Nutrition security emergency programming in diverse urban contexts

By Marie Sardier, Joanna Friedman, Maureen Gallagher and Julien Jacob

Marie Sardier is Food Security and Livelihoods Advisor with Action contre la Faim (ACF) in Paris

Joanna Friedman is Food Security and Livelihoods Advisor with ACF in New York.

Maureen Gallagher is Senior Nutrition Advisor with ACF in New York.

Julien Jacob is Senior Food Security and Livelihoods Advisor with ACF in Madrid.

The authors wish to acknowledge the work of the ACF country programmes featured in this article: Haiti, Democratic Republic of the Congo (DRC), the Philippines, and Ivory Coast.

The past decade has witnessed an increased volume of humanitarian programme implementation in urban environments, and Action Contre la Faim (ACF), has been a key player adapting to this trend. Since 2004, ACF has launched an increasing number of urban programmes globally, including nutrition prevention and treatment, food security and livelihoods (FSL), water, sanitation and hygiene (WASH), and care practices components with an overarching goal of nutrition security¹. The question for humanitarian actors is no longer whether we should intervene in urban contexts, but how we can do it better.

By 2050, 66% of the population in developing countries will live in urban areas. According to the Population Division of the UN DESA (Department of Economic and Social Affairs), the majority of the urban population live in slums². Here, people live in hazardous and volatile environments that are likely to degenerate and become full scale disasters as a result of additional complex environmental and political events³. ACF and other humanitarian actors have encountered new challenges in humanitarian emergencies in urban contexts that require further analysis in order to improve the pertinence and the quality of response, and ACF has developed a specific guide for identifying vulnerable people in urban settings⁴. The underlying vulnerabilities in urban contexts and the persistent nature of malnutrition, food insecurity and public health hazards can often constitute a ‘perfect storm’ that goes beyond humanitarian agencies’ operational capacity in an emergency response setting, touching on structural and policy issues of urban planning, public health infrastructure, urban migration and national politics.

Urbanisation increasingly shapes vulnerabilities, risks, and potential responses. Indeed, urban humanitarian emergencies are commonly seen as the result of a trigger event such as an earthquake or a violence outbreak, combined with the population’s underlying vulnerability to that event. Because of population density, chronic poverty and proximity to economic centres, urban settings may experience greater scale of disaster than rural areas in terms of public health and livelihoods consequences.

According to ALNAP, there are "a number of elements that would appear to be specific to urban disasters, most of which are related to the nature of cities and the nature of urban vulnerability. These fall into three broad categories of density, diversity and dynamics⁵." In its lessons for urban contexts, ALNAP has specifically highlighted the use of cash-based interventions and working with local private sector and market actors as key to the design and implementation of urban emergency response⁶. ACF case studies demonstrate that for humanitarian emergency response in urban areas, cash-based interventions (CBIs), encompassing a wide range of activities and delivery mechanisms, are highly relevant for immediate improvements in nutrition security. They also demonstrate that a greater density of population, civil society, private sector and humanitarian actors, along with greater proximity to government power brokers, can provide both increased opportunities and challenges for emergency response compared to rural contexts.

This paper will describe the challenges ACF has faced in four urban areas, with crises ranging from large-scale disaster to complex emergency to prolonged emergency levels of malnutrition. These food and nutrition security programmes took place in the Philippines, Ivory Coast, Haiti, and the Democratic Republic of Congo (DRC). The examples point to the relevance of CBIs, including debit cards, mobile phone transfers and cash vouchers in urban contexts, where flexibility and market linkages are key to improving food security and nutritional status and contributing to early recovery.

ACF urban programmes

Fresh food vouchers to prevent malnutrition in a rapid onset disaster in Port au Prince, Haiti (2010-2011)

In response to the January 2010 devastating earthquake in Haïti, ACF implemented a range of emergency activities in Port-au-Prince⁷ and Gonaïves including a pilot fresh food vouchers project to complement other food assistance and nutrition interventions.

ACF conducted a rapid market assessment in its area of operation, which indicated that staple and fresh products were locally available but inaccessible to the most vulnerable populations due to high food prices. ACF found that the use of vouchers, rather than an in-kind distribution of imported food, was the most appropriate response to improve vulnerable households’ access to a nutritious diet while supporting local vendors. Physical access to markets and a surfeit of payment institutions were also key factors in the decision to provide voucher-based assistance.

Two years following the earthquake, households in Port-au-Prince had not fully recovered. Their resilience to shocks and their food and nutrition situation was still severely eroded and food prices remained high. ACF began a voucher programme, in the form of a safety net, first in the north of the country, then in Port-au-Prince, aimed at restoring food security for vulnerable households and improving their nutritional status. By ensuring access to fresh and staple food through local markets, ACF supported the local economy to strengthen livelihoods recovery and to improve households’ access to a diversified diet. Overall, 4,500 families and 300 small traders benefited from the project. The possibility for families to purchase food with the vouchers allowed them to reimburse an average of 25% of their debt and to pay for school fees. Ninety per cent of traders assert that they had more benefits than before the programme. However, despite a temporary partnership with SogeXpress bank to reimburse traders and short-term benefits in improving diet diversity, the lack of long-term work with local civil society partners prevented the programme from having a long-term impact.

Nutrition and food security support for people living with HIV/AIDS in Kinshasa, DRC (2009-2013)

ACF used a similar approach of delivering vouchers for fresh food to improve dietary diversity and nutritional status and support local markets in Kinshasa, DRC beginning in 2009. In urban Kinshasa, chronic poverty and hunger persists far from the conflict-affected Eastern provinces but stemming from the same state failure to provide essential services and safety nets to the population. This crisis disproportionately affects the most vulnerable, including people living with HIV/AIDS (PLWHA) and their family members. The first evaluation of the programme in 2009-10 highlighted the fact that HIV/AIDS was a growing public health issue in Kinshasa due to the inadequate nature of health facilities, increasing prostitution levels and an already fragile socio-economic urban backdrop⁸.

In urban areas, households may have less opportunity to depend on the solidarity of family or other social networks as they might in villages. One of the major coping strategies identified amongst PLWHA households was up to a 40% reduction in food consumption, according to WFP⁹. Malnutrition is one of the main causes of global mortality amongst PLWHA, as it renders the immune system more susceptible to opportunistic diseases that can be fatal. Appropriate nutrition is essential to strengthen the immune system and to reinforce the efficacy of anti-retro viral treatment (ART), in order to prolong the lives of PLWHA and to prevent mother-to-child transmission of HIV/AIDS.

ACF thus initiated and continues to support a programme on nutrition, food security and livelihoods in Kinshasa since 2009, which includes the following key components:

• Treatment for severely acutely malnourished (SAM) children and adults, with ready-to-use therapeutic foods (RUTF).
• Treatment for moderately acutely malnourished (MAM) children and adults through fresh food vouchers supporting PLWHA as both clients and vendors. The voucher values were developed based an analysis of nutritional value and cost of a locally-appropriate food basket.
• Income generation activities for households of PLWHA whose members are discharged from MAM treatment, who host orphans and vulnerable children, and/or the income-poor who lack requisite purchasing power for a complete, nutritious food basket in urban markets.
• Provision of water filters to households receiving nutritional treatment, with priority given to households with infants and SAM cases.

Similar to the Port-au-Prince voucher scheme that was eventually integrated into a safety nets approach, the Kinshasa programme seeks to provide a continuum of care from treatment to self-sufficiency, whereby PLWHA and their families can maintain their health after malnutrition treatment has ended. The fresh food voucher approach led to weight gain in PLWHA, showing the relevance of this delivery mechanism in an urban setting. Income generation activities supported PLWHA both as clients and vendors, contributing simultaneously to the food security and livelihoods of this vulnerable group.

Vouchers for flood relief and pilot debit card intervention in Cotobato city and Sultan Kudarat, ARMM (Mindanao), the Philippines (2011)

In response to rapid-onset floods from the Rio Grande de Mindanao in the Philippines, ACF implemented a cash-based intervention in Cotabato City¹⁰ and Sultan Kudarat, in the region of Mindanao in June 2011. As in Haiti and DRC, ACF decided to use vouchers in order to focus its assistance to flood-affected households on both food and non-food items with light conditionality¹¹. In this case, local supermarkets served as vendors. The programme also piloted the first humanitarian use of electronic debit cards in the Philippines for 305 of the families.

ACF’s rapid assessments from June 2011 showed that overcrowding at Evacuation Centres (ECs) had caused a rapid deterioration in conditions. Early assessments showed that in-kind food aid from the government was insufficient in quality and quantity, and internally displaced persons’ (IDPs) purchasing power had been negatively affected by the floods. Many IDPs were selling assets they had salvaged during evacuation in order to buy supplementary foods. The state of local markets presented opportunities that supported the use of a CBI to respond to people’s immediate needs. Market assessments found that prices of staple commodities were relatively stable. Supermarkets were still conducting business as their supply chains had not been interrupted and their locations were unaffected by floods. Of the 35 ECs in Cotabato City, 25 were located within 1-2 kilometres of these markets and were accessible by public transportation or by walking.

Overall, beneficiaries found CBI to be a more effective mechanism than in-kind interventions due to the flexibility it gave them to cover their needs. There were advantages to the use of debit cards for both staff and beneficiaries: distribution only occurred once as card ‘reloading’ happened electronically, and beneficiaries could shop multiple times at their discretion. Implementing a CBI also alleviated local cultural apprehensions about the use of cash and demonstrated that vouchers or cash were an appropriate response, despite high local political tensions between the national government and the Moro Islamic Liberation Front in the area.

See field article in this issue of Field Exchange that elaborates further on the experiences from the Philippines.

Unconditional Cash Transfer (UCT) by mobile phone to increase food security and protect livelihoods in a post conflict context in Abidjan, Ivory Coast (2011)

A similar approach using new technologies was used in 2011 in Ivory Coast, where ACF piloted the first humanitarian use of transfers via mobile phones in the country, in Abidjan, following the violence that erupted after the November 2010 elections. Insecurity and violence led to an increase in staple food prices and worsened already high food insecurity levels. Combined with the reduced availability of health services, the people of Ivory Coast were facing a rapid decline in nutritional status¹².

In this context, the project established a cash transfer programme via mobile phones, to provide poorest households in two of the most affected neighbourhoods with essential food items. By June 2011, WFP decided to pursue this type of intervention because civil security had improved in the highly impacted neighbourhood of Abobo and Yopougon in Abidjan. Markets then had adequate supplies of basic commodities and stable prices but many people had lost their source of income and lacked purchasing power. WFP selected ACF as its operational partner and the mobile phone service provider MTN as a partner for distributing the cash.

A total 10,800 households received assistance via mobile phone SIM cards. Households headed by women, with children under 5 years, dependent on community assistance, with a nursing and/or pregnant woman, with disabled and/or elderly person(s), or affected by HIV/AIDs were prioritised in targeting. Each household received 33,000 CFA franc once a month for three months. The advantages of transfer via a SIM card were found to be rapid and secure transfers, capacity for multiple withdrawals in varying amounts, mobile phones can be used directly to pay for commodities and services, and aid agency can send SMS messages to beneficiaries to spread information and increase awareness about the programme and other initiatives (e.g. health/nutrition information).

Improving nutrition security in emergencies: opportunities and challenges of the urban context

In the examples presented above, and in urban contexts in general, the complexity of the response is exacerbated by two main features: population density and the complexity of the environment (physical, social, political, economic) as laid out in a 2009 ALNAP paper¹³. In these contexts, cash-based interventions in various forms proved to be timely, appropriate, and flexible. The density, diversity and dynamics of urban areas may vary, but ACF’s work in the Caribbean, Latin America, Africa and Asia has shown that CBI such as fresh food vouchers, mobile transfers and SMS messaging, debit card transfers, and income generation activities can contribute to food security and nutrition outcomes early on in emergency response, while also contributing to longer term recovery and maintenance of health and livelihoods.

In all four cases highlighted in this paper, and in urban contexts more generally, people access food through purchase in their local markets. Cash-based rather than in-kind assistance is thus particularly relevant for urban contexts, and can be prioritised as long as markets are functioning and other important criteria are met¹⁴. In the Kinshasa programme, nutritionally at-risk households were both clients and vendors, and food vouchers as well income generation support were able to contribute to both food security and longer-term livelihoods recovery. Similarly in the Abidjan programme, four categories of spending accounted for 80% of total reported spending and contributed to both immediate food security and longer-term activities (41% reported spending on food, 23% on income generation activities, 8% on education and 7% on health)¹⁵.

Urban areas are physically dense and socially dynamic, which can sometimes pose a challenge for targeting and partnering, but they also provide relatively easy physical access to markets and a greater access to financial service providers and payment institutions than a village might. Hundreds of thousands or even millions of people may be affected by a shock, but density can also broaden the opportunity to reach more people faster after an emergency. This is particularly true, as ACF found in the Philippines and Ivory Coast, when remote payment and communication mechanisms such as text messaging, electronic transfers and mobile phone banking are used. Population density also provides incentive for mobile and internet companies to scale up network access, and crowdsourcing¹⁶ for new electronic and mobile products and services. Crowdsourcing can also be used to spread nutrition and public-health awareness messaging and to improve financial literacy.

CBIs in urban areas can also contribute to livelihoods recovery rather quickly. This is quite different from experiences in rural areas in general and agro-pastoralist zones in particular, where livelihoods recovery may take years or be impossible, e.g. due to environmental change. Typically, urban cash-based livelihoods activities can get a quick boost from CBIs. CBIs and support for local markets can help provide a continuum of care, moving from immediate nutrition and food security assistance to livelihoods recovery and resilience within the same programmes, sometimes within an emergency timeframe.

The challenge of urban density, however, is often linked to its diversity and dynamics¹⁷. Urban populations are often more diverse than rural populations within fairly small geographical areas. A challenge that arose, particularly in Port au Prince, Abidjan and Kinshasa, was to target the ‘right’ beneficiaries¹⁸. ACF has developed vulnerability identification guidelines for urban settings¹⁹ and these were used and improved upon in Abidjan and Port au Prince.

In Abidjan, after geographical targeting, ACF conducted a house-to-house survey using standard food security indicators. A large survey team was able to go through 10 neighbourhoods in 2.5 weeks, registering everyone they could find and completing a list of beneficiaries three weeks from the start, with rolling data entry. This was as quick a method as community-based targeting mechanisms, yet better fitted to the political complexity of the situation. Surveyors would not make targeting decisions in the field, partly to avoid bias and partly for their own safety. They covered around 25,000 households and subsequently selected 10,800.

In Port-au-Prince, ACF developed a scorecard that would be used for practical targeting by collecting data on socio-economic status measured by income, and running regressions to identify simple and easily collected and verifiable indicators that correlated with income. The methodology used to create the score-cards revealed issues specific to urban targeting; people were in general less worried about their absolute level of income than about the reliability and regularity of that income. This makes sense in areas where households rely on the market for all essential items. Households differentiated between regular and occasional small business for the same reason. Commonly-used indicators, such as the dependency-ratio, turned out not to be relevant, while specific indicators, such as not eating chicken on a Sunday, were very relevant. The implication is that more generic poverty scorecard measures would not have been sufficient; the Port-au-Prince scorecard was highly context specific. In general, the scorecard was felt to be effective and was used by other organisations as well.

The urban environment offers greater proximity to national policymakers. In the DRC, ACF contributed to the development of a HIV/AIDS nutritional treatment protocol to address the lack of policy framework on HIV/AIDS and public health. ACF also works in collaboration with the DRC health sector and partners who provide ARVs and psychosocial support to PLWHA and their families. Integration of CBIs into social policies may prove more challenging, considering government buy in and financing challenges. In Kinshasa, coordination was very positive with other partners supporting interventions for PLWHA, yet more challenging with health authorities than in rural areas. Nonetheless, proximity and access to high-level decision-makers may prove an opportunity to work towards increased government capacity to deliver social protection schemes and implement better policies for nutrition and food security.

Civil society can be more established than in rural areas, giving humanitarian actors the opportunity to work through existing structures to respond and hand over to communities more quickly. ACF has worked closely with civil society partners in Kinshasa since 2009, training them to identify malnourished PLWHA and refer them for treatment. As the programme continued over two years, more emphasis was placed on the responsibility of existing national structures to take over and manage rather than simply engage in the referral and treatment activities. Civil society can also, however, conceal entrenched power structures and figures that may resist humanitarian selection criteria and even retaliate against humanitarian actors who do not provide support to their constituents. ACF staff had to deal firmly yet diplomatically with various non-state actors in Port-au-Prince.

There may be a higher number of partners in an urban rather than a rural emergency. This can result in a setting of coordinated interventions addressing food, health and nutrition issues to contribute to nutrition security, but it can also add to confusion and duplication. In Port au Prince and Abidjan, which were large-scale emergency responses, coordination with other local or international humanitarian actors and partners proved challenging. There, the multiplicity of government actors, and the often weak accountability processes that bind them, complicated coordination mechanisms. In Haïti, for instance, efforts to set up a decentralised disaster-risk-reduction committee to prepare for further disasters were hampered by this complexity and by lack of capacity. In Abidjan, on the other hand, laudable efforts at coordination with other agencies, as well as with the Préfecture and Mairie, proved that we could avoid duplication through agreed geographic targeting, beneficiary-list-sharing, and harmonisation of rates.

An analysis of these four programmes, therefore, demonstrates that urban diversity, dynamics, and population density often create a challenging context for emergency programme implementation, especially with regards to coordination (with the government, with civil society, among agencies), and to targeting. They can also, however, provide increased opportunities for emergency response. In contexts such as those described above, where urbanisation increasingly shapes vulnerabilities, risks, and potential responses, the four programmes demonstrate that thanks to their flexibility, CBIs appear most relevant to respond to the diversity of people’s needs. Where flexibility and market linkages are crucial to improving food security and nutritional status, they can indeed contribute to food security and nutrition outcomes rapidly and at scale in emergency response, while also contributing to longer term recovery and maintenance of health and livelihoods.

For more information, contact: Marie Sardier, email: msardier@actioncontrelafaim.org, Joanna Friedman, email: jfriedman@actionagainsthunger.org, Maureen Gallagher, email: mgallagher@actionagainsthunger.org and Julien Jacob, email: jjacob@achesp.org

¹Nutrition security exists when all people/household members, at all times, have physical, social and economic access to sufficient, safe and nutritious food that meets their dietary needs and food preferences, combined with a sanitary environment, adequate health services, and proper care and feeding practices to ensure an active and healthy life for all people/household members. ACF has carried out or currently implements urban programmes in Kabul, Afghanistan (since 2004); Monrovia, Liberia (2005); Gonaïves (2005) and Port au Price, Haïti; San Pedro (2007) and Abidjan, Ivory Coast; and since then also in Bangui, Central African Republic; Ouagadougou, Burkina Faso; Conakry, Guinea; Freetown, Sierra Leone ; Gaza, oPt; Djibouti; Nakuru, Kenya; Mogadishu, Somalia; Cotabato City, Philippines; Bamako, Mali; Ulaanbaatar, Mongolia; Kinshasa, Democratic Republic of Congo.

²World Urbanisation Prospects: The 2009 Revision, Highlights; ESA/P/WP/215, United Nations Department of Economics and Social Affairs/Population Division 3, March 2010.

³Humanitarian Action in Urban contexts, HPN N° 35, November 2006.

⁴See news pieces in this edition of Field Exchange, The guidance is available at: http://www.actionagainsthunger..org/sites/default/files/publications/2010_acf_identifi
cation_of_vulnerable_people_in_urban_environments_guideline_en.pdf

⁵Ramalingam, Ben and Paul Knox-Clarke. Meeting the Urban Challenge: Adapting Humanitarian Efforts to an Urban World, ALNAP, July 2012.

⁶Sanderson, David and Paul Knox-Clarke. Responding To Urban Disasters: Learning From Previous Relief And Recovery Operations, November 2012. See news piece in this issue of Field Exchange.

⁷The population of Port au Prince was 704,776 in 2003, and was officially projected to have reached 897,859 in 2009. Unofficial estimates, however, put the city and its surrounding areas’ at two million inhabitants in the late 1990s, reaching 3.6 million inhabitants in 2010.

⁸Evaluation report on the impact of the income generation component of the HIV project, ACF 2009.

⁹Feasibility study for HIV/AIDS project, ACF 2010.

¹⁰Cotabato's population was about 271,786 in the 2010 census; it is bounded by the municipality of Sultan Kudarat to the north, which has a population of about 94,861 people.

¹¹Vouchers may only be exchanged with vendors identified by and linked to ACF for the purposes of a project, and in some cases they may only be valid for the purchase of a specific range of items at those vendors. This means that beneficiaries have less flexibility on their purchases than they would with an unconditional cash grant, but a great deal more flexibility than through an in-kind kit distribution.

¹²In the capital, this turmoil was taking place in the second largest city in West Africa. According to the national census, there were 5,068,858 inhabitants in the metropolitan area of Abidjan in 2006, and 3,796,677 in the municipality per se. UN world Urbanisation Prospects estimate for 2007, UN 2011 (Archived from the original on 27 April 2011).

¹³O’Donnell, Ian and Kristin Smart with Ben Ramalingam. Responding to urban disasters: Learning from previous relief and recovery operations. ALNAP Lessons Learnt, July 2009.

¹⁴See the CaLP toolkit on Cash Transfer Programming in Urban Emergencies, among others: http://www.cashlearning.org/resources/library/251-cash-transfer-programming-in-urbanemergencies-a-toolkit-for-practitioners?keywords=Tools

¹⁵WFP/ACF Unconditional Mobile Cash Transfer in Abidjan, Ivory Coast. External Evaluation. March 2012

¹⁶Crowdsourcing is the practice of obtaining needed services, ideas, or content by soliciting contributions from a large group of people, especially common with online communities.

¹⁷O’Donnell, Ian and Kristin Smart with Ben Ramalingam. Responding to urban disasters: Learning from previous relief and recovery operations. ALNAP Lessons Learnt, July 2009.

¹⁸There is no single approach to targeting criteria in urban areas and no best practice on whether to select the most affected by a disaster, poorest, most vulnerable to a future disaster, or households in certain categories. This is highly context-specific.

¹⁹Identification of Vulnerable People in Urban Environments: Assessments of Sustainable Livelihoods and UrbanVulnerabilities. ACF, 2010. See news piece in this issue of Field Exchange.