.6%. For the first time since the beginning of the conflict, the malnutrition rates dropped below the emergency threshold. The GAM and SAM rates were found to be significantly lower when compared to the situation the previous year at the same time period (respectively 22.6% and 2.7% in November 2006 - see Figure 1)²³.

Caregivers reported during focus group discussions that children were given a first meal of BP5 porridge in the morning and that children rarely asked for more food before the fatur (lunch). This is reportedly common when other food items (most commonly those provided in the general food distributions) are used. In terms of satisfaction with the product, mothers compared it favourably to the traditional porridge, madida, which was used prior to the conflict and was composed of millet, oil, sugar, milk and salt.

While the provision of adequate complementary food during the peak of the hunger gap undoubtedly contributed to improvement of the nutritional situation, seasonal factors also impacted positively. Overall food availability increased with the onset of the harvests and the workload for caregivers decreased. In addition to this, sensitisation and awareness raising campaigns associated with the blanket distribution put child feeding and care practices high on the agenda in the camps. Beneficiary satisfaction with BP5 biscuits, their acceptance and understanding of the aims of the project were also key factors in the success of the operation.

Conclusions and outstanding questions

This experience from Darfur shows that timely blanket distributions, which use appropriate products and are accompanied by sensitisation and awareness-raising, can be an effective measure to tackle transitory peaks in malnutrition. Such distributions, however, suffer from two main drawbacks - the distributions remain costly and their impact, especially as a stand-alone response, is not sustainable.

Cost is particularly high when foreignproduced, highly sophisticated and expensive products are purchased and airlifted to the project area. In this case, roughly 35% of the budget was used for the purchase of BP5 and 30% for international air transport. However, there were no appropriate local alternatives available at the time of the crisis. Further research into local fortification and/or local production of supplementary foods may provide future solutions that are less costly and more sustainable than the options that are currently available. The organisation of a parallel registration exercise, two-week distribution cycles and thorough monitoring also increased the cost of the intervention, but were c r u cial to ensure adequate quality.

The role of food aid in saving lives and preserving livelihoods in the current conflict in Darfur is widely recognised²⁴. At the same time, it is clear that food aid alone, including blanket distributions, does not provide sustainable long term solutions for preventing malnutrition, even if, in the short term, its impact can be life-saving. Food aid can have a sustainable impact on livelihoods, food security and ultimately malnutrition only when the immediate, underlying and basic causes of malnutrition are understood and tackled. In the long term, security measures, land tenure and market issues as well as peace build- Figure 2: Use of BP5 within the households Figure 3: Sources of information for the distributions ing at the community and national levels are essential for food aid to have a meaningful effect on livelihoods in Darfur²⁵. Deep-rooted cultural practices are among other causes of malnutrition. These require careful analysis and the development of long term approaches to achieve behavi o u ral change.

The current experience also highlights the need for food security surveillance to rapidly detect potential problems. A change in ration composition is one of the key early indicators in areas where food aid is the main source of food and income. Targeted supplementary feeding programmes, where these are in place, may also play a role in early warning through the monitoring of admission numbers.

Another question arising from this experience is whether the ration composition in the general food distribution is adequate for all population groups in terms of macro- and micro-nutrients and their bioavailability. The GAM rates increased to above 30% while the general food distributions were ongoing with a theoretical ration providing over 2000 kcal/person/day, at a time when morbidity and mortality rates had not changed significantly²⁶.

For further information, contact: Hanna Mattinen, email: hmattinen@actioncontrelafaim.org

¹Buchanan-Smith M and Jaspars S (2007). Conflict, camps and coercion: the ongoing livelihoods crisis in Darfur. Disasters, 31 (s1):s57-76. Blackwell Publishers, London.

²See footnote 1.

³WFP, FAO, Unicef, MoA/GoS, MoH/GoS and CDC (2007). Food Security and Nutrition Assessment of the conflictaffected population in Darfur, Preliminary Results. August/September 2007.

⁴Blanket under-5 distribution refers to a distribution that targets children under 5 years of age (6-59 months) in a given geographical area.

⁵For a detailed analysis of ACF nutritional programmes in North Darfur, please refer to the evaluation Action Contre la Faim nutritional intervention in North-Darfur 2004-2007 carried out by B. Feeney, Valid International in March-April 2007.

⁶The traditional hunger gap period falls roughly between May and September/October each year.

⁷Action contre la Faim. June, 2007. Nutritional Anthropometric and Retrospective Mortality Survey, Children aged 6-59 Months. Abu Shok and As Salaam IPD Camps. El Fasher, North Darfur State. GAM reported as weight/height below - 2 Z-scores and/or oedema; SAM defined as weight/height below - 3 Z-scores and/or oedema.

⁸Action contre la Faim (2007). Nutritional Causal Analysis. North Darfur Camps. North Darfur State.

⁹Caregivers were interviewed on breastfeeding practices and an event calendar was used to define the time period, when needed. It is acknowledged that this method may induce bias and allows only for a rough estimation.

¹⁰CSB is the most richly fortified item in the food ration.

¹¹ACF closed down its supplementary feeding programmes in Abu Shok and As Salaam camps in October 2006. While it is unlikely that this measure impacted the drastic increase in malnutrition rates, monitoring of admission numbers in such programmes may have provided useful early warning information on the deteriorating nutritional situation.

¹²Tearfund (2007). Darfur: Water supply in a vulnerable environment. Darfur, Sudan.

¹³ACF is currently rehabilitating a dam approximately 2 km from the camps and it is hoped that the water made available will be used for livelihoods activities.

¹⁴The lack of adequate food was particularly clear for children under 5 years, especially at the age when complementary foods were being introduced.

¹⁵SPHERE (2004). 'SPHERE. Humanitarian Charter and Minimum Standards in Disaster Response'. http://www.sphereproject.org

¹⁶The nutritional requirements of a child under five are estimated at 1,200 kcal/day, varying according to the child's age. The ration of three BP5 bars a day provides 756 kcal and covers 63% of the daily requirements in energy and micronutrients.

¹⁷The end of the blanket distribution was not conditional on reinstatement of the full CSB ration in the general food distribution because there were no clear provisions made for this.

¹⁸This amount excludes the cost of a reserve stock and its transport, which was not distributed within the current project.

¹⁹Caregivers noted dissatisfaction with CSB-oil-sugar mix as one of the reasons for defaulting in ACF supplementary feeding programmes in Darfur.

²⁰According to WHO standards, children measuring under 110cm are considered under 5 years of age.

²¹Action contre la Faim (2007). 'Post Distribution Monitoring. Blanket distribution for children under 5 years old. Abu Shok and As Salaam IDP camps'. El Fasher, North Darfur State.

²²Action contre la Faim (forthcoming): 'Nutritional Anthropometric and Retrospective Mortality Survey, Children aged 6-59 Months, November 2007. Abu Shok and As Salaam IPD Camps.' El Fasher, North Darfur State.

²³Note that the malnutrition rates in November 2006 were found to be higher than expected due to the delayed rainy season and high prevalence of disease.

²⁴Gelsdorf K, Walker P and Maxwell D (2007). Editorial: the future of WFP programming in Sudan' Disasters, 31 (s1):s1- 8. Blackwell Publishers, London.

²⁵Young H (2007). Looking beyond food aid to livelihoods, protection and partnerships: strategies for WFP in the Darfur states. Disasters, 31 (s1):s. Blackwell Publishers, London.

²⁶Note that WFP plans to include in the general food distributions in North Darfur a supplementary ration including CSB mixed with milk powder for children under five years of age during the lean period in 2008.