The Haiti Earthquake - Country and Global level Cluster Coordination Experiences and Lessons Learnt

By Carmel Dolan and Mija Ververs

Carmel Dolan was Global Nutrition Cluster Coordinator-Consultant at the time of the earthquake and located from the UK to UNICEF Headquarters in New York soon after the earthquake struck to support coordination. She has been involved with the Global Nutrition Cluster for the past four years, particularly in the area of capacity development. She is a partner in the consultancy group, NutritionWorks, and recently joined the ENN as a Technical Director.

Mija Ververs was Country Cluster Coordinator for first month of the crisis based in Haiti. Mija has extensive experience of nutrition, food security and public health in emergencies. She has been involved with the Nutrition Cluster as a Red Cross/Red Crescent Societies' representative/independent since its outset.

The findings, interpretations, and conclusions in this article are those of the authors. They do not necessarily represent the views of UNICEF, its Executive Directors, or the countries that they represent and should not be attributed to them.

This article describes the experiences of the Nutrition Cluster in response to the Haiti earthquake which struck in January 2010. The article aims to capture what the cluster did well and what it did not do so well in the first month of the response and to highlight key lessons for future Nutrition Cluster Coordination and for UNICEF as the cluster lead agency.

On 12 January 2010 at around 5 pm local time, an earthquake measuring 7.0 on the Richter scale, hit Haiti. The earthquake struck Ouest Province around an epicentre 17 km south-west of Haiti's capital, Portau- Prince (PauP), which suffered extensive damage. The nearby cities of Carrefour and Jacmel and other areas to the west and south of PauP were also affected, with the town of Leogane, reported to be 80% destroyed (see map and picture). By the 18th February, the number of people killed stood at over 217,000 with over 300,000 wounded. The Government of Haiti (GoH) estimated that three million people had been directly affected, of which 1.9 million lost their homes and over 1 million were displaced¹.

Government, international and national organisation staff in PauP suffered loss of colleagues, family members and friends, as well as the destruction of office buildings and their homes. The seaport, a major route for trade and supplies was heavily damaged and aid (personnel and supplies) had to come in via the capital's airport (itself highly constrained) and overland via the Dominican Republic. The main road into PauP also sustained damage. The extent of physical destruction and loss of life, the emotional and physical trauma faced by survivors and the logistical bottlenecks were considerable. The fact that the earthquake had 'decapitated' much of the capital city posed a particularly challenging context for the humanitarian response.

Haiti, prior to the earthquake, was an impoverished nation with 55% of the population below the international poverty line of US$1.25 per day. The country has a history of repeated natural and conflict related emergencies, as well as substantial nutritional problems. The Demographic and Health Surveys over the period 2005-2008 reported that 29% of the under-five age group was stunted and that rates of exclusive breastfeeding (EBF) were 41%² (although international non-governmental organisations (INGOs) estimated this was much lower at 20-30%). An estimated 5% of the under-five population were acutely malnourished, of whom 0.8% suffered from severe acute malnutrition (SAM)³.

Activating the Cluster Approach

Two days after the earthquake struck, the Cluster Approach was activated. Five clusters were to be immediately established based on previous coordination arrangements laid out in the Haiti 2008 Flash Appeal (for response to the floods). The five clusters/lead agencies were Logistics/WFP, Emergency Shelter/International Organisation for Migration (IOM), WASH⁴ /UNICEF, Health/WHO and Food/WFP and Nutrition/UNICEF. The Nutrition Cluster was activated within 1 week of the earthquake, along with a number of other clusters.

Response and Achievements

Global Cluster Coordination

Two days after the earthquake struck, a Global Nutrition Cluster (GNC) emergency coordination (telephone) meeting was held with many of the global partners. These meetings were convened and chaired by the GNC-Coordinator every two to three days for the first two weeks, then twice per week and thereafter as needed. The meetings provided an opportunity for United Nations (UN) agencies, non-governmental organisations (NGOs) and other agencies and institutions to share information on the assessment of the situation, discuss key nutrition issues of concern and to provide an update on who was doing what and where. The meetings were very well attended and represented around 20 GNC partner agencies⁵.

Until such time as the country level, cluster coordination meetings were up and running (see below), the global level meetings provided the main source of information on the nutrition situation. They formed the basis for regularly written updates that were widely disseminated to GNC partner agencies, the Office for the Coordination of Humanitarian Affairs (OCHA) and UNICEF, as well as to agencies on the ground⁶ and were translated into French to ensure accessibility in Haiti.

The town of Leogane was 80% damaged by the earthquake

The GNC meetings benefited from direct briefing (via skype or mobile phone) from the Country Nutrition Cluster (CNC) Coordinator in Haiti. The GNC provided up to date information and helped to define the scope and focus of the discussions to respond, in real time, to key questions put forward by the country level to agencies at their headquarters. For example, concerns about WFP's food pipeline and the quality and quantity of the general rations, staff deployment/secondment issues within UNICEF and limitations with available nutrition assessment data were areas discussed.

In addition to providing a mechanism to jointly identify and discuss the main nutrition related issues of concern, the meetings also led to global level action. An immediate area of focus was on infant and young child feeding in the emergency (IFE) because of potential separation of children from mothers, concern around management of newborns and the reduced access to appropriate complementary foods. Previous experiences from responding to earthquakes in Indonesia (2004), in China (2006) and the cyclone in Myanmar and floods in Philippines (2009) were highlighted by the Emergency Nutrition Network (ENN) representing the IFE Core Group⁷ and helped in highlighting the range of IFE issues that would need to be addressed.

The following areas of concern were immediately raised by the IFE Core Group:

• Mothers of newborn infants needed support for early initiation of exclusive breastfeeding taking into account the reality that some mothers would be forced to give birth amongst the ruins and on the side of the road.
• Infants whose mothers have died or been seriously injured needed an assessment of the response options, for example wet nursing, or as a last resort, well managed artificial feeding.
• Urgent action to prevent unsolicited donations of breastmilk substitutes (BMS) and manage those already being sent when they arrived. From early media reports, large donations of infant formula/milk powder were being requested from many sources and despatched to Haiti.

The Operational Guidance on Infant and Young Child Feeding in Emergencies (OG IFE), available in 13 languages, was immediately shared with GNC partners and a link to relevant key resources setup on the ENN and GNC websites. Mindful of the consequences of delays in dealing with IFE issues, the GNC quickly agreed that a UN interagency Joint Statement (JS) on IFE was needed to raise the issues and clarify best practice in dealing with infant feeding. Nine days after the earthquake, UNICEF, WFP and WHO headquarter staff with GNC and IFE Core Group support, had adapted a JS used in Myanmar and China⁸ to fit the Haiti context and disseminated this to all operational agencies.

The speed of this action was unparalleled in other emergencies and underscores the value of the Cluster in being able to quickly tap into existing partnerships and having access to preprepared resources for adaptation. It also highlights the considerable contributions that partner agencies made to enable the cluster role. The JS was translated into French soon after and a good deal of work was undertaken in-country to get approval from the Ministry of Health and for the JS to reflect national considerations. The JS was followed by radio broadcasts disseminating ten key messages on IFE in Haiti Creole - modelled on messages prepared for radio to the besieged population during the 2008/09 Gaza conflict and adapted to key issues affecting this population.

What is the Cluster Approach?

In 2004, following identification of major failings in the humanitarian response to a number of crises, the UN Emergency Response Coordinator commissioned a review of the international humanitarian system and identified major gaps in areas of humanitarian response, as well as problems of coordination. The cluster approach was introduced as part of a general reform to improve overall coordination and response. Other reform measures dealt with humanitarian financing, the Humanitarian Coordinator system and partnership among all humanitarian actors.

Wet feeding in Jacmel

With the Cluster Approach, UN agencies with a particular technical and institutional capacity are designated as 'lead agencies' and are responsible for convening and facilitating coordination meetings at the global and country level, undertaking gap analysis, mapping capacities for response and working with partners to fill identified gaps, strategic planning, raising funds and supporting programme quality, expansion and coverage. The lead agency is also expected to act as the 'provider of last resort' where gaps arise in the emergency response. The lead agency for the Nutrition Cluster is UNICEF.

For more information, visit: http://www.humanitarianreform.org

Ready to use infant formula (RTUIF) in place of powdered infant formula

The Haiti emergency response was unique in that for the first time the Nutrition Cluster partners were able to use RTUIF available in cans or cartons as an alternative way to feed an infant where breastfeeding had been excluded as an option. The quality and quantity of available water was insufficient and the means to mix powdered infant formula, boil water, etc was very limited. The Nutrition Cluster facilitated the use of RTUIF (fed with cups and spoons) under highly supervised conditions and supported by development and harmonisation of guidance, tools and training¹².

A related global action was the development, in the week following the release of the JS, of an UNICEF/WHO technical note on infant feeding in the context of HIV for Haiti⁹. This too was translated and widely disseminated.

Following discussions with the GNC partners and with UNICEF nutrition section infant and young child feeding (IYCF) staff, (and at country level), it became clear that there was an urgent need to procure an appropriate BMS (infant formula) to meet the needs of nonbreastfed infants¹⁰. The OFDA¹¹, a GNC partner, led on the procurement of ready to use infant formula (RTUIF) and identified Save the Children as the implementing agency in-country for storage, monitoring and distribution under highly controlled conditions. At the same time, OFDA facilitated the secondment to UNICEF of a specialist in IFE and in the treatment of acute malnutrition (CMAM) to coordinate the IFE and CMAM programming.

The fact that the RTUIF issue was so quickly acted upon is a credit to the agencies involved. This is a highly sensitive and often emotive issue yet it was addressed openly and objectively. The GNC meetings were an important forum to bring the key stakeholders together and to enable joint decisions to be taken.

In the early stages, it was apparent at the global level that realistic estimates of the proportion and numbers of the total affected children (3 million) that were under 6 months of age, under one years, between one and five years of age, of pregnant and lactating mothers, and of numbers moderately and severely acutely malnourished were needed in order to plan activities. The Centre for Disease Control (CDC) in Atlanta, a key member of the GNC, was able to quickly provide this demographic breakdown based on census data and previous representative nutrition surveys. This information was important at both the global and country level and was used by the country cluster partners for planning. It was also the basis for the revisions to the nutrition section of the Flash Appeal (see below).

Flash Appeal

An immediate focus of the GNC Coordinator was to work with UNICEF Nutrition Section staff to produce the nutrition component of the Flash Appeal (FA) for the first month. Unusually, the global level had to take a lot of responsibility for writing the FA due to the enormous demands faced at country level. The revision to the FA took place less than one month after the initial FA was released. Again this involved considerable global level input but also benefited from increased country level capacity to inform the revisions.

Human Resources

Considerable time at global level was needed to identify, brief and deploy the cluster coordination Team for Haiti¹³. The GNC had previously invested in the development of a roster of candidates to be deployed for cluster coordination as part of building its surge deployment capacity. This roster includes candidates who have had previous cluster coordinator training and those who have coordination experience but no formal cluster training. The roster, managed by UNICEF Emergency Human Resources section (HR), was used on day one of the earthquake to identify potential CNC Coordinators. A cluster coordination team was put together between the 15th and 18th January 2010 which was remarkable and a credit to the HR section.

Inter-cluster

The GNC Coordinator had useful and regular informal interaction with other global cluster coordinators based in UNICEF HQ which helped to clarify process and to make sense of the constantly changing situation. Opportunities to listen in on briefings/updates from the country based WASH staff, for example, were particularly useful, as well as the regular participation of UNICEF Health staff in the GNC meetings.

Country & Regional Level support

The enormous constraints in Haiti in terms of logistics, as well as affected populations moving to the border with Dominican Republic, meant that the UNICEF's Office in Dominican Republic became a significant hub to support efforts in Haiti, as well as for addressing the needs of those displaced. Regional level staff from Panama were actively involved in the regular GNC hosted teleconferences and fed information into the written situation reports.

Country Level Coordination

Nutrition Cluster Team

All the rivers were choked with rubbish

Three weeks after the earthquake struck, the CNC Team was fully functional with one CNC Coordinator, one deputy CNC Coordinator, one IFE/CMAM/Assessment-Monitoring¹⁴ specialist and Information Management (IM) specialist. Later, additional CNC staff were appointed including an IM assistant (local) and a Nutrition Cluster Coordinator¹⁵ for areas affected outside PauP (sub-clusters).

The immediate concerns of the CNC Team were on ensuring the scale-up of critical nutrition interventions to prevent and treat acute malnutrition as follows:

• Blanket supplementary feeding
• Protecting and supporting optimal infant and young child feeding
• Minimising the risks of artificial feeding
• Micronutrient supplementation-Vitamin A (and zinc/ORS and de-worming)
• Mapping referral centres for the treatment of severe acute malnutrition
• Control and coordination of BMS donations
• Capacity building in infant feeding in the emergency context, CMAM and in-patient care.

In addition, the CNC Team wanted to focus on the needs of other potentially vulnerable groups particularly the disabled/injured and the elderly, but information on these groups was patchy which made it difficult to determine needs and the necessary response.

Country Cluster meetings

The cluster coordination meetings were the main forum for bringing together agencies and government concerned with the nutrition response. The first Nutrition Cluster meeting was held on January 20th 2010 led by a senior nutritionist from UNICEF HQ. Thereafter, the CNC Coordinator took responsibility for these meetings from 24th January. The meeting frequency was initially three times per week for up to 1.5 hours. The scope of these meetings was on exchanging information on population needs, funding streams, use of the JS, press releases, training needs, scaling up of response plans, supply plans, geographical mapping, etc. Cluster partners also used these meetings to express their operational constraints, challenges and needs and to discuss possible solutions.

A market in Port au Prince

Following the coordination meetings, technical meetings on IFE and CMAM (called thematic working group meetings) were held for another 1.5 hours. On average 30 to 40 participant from 20 to 30 organisations regularly took part in these meetings. Critically important, the Director of Nutrition of the Ministry of Health almost immediately co-chaired the meetings with the CNC Coordinator. Government leadership helped ensure that the cluster was working within existing national nutrition policies and guidelines and that new policy and guidance was not being agency driven but government led. Minutes of all meetings were posted on the Cluster website (www.oneresponse.org/nutrition).

Key areas of activity

The following components were put in place within one month by the CNC Team with the support of the GNC in UNICEF HQ, the Haiti Nutrition Cluster partners including UNICEF Haiti:

• A website where all relevant nutrition information was accessible for all partners in a 'one stop shop' (see Box 1)
• An overview of interventions from nutritional partners covering the 'three W's' - Who, Where and What.
• A draft CNC strategy with short and mid term objectives and activities.
• A JS and press releases with Ministry Of Health (MoH) and UN agencies on IFE
• Numerous tools and guidance notes (especially on infant feeding)
• A gap analysis (a detailed analysis on which geographical areas were of humanitarian concern and that were insufficiently covered by nutritional services from NGOs and MoH) (see Figure 1)
• An 'antenna service' of NGOs to verify daily reporting of groups of children with uncovered and urgent nutritional needs
• Geographical mapping of existing referral points for the treatment of SAM
• The first blanket supplementary feeding programme initiated, managed and conducted by the CNC Team, WHO and UNFPA volunteers with supplies from WFP
• Functioning CNC coordination meetings twice weekly with active engagement of all partners.
• An operational Nutrition Sub-Cluster in Leogane
• Nutritional programmes for Residential Child Care centres throughout PauP (International Medical Corps as requested by the CNC)
• A support system for partners to scale up IFE programmes (capacity building) especially those implementing 'baby tents' and nutritional/psycho-social counselling points for mothers or caregivers (Action Contre la Faim, Concern)
• A phone helpline on infant feeding for nutrition partners
• Active participation of the CNC Coordinator in inter-cluster meetings (initially daily, later 2 or 3/week) and humanitarian forums (initially 3 or 4/week, later weekly).
• Mediation in conflicts and areas of tension between cluster partners

Information Management

Whilst some Clusters resorted to Google-email groups, the CNC Team decided to use the OneResponse website¹⁶ as the official way of communicating with its partners, both nationally and globally. This was only possible because internet connection was fairly good and reliable. Maintaining an updated distribution list was seen as too time consuming and there was significant staff turnover in partner organisations. The Nutrition Cluster website acted as an accessible platform to share harmonised, up to date knowledge and information among partners (see Box 1). There was great effort on the part of the CNC Team to ensure that information on this site was useful.

It was particularly important to have a cluster IM specialist from the first day of the emergency. In a highly demanding working environment, a person solely dedicated to mapping out the '3 Ws (who, what, where)' and somebody who provides population estimates per area and calculations, for example, on how many children at risk in a given geographical area is invaluable. The work by the IM specialist was not only important for supply forecasting but through mapping activities, the CNC Team and Cluster partners were also able to identify gaps and organise the response accordingly (see Figure 1 for an example of a map).

Global and National Cluster Partnership

A strong GNC partnership and the engagement of the GNC Coordinator at the onset contributed significantly to the success of CNC Team in an emergency of this scale. The GNC provided a great resource and network to obtain expertise and support where needed. GNC Partners acted as colleagues and effectively offered their services leading to a constructive atmosphere, both nationally and globally, with collectively borne responsibility and positive outcomes.

Key Challenges

GNC and UNICEF HQ capacity

For the year preceding the Haiti emergency, the GNC did not have a dedicated full time GNC Coordinator but had relied on temporary coordinators to fill the gap. When the earthquake struck, the GNC had one half-time Cluster Officer (shared with another section in UNICEF but largely working full time for the GNC) and one part-time GNC Coordinator based in the UK. The GNC Team was, therefore, running at about one third of its required capacity. The GNC Coordinator quickly re-located to UNICEF HQ to work full time on the earthquake response but the team remained without the one full time Cluster Advisor position. UNICEF's HQ Nutrition Section was also without key people having one Senior Advisor covering Nutrition in Emergencies (NIE) but one unfilled NIE post.

The challenge of meeting the unusually high demands of the Haiti crisis on the global level was keenly felt within UNICEF in terms of its nutrition programming and in relation to its role as lead agency for the Nutrition Cluster and as the provider of last resort¹⁷. The earthquake highlighted bottlenecks in the UNICEF system with respect to these crucial areas of responsibility. However, within many UN and NGO agencies weaknesses surfaced, not least because of the unprecedented scale of the disaster.

At the regional level, UNICEF's NIE capacity and understanding of the Nutrition Cluster was low. This added to the demands on HQ for technical support and for staff deployment to the Dominican Republic - all at a time when demands in Haiti were already stretching UNICEF's capacity.

Linked to the capacity constraints is the fact that the GNC has been without operating funds since 2008 for staffing and for new areas of development. Examples of unfunded but important capacity building initiatives include the much awaited Nutrition Cluster Handbook for CNC Coordinators and partners¹⁸, the shortage of training opportunities in cluster coordination, and capacity development of regional and country level staff (including government) in NIE during 2009. Had funds been available, the GNC would have been fully staffed, the pool to draw on trained coordinators increased, capacity in the regions and country improved and a key tool for cluster coordination would have been available.

Also linked is the disproportionate amount of time the GNC staff had to spend on identifying and contracting staff and in navigating their way through the HR bureaucracy. In the first few weeks, it became clear that UNICEF needed to urgently re-establish the emergency HR section, which had recently been closed. Dedicated and highly experienced staff were reinstalled to speed up the recruitment and contracting process. Whilst the GNC Roster contributed to the identification of cluster coordination staff, there was still a disproportionate need to rely on the re-deployment of UNICEF staff from other needy countries for UNICEF programming and for cluster coordination. This left gaps in some countries losing key nutrition staff and again highlights the need for UNICEF and the GNC to increase resources and processes for surge capacity.

In the first month, the twelve person combined CNC Team/UNICEF international team had just four external staff and further expansion of the team continued to be made up largely of UNICEF staff. The CNC Coordinator opted to secure funding¹⁹ and hire qualified international staff from NGOs, expediting hiring procedures. Bringing in NGO staff proved to be an effective stop-gap measure for hiring staff quickly. Another advantage was inclusivity in showing that the Nutrition Cluster was not an exclusively UN concern.

The humanitarian needs in Haiti were tremendous, especially in relation to food, health, shelter and sanitation. The onset of the early rains in February added to the urgency to scale up of what was a slow response in many of the sectors as all struggled to overcome enormous operational challenges. For example, the general food distribution overseen by WFP that aimed to reach two million people, did not achieve coverage for some weeks. The quality of the ration (rice) was also poor, prompting the need for blanket supplementary feeding of children under five and other vulnerable groups.

A lack of implementing partners for programming was a key underlying constraint for many agencies. For nutrition, capacity for the treatment of SAM was particularly low²⁰. This was compounded by the lack of available nurses as many had died after the collapse of a central nursing school. It also proved hard to get French or Creole speaking nutrition experts and many in-country-nutrition staff (both national and international) who survived the earthquake, were deeply traumatised and were unable to work effectively while others left their posts to deal with personal matters arising from the earthquake.

Understanding the Cluster Approach

The Cluster approach was not fully understood in the early stages of the emergency by some of the HQ, regional or country staff. For example, UNICEF internal and external reporting and briefing documents did not clearly distinguish between cluster partner nutrition programmes and UNICEF's own nutrition programmes, and the differing roles and responsibilities of the coordinator and advisor were not readily distinguished. At country level, the CNC Coordinator was discouraged from reporting back during internal UNICEF meetings on cluster activities as these were not readily viewed as a UNICEF specific concern. Over time, however, these problems were resolved as awareness and understanding of the Nutrition Cluster increased.

An additional challenge was when the Nutrition Cluster focus in Haiti went beyond the mandate of UNICEF. The Nutrition Cluster identified the elderly as a particularly vulnerable group that falls firmly within the cluster's mandate. However, UNICEF's mandate which focuses on women and children conflicted with this and senior UNICEF staff in Haiti voiced resistance to the Nutrition Cluster providing programming to the elderly population. The Nutrition Cluster was required to advocate for the needs of the elderly to be incorporated in the FA to ensure that agencies with a mandate to meet their needs were able to access funds and thereby, avoid any potentially serious omissions for this group.

Flash Revisions

The FA revisions were intended to take account of new assessment information, agencies project proposals and a one year time horizon for programming. The work involved in overseeing the revisions, though a key and important function of the Cluster Coordinators, placed a considerable strain on the cluster, particularly at country level at that time in terms of managing the huge demands. As aptly stated by the CNC Coordinator, 'Time spent on the Flash Appeal text was time not spent on support to scaling up of life saving programmes'. In order to mitigate the potentially negative impact on country level activities, the global level took a central role in the FA revisions. A key constraint, however, was that although various assessments had been undertaken, reporting from these was very limited and so new information on needs was not readily available to inform the revisions.

Infant and Young Child Feeding

An unknown number of children had been separated from their parents and other infants had traumatised mothers that impacted their care practices. Unsolicited donations (e.g. powdered infant formula, milk powder, frozen donor breast milk) entered or were about to enter Haiti. Some organisations initiated or accepted donations based on lack of knowledge, responses to 'dying babies' alerts (army, individual well wishers, US congress men, etc) whilst others were influenced by media pressure to engage in action - particularly visible activities such as handing out infant formula. The CNC Team regularly heard reports of organisations randomly distributing infant formula and the International Code on Marketing of Breast Milk Substitutes was often breached. It took an estimated 25 percent of the CNC Coordinator's time to try to control unsolicited goods.

Assessment of need for artificial feeding proved extremely difficult due to lack of data on which to base case estimates. For example, some infants housed in orphanages were not 'true' orphans but had families. The lack of detailed programming guidance on how to manage artificial feeding in an emergency and the remit of breastfeeding support units, e.g. 'baby tents', meant that the CNC team and partners had to work from scratch to develop terms of reference, supply chain management, monitoring tools, etc. This concerted effort by those on the ground led to a rapid technical response, and significant developments in IFE programming and learning as a result²¹. However, the inadequacies of the general food ration were a major concern, to the degree that staff found it difficult to counsel on optimal infant and young child feeding practices when mothers were reporting their ongoing lack of food. The Operational Guidance on IFE emphasises the need for basic cross-sectoral interventions to accompany IFE - adequate food, shelter, security, WASH, cooking equipment for families with children under 2 years. Without these, technical interventions on IFE are undermined. The Haiti response really 'stepped up' in terms of technical interventions, both on skilled breastfeeding protection and support and interventions to minimise artificial feeding risk. The Haiti experience indicates that concerted effort is now needed to establish how to ensure that basic needs are met in future emergencies.

Many houses were perched on hillsides in Port au Prince

The CNC Team used the JS with the MoH, issued national press releases and recommendations for customs clearance texts in order to reduce the risks and damage done by those importing the breast milk substitutes. The Associated Press and Reuters were used to convey messages to the international humanitarian forum and subsequently, naming and shaming of those that breached the Code. The CNC Team did, to a certain extent, correct malpractice concerning IFE but it was highly labour and time intensive. Also lacking, was the ability to quickly adapt global guidance such as the JS in a more accessible format for those working on the ground and ultimately making the key decisions.

Apart from the nutrition sector, one aggravating factor was that infant feeding is generally not appreciated as a consideration in the general emergency response. Because of this, the protection, promotion and support of appropriate infant feeding practices is often not prioritised in other sectors or integrated within programmes, e.g. offering/ referral for breastfeeding support to mothers undergoing trauma surgery who have young infants. Whilst many deaths had been counted in Haiti and patients in need of operative care had been treated, appropriate feeding of infants is a life saving activity that needs protection and support across sectors and at many levels.

Supplies constraints

The nutrition supply pipeline from UNICEF in Haiti was complex and the system did not function well. Changes to the nutrition supply lists were made at higher organisational levels including HQ and the regional office, over-ruling decisions made by nutritionists at field level which created confusion, delay and tensions. UNICEF nutritionists did their utmost to start mapping out the availability of supplies and forthcoming needs as early as possible, especially because scaling up of programmes was envisaged. However, the biggest weakness was on coordination of the logistics chain and subsequently UNICEF was unable to move supplies from well stocked warehouses to the field in a timely manner at the beginning.

Future Action Points

UNICEF and the Nutrition Cluster donors need to carefully consider the human, financial and institutional resource requirements that are necessary for UNICEF to fully realise its mandate as the Nutrition Cluster lead agency and as provider of last resort for NIE. The Haiti crisis has highlighted significant gaps that place the Nutrition Cluster at risk of not fulfilling the stated aims of humanitarian reform.

The substantial bottlenecks felt in the early stages of the crisis underscore an urgent need for the GNC and UNICEF to consider institutional contracts/ Memoranda of Understanding with key nutrition technical agencies that can deploy at short notice and provide the needed surge capacity in key areas such as IFE, CMAM, IM and for UNICEF programmes. It would have been more effective to expand the CNC Team with externally recruited staff as far as possible, to avoid the risk of 'depleting' other countries and regions of key staff. The secondment of the FANTA IFE/CMAM specialist to the CNC enabled the cluster to have this key person in country very quickly and provides one option for the future for UNICEF and the GNC to explore the creation of a more effective surge capacity. Surge capacity is a priority area previously identified by the GNC which requires financial resources from the Nutrition Cluster donors.

The necessity of revising the FAs so soon after the initial Flash is questionable given the lack of new information on assessment of needs and the pressure all staff were under trying to recruit, plan, coordinate and respond on a massive scale.

In order to reduce breaching of the Code and uphold the provisions of the Operational Guidance on IFE, a stronger stand (inter)nationally is needed prior to and during emergencies. Within the IFE Core Group and collaborators, much effort has been put into realising technical interventions on IFE in emergencies. There is much to learn from the Haiti response in this regard. Furthermore, any evaluation of the IFE response in Haiti should include whether the basic needs of mothers and children were met. The experiences reflected here indicate that meeting these basic needs in emergencies requires particular attention and should become a priority focus of the IFE Core Group. It is also important to consider whether there was an opportunity cost given considerable time and resources spent by agency country and international staff in dealing with issues around infant formula for the minority of infants. Consideration also needs to be given by UNICEF and WHO to RTUIF as a generic commodity and possibly, as a 'borderline' substance on an essential drug list, for example, and mechanisms by which this could be managed.

The understanding of the Nutrition Cluster and UNICEF's accountabilities in fulfilling its mandate as the lead agency and the provider of last resort for Nutrition at HQ, Regional and Country level needs strengthening and there is a pressing need for the GNC to focus on building understanding and capacity for cluster coordination at all these levels. Priority must be given to an orientation on the Cluster Approach and the Cluster responsibilities for UNICEF HQ level staff as much can be gained by improving communication to bring about much greater clarity and appreciation of the roles and functions of the Cluster. In addition, training on Cluster roles and responsibilities and in particular, on coordination will be needed for UNICEF staff at regional and country level with priority given to disaster prone countries and regions. Cluster coordinator training should also be re-established to expand the GNC Roster and thereby, increase the pool of potential coordinators (UNICEF and non- UNICEF) for short and medium term cluster related deployment. This too requires donors to provide adequate resources.

Lastly, it is evident that reliable donor support to fund (nutrition) Cluster positions is of utmost importance to help ensure a timely and coordinated response at country and global level. The Haiti experience clearly shows what can be achieved where dedicated cluster teams are actively coordinating emergency nutrition response.

For more information, contact: Carmel Dolan at cmadolan@aol.com and Mija Ververs at mijaververs@hotmail.com

¹Revised FLASH Appeal 18 February 2010, Office for the Coordination of Humanitarian Affairs (OCHA).

²At a glance: Haiti - statistics, UNICEF. http://www.unicef.org/infobycountry/haiti_statistics.html#64

³Nutrition Cluster update - Haiti, 4 February 2010. See Haiti section of http://www.oneresponse.info

⁴Water, sanitation and hygiene

⁵GNC partner agencies involved in the telecoms were Action Against Hunger Alliance, Center for Disease Control (CDC), Concern Worldwide, CARE USA, Emergency Nutrition Network (ENN), International Medical Corps, Institute of Child Health/UK, Merlin, Oxfam UK, Save the Children Alliance, Standing Committee on Nutrition (SCN), Tufts University Feinstein International Center, UNHCR, UNICEF, Office of Foreign Disaster Assistance (OFDA)/USAID, Valid International, WFP, WHO, World Vision. Médecins Sans Frontières - France

⁶See Haiti section of www.oneresponse.info for meeting minutes.

⁷An informal interagency collaboration concerned with developing policy guidance, capacity building on IFE. Coordinated by the ENN, members are UNICEF, WHO, UNHCR, WFP, IBFAN-GIFA, CARE USA, SC UK, SC US, Concern, and associate member Fondation Tdh. www.ennonline.net/ife

⁸This in turn had been based on a model joint statement produced in a collaborative effort by participants in a regional workshop on IFE in Bali 2008

⁹Available at http://www.ennonline.net/resources/738

¹⁰Non-breastfed infants with no potential to breastfeed were considered most urgently in need of identification and support. Artificially fed infants who were also breastfeeding may need artificial feeding support in the immediate term but re-establishing full breastfeeding would be supported as a preferable less risky option.

¹¹Office for US Foreign Disaster Assistance

¹²Since the Haiti response, an evaluation of the use of RTUIF is being planned by global and country cluster partner agencies, focused especially on the first two months. An addendum to the Operational Guidance on IFE (2007) around provision of BMS has been agreed by the IFE Core Group in collaboration with UNICEF programming and cluster leads. This has been informed by Philippines and Haiti experiences especially (see news item, this issue of Field Exchange).

¹³There were also considerable demands for HR for the Dominican Republic to provide cluster coordination for the programming for populations displaced at the border as well as within the Dominican Republic.

¹⁴The tasks varied over time and was dependant on the emergency phase and the available expertise within Unicef that complemented the NCC Team.

¹⁵This person was employed to engage half in Nutrition Sub- Cluster work, half in UNICEF's nutritional programme activities.

¹⁶http://oneresponse.info/Disasters/Haiti/Nutrition/Pages

¹⁷Other Nutrition Section staff rallied to support the response from HQ and this undoubtedly helped to fill a significant gap.

¹⁸This would contain key tools for the CNC Team such as examples of press releases, joint statements on specific pressing issues, generic job descriptions for national and international cluster staff, examples of nutrition strategies, etc

¹⁹This funding came from the Emergency Relief Response Fund (ERRF) from OCHA in Haiti.

²⁰There was a good national treatment protocol in draft form and a national training on CMAM was planned to take place on 18 January 2010, 6 days after the earth quake struck.

²¹ACF and Concern's existing baby tents helped to guide other NGOs in implementing similar programme initiatives.