Fresh food vouchers for refugees in Kenya

By Lani Trenouth, Jude Powel and Silke Pietzsch

Lani Trenouth and Jude Powel were the ACF Food Security and Livelihood programme managers who implemented the programme in Dadaab.

Silke Pietzsch is the Food Security & Livelihood Advisor for ACF-USA, supporting the Kenya mission.

Special thanks go to Sophia Dunn (Consultant) and the ACF Dadaab team for the implementation of the programme. The funding support of the French government is gratefully acknowledged.

This article outlines an intervention by ACF in Dadaab to improve the nutritional intake and dietary diversity of the refugee population of Dadaab, Kenya, through a complementary food voucher scheme targeted at malnourished children.

The town of Dadaab in North Eastern Kenya is home to three refugee camps, Hagadera, Dagahaley and Ifo, together hosting over 240,000¹ people. The camps were established in mid-1992 after the closure of the Liboi camp, which was too close to the Kenya/Somali border to ensure adequate security for the refugees. The current camps host refugee communities from various countries, i.e. Somalia, Ethiopia, Democratic Republic of the Congo (DRC) and Sudan, but the Somali population is the biggest in numbers. Due to ongoing insecurity in Somalia, regular influx into the camps has continued, with the population increasing at an average rate of 5000 per month during 2008.

The three camps are managed by the United Nations High Commission for Refugees (UNHCR). Food is provided by the World Food Programme (WFP) as a general dry ration, comprised of cereal, legumes, oil and sugar. Currently the ration provided to all residents does not include fresh foods, such as vegetables or fruit, and many residents have little access to food beyond that which is provided. Each of the camps has a market where resident vendors sell a variety of items, including fresh foods. However, since residents are prohibited from employment, their ability to access these foods is closely related to the limited external support they get from remittances or through the sale of part of the general food ration.

Malnutrition rates have been high in the camps (22% global acute malnutrition, 4.5% severe acute malnutrition (2006))² but through concerted interagency action, had fallen considerably to an average of 14.7% GAM and 2.9% SAM for the three camps by June 2007³. Lack of nutritional diversity was identified as an ongoing underlying cause of malnutrition. To increase the consumption of nutritious fresh foods by the refugee population, a voucher programme was implemented by Action Against Hunger USA (ACF - USA) between September 2007 and April 2009, funded by the French Government.

Programme objectives

The programme targeted children 6 months to under five years of age enrolled in GTZ (Gesellschaft fuer technische Zusammen-arbeit) and International Rescue Committee (IRC) selective feeding programmes⁴. It provided their caregiver with vouchers worth 600KSh per month to enable them to buy fresh vegetables and fruit, milk and eggs in the local market. The programme also aimed to address the sub-optimal practices of primary caregivers in terms of infant and young child feeding practices, balanced diets and good food hygiene. Follow up at household level was carried out to reinforce the health education messages given during the voucher distribution, as well as to observe the households and the children.

Since each camp has functioning markets with vendors specialising in the sale of fresh fruit and vegetables, a local supply⁵ was easily accessible to the beneficiaries. In addition, vendors were able to increase their supply if there was a guaranteed demand. The proximity of the markets and the availability of local produce meant that in-kind distributions would be unnecessary and a cash or voucher response would be more appropriate.

By providing a voucher for a defined list of items instead of providing cash, ACF has been able to maintain some control over beneficiary spending and in doing so, has been able to meet the objectives of the programme.

Targeting

The ACF programme targeted households with malnourished children. To reduce the workload on the small number of ACF staff and avoid duplication, the programme directly targeted a sub-set of GTZ/ IRC nutrition programme beneficiaries. As such, the targeting procedures are dependent on GTZ/IRC staff ability to correctly admit and discharge beneficiaries.

The selection criteria for inclusion in the ACF voucher programme were:

• Households with severely malnourished children enrolled in the GTZ/IRC outpatient therapeutic care programme (OTP).
• Households with moderately malnourished children enrolled in the GTZ/IRC supple mentary feeding programme (SFP)
• Households with mothers who have recently been discharged from the GTZ/IRC antenatal care programme and now have a baby at complementary feeding age (6 months).

Clear targeting criteria helped the transparency of the programme as the community understood that the programme targeted malnourished children, with the purpose of improving their nutrition status.

The voucher process

The value of the voucher was defined based on the 'ideal' complementary⁶ food basket and the value of items within it calculated based on market prices (October 2007). This came to 1494 KSh per child per month (see Table 1). However, because the team were planning to target children in selective feeding programmes who would also be receiving ready-to-use therapeutic food, or fortified foods such as Corn Soy Blend (CSB), vouchers to purchase around half of the ideal complementary food basket were distributed. Thus, each child in the nutrition programme was entitled to a voucher worth 600KSh per month that could be divided easily into two 300 KSh vouchers. Once a child was discharged from the selective feeding programme, they were discharged from the voucher scheme.

Table 1: Voucher value rationale (ACF Capitalisation report, 2008)
Food Group	Locally available items	Serving/day	Serving/ month	Cost/day	Cost/ month	Cost per food group /month
		kg	kg	KSh	KSh	KSh
Fruits	Mango	0.66	19.8	15	297
	Orange	0.66	19.8	10	198
	Banana	0.66	19.8	5	99	594
Vegetables	Sakuma wiki	0.2	6	10	60
	Tomatoes	0.065	1.95	40	78
	Potatoes	0.065	1.95	40	78	216
Protein	Eggs	0.28 eggs	8.4 eggs	10	84	84
Dairy	Cow's milk	1 cup	30 cups	20	600	600
Value of Ideal Complementary Food Basket (Oct 2007)						1494 KSh/month

The voucher approach consisted of three main implementation processes as shown in Figure 1.

1. Voucher distribution to beneficiaries
2. Voucher redemption by beneficiaries at designated fruit and vegetable vendors in the local market.
3. Vendor payment by ACF.

To complement the voucher component, health education was provided to all beneficiaries as part of the voucher distribution process. Health education sessions focused on food hygiene and balanced diet and included cooking demonstrations, as well as information on how to use the voucher with the market vendors.

Programme implementation

The programme has been implemented by a small team of contracted ACF staff, with significant support from camp based incentive workers and volunteer mothers. In addition, local camp management and the community have appreciated ACF efforts to keep them informed throughout the programme.

To pay the vendors when redeeming the received vouchers, the programme utilised the services of the Kenya Postal Service (PostaPay), who were responsible for cash carrying and distribution to vendors in Dadaab. During the rainy season, some problems were encountered due to poor road conditions which resulted in payment delays to the vendors and affected their supply line in some cases.

Programme Results

Beneficiary Numbers

The intended beneficiary numbers and the actually realised numbers differ vastly, mainly due to the continuous high admission rates to the GTZ/IRC nutrition programmes (see Table 2). By February 2009, a total of 63,930 households have received fresh food vouchers, which amounts to 182% of the initially set objective. This was only possible due to the extension of the running contract with the French Government and their commitment to additional funds for the programme.

Table 2: Difference between planned and actual voucher beneficiaries
Beneficiary Group	Planned number of households per month	Actual number of households per month (Jan 2009)
OTP	170	250
SFP	2600	6000
Weaning Babies Programme8	500	1500
Total	3270	7750

 

Increased household dietary diversity

Dietary diversity is a qualitative measure of food consumption that reflects household access to a wide variety of foods. It is also a proxy indicator of the nutrient adequacy of the diet for individuals⁹. As indicated in Figure 2, before the voucher distribution, most households were reporting consumption of 5-7 food groups (cereal, pulses, oil, miscellaneous, sugar and some vegetables), most of which are provided by WFP. After the voucher distribution, households reported increased consumption of eggs, milk, vegetables and fruit (average of 10 food groups) as intended. This is a positive outcome and shows that it is possible for refugee households to consume a balanced and varied diet.

Information on the percentage of households reporting consumption of each food group is documented in Figures 3 and 4. Comparison of the data from March 2008 to January 2009 shows that even consumption of many of the food groups pre-voucher distribution has reportedly increased. Beneficiaries attributed the change in their consumption to health education and improved availability of fruit and vegetable items in the market.

OTP beneficiaries reported that the cooking demonstrations provided them with increased awareness of new vegetables, especially sukuma wiki (dark green leafy vegetable) and cabbage. Beneficiaries and ACF staff also reported improved knowledge levels on a range of health education topics, although putting certain education messages into practice still causes some challenges. Though the programme concentrated on food hygiene messages, some non-food related messages were also included. Cleaning the compound regularly, washing hands after using the latrine and before food handling, are all messages that beneficiaries reportedly found easy to put into practice.

The benefits of the health education sessions are likely to have been disseminated to non-beneficiaries because many households live within the same compound. Health education sessions given at the health posts are often attended by non-beneficiaries and by GTZ incentive workers too, and hence provide an ideal ground for trickle-out effects to the community.

Improved coverage of nutrition programmes

The ACF fresh food voucher has clearly been a strong influence on mothers' motivation to bring their children to the GTZ/IRC nutrition programmes. As a result, GTZ staff noted a decreased need for active case finding by community health workers. In previous nutrition surveys (GTZ 2003-2007), SFP coverage rates have been as low as 25.1% (2003) due to lack of food provided to caregivers, non- palatability of CSB and poor quality health services. Admission numbers and coverage rates to the nutrition programmes have since markedly increased, despite an improvement in the overall malnutrition rates in each of the three camps (average of 11.3% GAM and 1.3% SAM for the three camps, August 2008, UNHCR). Increased admissions may partly reflect influx into the camps in late 2008/early 2009.The latest nutrition survey conducted by GTZ (August 2008) indicated SFP coverage rates of 57.8%¹⁰.

Improved market supply

Unfortunately, no data were collected about the changes in the business of vendors participating in the programme until November 2008. However, informal evidence from beneficiaries, non-beneficiaries and other key stakeholders point to a number of changes in the market as a result of the ACF programme. The programme intended to improve beneficiary access to fresh food, fruit and vegetables. While this has clearly been the case, an unintended impact of the programme has been a general increase in the availability of fresh fruit and vegetables in the market. The range of fruit and vegetable items in the market has improved, notably the range of leafy green vegetables. Sukuma wiki and cabbage are now regularly available in the market, even though they were unfamiliar vegetables to many Somali refugees before the programme started. Eggs are also available in larger quantities.

Improved business of programme vendors

The programme has helped improve the business of the programme vendors in camp. ACF data since November 2008 indicates that the programme vendors have increased their business profits by up to 45% and their stock by up to 60%. Their customer base has also risen. This has enabled them to expand their business and take on extra employees. Local milk suppliers have benefited also from the programme. Many of the fruit and vegetable vendors did not sell milk before the ACF programme. In order to meet the list of items for the programme vouchers, some vendors have made informal agreements with milk vendors to sell milk at their shops. In return, the milk suppliers were paid in cash by the programme vendor when beneficiaries elected to purchase milk.

Further considerations

Two adverse effects of the programme were noted.

Some of the key informants felt that by targeting malnourished children, the programme was in conflict with prevention messages about eating a balanced diet, i.e. it was "rewarding negative behaviour contributing to malnutrition". If the programme were to be continued, it might be worth looking into the possibility of linking the targeting to a 'positive action', such as growth monitoring, rather than "rewarding" a negative action or benefiting from having a malnourished child. However, informal investigation with the community indicated that the voucher scheme was not an incentive to 'keep' a child malnourished and participating in the programme.

The delays in paying vendors by 3-4 weeks damaged their credit rating with their suppliers. While not having a long term negative consequence, the impact was passed onto programme beneficiaries when some vendors increased their prices to ensure their costs could be covered. A review of the vendor payment system would probably remove this problem.

Considerations for improving the current programme are:

Programme target groups

The ACF programme has generated much interest from the community and nutrition/health non-governmental organisations and United Nations agencies as a possible tool for preventing anaemia and improving the general health of the refugee population. If the programme is to be continued, there should be a review of the programme objective (and the target groups) in order to meet the specific health needs of the refugee community. Targeting population groups most at risk of anaemia, e.g. under 5's and pregnant women, may be a good place to start. Additionally, other vulnerable groups, like HIV positive individuals and the elderly, could be considered.

The value of the voucher

Throughout the period of implementation, the value of the ideal food basket has changed, from 1494 KSh in October 2007 to 1600 KSh in January 2009 (range = 1554-1649 KSh), with seasonal price fluctuations in between. Unfortunately the value of the food voucher remained unchanged until January 2009. In addition to the price rises, it became clear that some programme vendors charged more for some items to voucher beneficiaries, due to the delays in payment and vendors wanting to ensure that their costs would be covered. As a result, the voucher no longer provided the intended 50% value of the ideal basket. The main effect of the reduced 'value' of the voucher was to diminish impact on the household's dietary diversity, i.e. it was shorter-lived (on average households had less than 10 days benefit per month from the voucher). After this period, the household's dietary diversity score probably returned to the baseline of five groups provided by WFP. A longer-lasting and more consistent impact may have been achieved had the value of the voucher been better monitored and modified according to market price changes.

Programme monitoring & sustainability

The ACF programme has addressed a clear, long term need of the refugee population but was never designed to be sustainable. One of the intentions of the programme was to demonstrate that a voucher approach to providing complementary foods could work. Hence monitoring was a crucial programme component, so that data could be used as proof of success. However, programme monitoring has been difficult for the programme due to several changes to the monitoring system, staff turnover and a review of the monitoring methodology.

Conclusions

The context provided by the Dadaab camps, with local, functioning markets and a clear need for complementary foods has been an ideal opportunity for ACF to demonstrate that a voucher approach is an appropriate means of providing fresh foods to a refugee population. The programme has also demonstrated this to be a means of addressing the needs of a large population without the necessity for large logistical input. In addition, since the approach utilises the existing market infrastructure, the method helps improve the local economy while providing the required foods to beneficiaries.

The ACF programme has had a range of positive impacts; it improved the dietary diversity of refugee households while also helping to improve the coverage rates of the nutrition programmes. The community has appreciated the voucher approach as it provided them with an increased level of choice about the foods to purchase.

The Dietary Diversity Score has proven to be a good tool to measure and follow up on dietary changes of the targeted population. At the same time, the presentation and practicality of the tool has been useful in focus group discussions and education sessions.

The camp community is dependent on aid organisations to meet their basic needs, and while this programme has also provided items of food assistance to beneficiaries, it has done so in an indirect way that has maintained the dignity of the beneficiaries and should therefore be a preferred approach where feasible.

However, a long term solution needs to be found for the ongoing provision of complementary foods to this refugee population. The ACF programme funding ended in April 2009 and to date, no interest in taking over the programme has been expressed by partners working in the camps. Discussions and advocacy to transfer programme activities to other interested partners are currently ongoing.

For further information, contact: Silke Pietzsch, email: spietzsch@actionagainsthunger.org

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¹UNHCR figures (January, 2009) indicate a population of 247,182 people: Hagadera - 25,388 households (91,634 people), Dagahaley - 20,391 households (71,768 people), Ifo - 24,421 households (83,780 people)

²Source of figures: GTZ, 2006

³UNHCR interagency annual survey, June 2007: global malnutrition rates of 12.5% (Dag); 10.4% (Hag), 12.9% (Ifo), severe acute malnutrition rates of 2.4% (Dag); 1.0 %(Hag); 1.5% (Ifo).

⁴The GTZ and the IRC are running the supplementary and therapeutic feeding programmes in the Dadaab camps. IRC has only taken on some parts of the programme since 2008.

⁵From Garissa, the next biggest market town with good connections to Nairobi and local vegetable production

⁶Here, complementary food refers to foods, beyond the basic food aid commodities, given to an affected population to diversify their intake and complement the ration.

⁷Other fruit and vegetable items could be purchased with the voucher, depending on availability/ seasonality.

⁸The Weaning Babies Programme refers to the number of malnourished infants aged 6-12 months admitted to the selective feeding programme and enrolled on the voucher scheme. This age-group were recognised as especially vulnerable to malnutrition.

⁹Household Dietary Diversity Score (HDDS) for Measurement of Household Food Access: Indicator Guide, FANTA 2006

¹⁰Calculated from weight for height median (coverage rate 69.2% by MUAC).