Review of integrated nutrition programming by ACF International

A pond to breed fish as a part of an income generation scheme in West Timor, Indonesia

Summary of review¹

Action Against Hunger International Network (ACF) recently commissioned a review of their 'integrated' nutrition programming with the following aims:

• To review ACF's present practices and policies in relation to implementing integrated approaches to treat and prevent acute malnutrition with a specific focus on evidence for successful integrated programmes.
• To assess whether and how monitoring and evaluation tools could be strengthened to provide a greater understanding of the processes and outcomes of integrated programmes.
• To identify and analyse opportunities and constraints to having integrated programmes, including funding and partnerships with other agencies.
• To recommend practical steps to improve the implementation of integrated approaches to programmes.
• To provide support to ACF's efforts to promote an integrated approach to programmes.

The process of the review involved reading background documents, meeting staff of ACF UK, ACF France and ACF Spain, visits to review specific programmes that were considered by ACF to be integrated (Mali, Zimbabwe, Indonesia and Myanmar) and interviews by telephone or in person with key staff to review specific programmes (Kenya, South Sudan, Bangladesh, Niger and Darfur). Staff from key ACF donor organisations were also interviewed, i.e. Europaid, European Commission's Humanitarian Office (ECHO), Spanish Aid and the US Office of Foreign Disaster Assistance (OFDA).

Current treatment and prevention programmes

ACF treat acutely malnourished children either at in-patient 'stabilisation' centres or by providing highly nutritious food supplements to take home. Where the Ministry of Health has taken over the running of these stabilisation centres, then ACF provides technical support to local Health Centre staff. In circumstances in which the prevalence of acute malnutrition (wasting) is low, ACF may refer wasted children to government health centres rather than operating their own stabilisation centres. ACF usually relies on government health systems or NGO partners such as Médecins sans Frontières (MSF) or Médecins du Monde to provide diagnostic medical services and give treatment for underlying diseases.

ACF prevents malnutrition mainly by interventions directed at its underlying causes:

• Insufficient food, targeted through programmes related to nutrition, food production, income generation and food assistance.
• Inadequate services addressed mainly through programmes that provide water and sanitation, but sometimes by providing or arranging preventive and curative health services such as bed nets and vaccinations.
• Inadequate care addressed through programmes of health, hygiene and nutrition education and by promoting improved child care and psychological support to mothers.

ACF has considerable expertise in the fields of nutrition, food security and water, sanitation and hygiene, as well as expertise in psycho-social aspects of child development and caring practices.

Defining integrated programming

There is no standard definition of what integrated programming means for an NGO such as ACF. For the purposes of this review, an integrated programme was defined as:
The joint operation, coordination and management of all interventions needed to treat and prevent acute malnutrition that achieve the greatest impact, with the most efficient use of resources and at lowest cost.

Similarly, there is no document or set of guidelines to explain precisely what integration means to ACF, how it could be achieved, how integration can be measured, and what benefits it brings. ACF has identified the UNICEF conceptual model of the causes of malnutrition as a useful tool to analyse and explain what it does. The level of analysis undertaken by ACF using the UNICEF conceptual model tends to focus on the immediate and underlying causes of malnutrition, and not so much on the basic causes.

Findings

The review found a discrepancy between what ACF aspires to do in terms of integrated programmes and what happens in practice. There is a lack of clarity about what integration is, in concept and in practice. The lack of a unified, documented and consistent strategy by which integrated programmes can be put in place and implemented means that integration is poorly communicated at all levels of ACF.

Each ACF mission also appears to have different experiences of integration and perceptions of its importance. Some missions have been trying to integrate programmes for some time, while others have not, because of the lack of evidence of impact. In certain countries, the sources of funding have been more conducive to developing integrated programmes.

A child in a therapeutic programme in Sittwe, Myanmar

At the country level, the review identified a few examples of integrated approaches to treating and preventing acute malnutrition but overall, these have been limited to one or two sectors and rather piecemeal. It has not been possible to identify specific examples of integrated approaches throughout the project management cycle, starting with an integrated assessment and ending with integrated evaluation. What has been observed in programmes is more of an incremental approach to integration; the entry point is an emergency. ACF often starts with water, sanitation and hygiene (WASH) programming and then other activities are added, depending on needs assessments and the funding available. As the emergency subsides, funding is then sought for long term projects, such as food security, which typically requires stability. The net result is a multi-sector programme with, at best, partially integrated elements.

The case studies compiled for the review showed a wide range of integration practices from almost complete lack of integration in South Darfur, to what is believed to be a near fully integrated approach in Kenya. Zimbabwe, where WASH and food security activities are integrated, and Mali, where there are many donors but considerable geographic overlap, fall somewhere between.

ACF have not conducted any studies to demonstrate synergy of integrated programming or greater impact than programmes that are not integrated. Nor have ACF evaluated integrated programmes with a view to demonstrate other benefits, e.g. administrative efficiency, cost saving, etc. However, in current programmes, ACF do endeavour to show how programmes are integrated.

Major bilateral donors appear willing and able to fund an integrated programme with one overarching goal, providing that adequate justification is given in the proposal, such as added value, administrative efficiency, and long-term impact. None of the donors interviewed had any conceptual or theoretical objection to the idea of funding one agency to implement a multi-sector integrated programme, although a number of potential complicating issues were raised. At the same time, donors indicated that the likelihood of obtaining support for an integrated programme will be increased by generating robust evidence of the added value of such an approach.

Conclusions and recommendations

Concepts v practice

The idea of integrated interventions to treat and prevent acute malnutrition has a sound conceptual logic when it is considered that malnourished people rarely just need adequate food or the resources to obtain food, they need treatments for current disease as well as protection from future disease. But the premise that different interventions to prevent malnutrition and infection can act synergistically has not been proven. This will require research, which could provide evidence for the purposes of advocacy and fund raising.

The current focus of ACF on acute malnutrition, manifested as wasting, does not really reflect the actual focus of all country programmes. In practice, the interventions that ACF usually implements are likely also to have an effect on chronic malnutrition and perhaps on micronutrient status too, so the potential for added benefit is large.

Although the sector strategies of ACF have been developed with the idea of integration in mind, they seem to remain largely independent of each other and are not clearly linked or integrated. There needs to be an overarching strategy for the agency that captures integration of the separate technical sectors.

The UNICEF model is a very useful starting point to analyse the possible causes of malnutrition and identify needs, but its limitations need to be recognised. While the model helps to identify all potential causes of malnutrition, not just wasting, it cannot be used to determine how any given child came to be wasted or to estimate the balance or proportionality that is required between interventions in different sectors to prevent malnutrition. But the model can be used as an analytical tool to help the different technical sectors appreciate the importance of links with each other.

When should integration begin?

Integration needs to occur throughout the programme cycle, from start to finish. First, an integrated needs assessment should be done before any programme is designed. This may require ACF to invest its own funds in surveys before external funding is obtained. Once the initial needs of the community to tackle the underlying causes of malnutrition have been assessed and if ACF anticipates a programme lasting more than a year, an assessment should be made of factors contributing to the basic causes of malnutrition. Ideally the assessment of needs should lead to a programme proposal in which all the components and sectors are integrated, to achieve both an effective outcome and efficient implementation.

Writing proposals poses one of the greatest challenges to ACF because of the need to design and describe an integrated programme that tackles all the immediate and underlying causes of malnutrition. The part of the document that describes integration need not be long or complex and could consist of matrices or logical frameworks that identify overlaps in terms of beneficiaries (including localities), intentions, activities, messages and planning. The added value of an integrated programme should be set out as clearly as possible.

Cross-cutting components

There are two main programme components that could be integrated because they cut across several technical sectors: behaviour change communication, and monitoring and evaluation.

There could be a person or unit responsible for all behaviour change communications in nutrition, food security, caring practices, water and sanitation and health. If there was a high degree of overlap of beneficiaries, then all messages would be directed at the same individuals or households and could be consistent and reinforcing. This could serve to avoid repetition of messages and could give the unit a view of ACF programmes that cuts across sectors, thereby helping to achieve economies in training.

The second cross-sector component is to have a separate monitoring and evaluation person or unit, again depending on the scale of ACF operations, but most likely at a national level. By removing from each sector the responsibility to monitor and evaluate their own activities, a degree of objectivity and impartiality could be achieved. Furthermore, data on several sectors could be obtained during the same surveys at the same time thereby avoiding duplication of effort. Staff time could be used more economically if sector surveys were combined, and the quality and consistency of data, analysis and reporting could be improved by giving the job to specialists.

Meeting health needs

If ACF is to have truly integrated programmes then the need for health services will have to be addressed during any needs assessments and then met if considered to be important. ACF has working relationships with MSF, Artsen Zonder Grenzen (AZG) and Médecins du Monde at stabilisation centres but these relationships would need to be developed further. This might include memorandums of understanding if help is to be given during needs assessments and when delivering preventive interventions, especially if the two agencies do not work in the same area.

Measuring impact

If treating and preventing wasting is to remain a key objective of the agency, then a change in the prevalence of wasting should be an indicator of the effectiveness of all programmes. If surveillance is possible, then the incidence of wasting might also be estimated. However, in order to measure the attributable impact of any programme on preventing wasting, the agency will need to consider methods of having controls in order to account for secular change, natural recovery and other uncontrolled factors. The use of a stepped wedge design should be considered when new programmes are designed. Although this is quite specialised and could be considered to be research rather than evaluation, a dedicated unit could allow such evaluations to be done.

There is a need to develop and use a set of indicators of integration, such as the degree of overlap in beneficiaries or the number of integrated needs assessment and multi-sector training courses, etc. These will be specific to the context of the programme.

Coordination

Every major programme should have a coordinator whose aim is to integrate the activities in each sector and focus them on common objectives. Ideally such a person would have considerable field experience, most likely in nutrition, but also have an authoritative understanding of the roles of infectious diseases, food security and caring practices. Such a person also needs to work closely with staff concerned with logistics and administration to ensure that every opportunity for integration is taken. The Coordinator would play a major role in writing integrated proposals and reports.

To promote integration all staff should be aware of the work of other sectors within ACF. To achieve this all new staff should spend time familiarising themselves with what other sectors do and it should be required that they look for opportunities to integrate their activities with the other sectors during regular coordination and integration meetings.

Developing an evidence base

If ACF wants to convince donors that integrated programmes have a greater effect than separate, individual components, it will probably have to obtain that evidence. ACF could do this as part of programme evaluations, which might be more costly than most normal evaluations, or it could seek external funding and call it research.

Donors are generally receptive to the idea of integration but it would help to have a stronger and well argued evidence base that integration brings efficiency and added value. However, it cannot be assumed that an integrated approach will be suitable for all donors in the short to medium term. ACF must ensure that any research on integrated programmes or on the benefits of components of programmes is published in peer reviewed journals and used to inform donors as part of a strategy to advocate for integrated programme funding.

The reviewers are not advocating for a 'one size fits all approach'. They do not expect that ACF should routinely implement integrated programmes in every situation and context. Ultimately, the need for, and advisability of an integrated programme and the level of integration will need to be determined on a case-by-case basis. It must be based upon the findings of the needs assessment as well as a thorough analysis of internal capacity, the context and the funding available.

¹Dolan. C et al (2009). A review for ACF International of integrated approaches to treat and prevent acute malnutrition. August 2009