ENN’s perspective on the nutrition response in the Syria crisis
By Carmel Dolan, Marie McGrath and Jeremy Shoham
Unless otherwise stated, referenced articles feature in Field Exchange 48.
While the ENN’s role is first and foremost to capture programming experiences and lesson learning (and we hope we have done this successfully), it is perhaps inevitable that the ENN team would make observations and therefore formulate views about the response from a nutrition perspective. Given the sheer amount of content generated across a breadth of programming and contexts, our observations go beyond a typical editorial and we have taken the liberty to write this views piece. In it we share our perspective on what we have observed regarding programming experiences and the related institutional architecture and challenges involved in coordinating the response.
It is hoped that our reflections will contribute to collective learning and may help inform the ongoing response in Syria, as well as future programming in similar contexts. However, it should be stressed that this is not an evaluation or review by the ENN. Rather, this views piece is a convergence of perspectives amongst the ENN team who visited the region as we reflected on what we were hearing and reading, and as themes and patterns began to emerge. In order to bring coherence to our views, a guiding question we have posed has been ‘how effective has the humanitarian sector been in addressing the nutrition needs of those affected by the Syria crisis?’ We have largely considered this on a technical and programmatic level although perhaps inevitably issues that have underpinned and shaped the response, e.g. analytical capacity, leadership and coordination, have emerged as critical factors for consideration.
Overview
The Syria crisis has resulted in an unprecedented number of refugees and displaced people in need of food, health, shelter, protection and other basic services. The refugee hosting Governments of Jordan, Lebanon, Turkey, Egypt and Iraq1 with the support of the traditional and non-traditional2 humanitarian community, have been meeting these needs with an enormously impressive programme of support. At the time of writing (September 2014), these host Governments continue to support 3,030,653 million Syrian ‘people of concern’ (2,998, 118 registered refugees) at an estimated annual cost to these governments of over $3.7 billion3. In Lebanon and Jordan, the government policy is to facilitate integration of the Syrian refugee population into the host population or into informal tented settlements (ITS). In Turkey, the government’s policy has seen 220,240 Syrians hosted in 17 camps, and 623, 385 Syrians settled amongst the host community4. Within Syria, the humanitarian community is responding to the needs of the internally displaced either from the capital Damascus or through cross border operations implemented largely from southern Turkey and Jordan. The combination of displaced and refugee populations makes the Syria situation the largest crisis of its kind in living memory and the largest refugee crisis in UNHCR’s 64 year history. Another feature of the crisis has been the transition from early blanket food aid distributions to a highly targeted, organised and unprecedented humanitarian cash and voucher programme, meeting food, health, shelter, livelihoods and non-food needs.
To date, the overall refugee response seems to have successfully averted a nutritional crisis in spite of the unprecedented scale of this emergency and the challenging context, including the dispersed nature of the population and difficulty of providing services to large non-camp as well as camp dwelling populations. Prevalence of acute malnutrition is low in Jordan and Lebanon and as implied by the lack of nutrition survey data from Turkey, is not considered an issue amongst the refugees hosted there. Due to access constraints, up to date, representative nutrition data from within Syria are not available and therefore, the picture in Syria is less clear. However, following a number of pilots, great efforts are underway to establish credible nutrition surveillance systems in key conflict affected governorates5. It is hoped that this initiative will rapidly fill the nutrition data gap in.
The nutrition sector’s response: treatment of acute malnutrition and infant and young child feeding (IYCF)
The profile of collated nutrition articles in this edition of Field Exchange demonstrates that the nutrition sector identified and focused on two main programming areas: establishing capacity for the treatment of acute malnutrition in children (particularly in Lebanon and Jordan) and support for IYCF, in particular, breastfeeding support. Whilst nutrition activities in Syria also have heavy emphasis on acute malnutrition treatment and breastfeeding support, there is “equal importance” given to preventive measures in evolving programming, such as micronutrient supplementation.6
Treatment of the acute malnutrition
Pre crisis, the nutrition situation is Syria was defined as ‘poor’ with global acute malnutrition (GAM) prevalence reported at 9.3%, stunting at 23%7 and under-fives anaemia at 29.2%8. In late 2012, an initial nutrition survey of Syrian refugees in Lebanon and Jordan indicated a low prevalence of GAM: (4.4% in Lebanon; Jordan, 5.1% in the non-camp population and 5.8% in Za’atari camp). The continued influx of refugees, poor living conditions in the ITSs in Lebanon, low breastfeeding rates and the widespread use of infant formula in the host and refugee populations, combined with anecdotal reports of acute malnourished children, led to increasing concerns amongst the nutrition community about threats to nutritional status9. Furthermore, whilst the recorded prevalence were ‘acceptable’ in global terms, to national representatives, any cases of acute malnutrition were unacceptable in this context10. These factors prompted the decision by UNICEF and a number of non-governmental organisations (NGOs) to scale up treatment programmes in Lebanon (such as described by International Orthodox Christian Charities (IOCC)11 and Relief International12) and in Jordan (such as implemented by Medair13, Jordan Health Aid Society (JHAS)14 and Save the Children Jordan15). As neither country had prior experience of implementing treatment programmes, considerable investment was made in building national capacity16 and in training initiatives17. These experiences are featured in a number of interesting articles, many that worked to integrate scute malnutrition treatment in the healthcare systems in Jordan and Lebanon. A similar scale up has not been seen in the Turkey Government led response.
A subsequent cross-sectional cluster survey in Lebanon in 2014 appeared initially to confirm the fears of an impending nutrition crisis, with the prevalence of GAM increasing from 4.4% to 5.9% in Lebanon and to just under 9% in the Bekka Valley where a substantial proportion of refugees resided However, the anticipated case load from this prevalence estimate was not being seen in screening activities in Lebanon or Jordan18 or found in other assessments19. Furthermore, the few cases that were detected often had pre-existing co-morbidities20. Increasing uncertainty about the reliability of the Lebanon survey data, led to UNICEF requesting CDC21 to carry out a re-analysis of the data in 2013. This revealed that there had been some data manipulation regarding height measures22 and resulted in a readjustment of GAM prevalence to just 2.2% (0.4% SAM). Doubts have also been cast about the validity of the earlier Lebanon 2012 survey and Jordan 2012 nutrition survey23, fuelled by the recent UNHCR survey in Jordan in 2014, which suggested a dramatic fall in GAM to 1.2% amongst non-camp and 0.8% in camp refugees24.
It is certainly good news that the prevalence of acute malnutrition is so low in this population. However, the issues around the integrity of nutrition data raise the real prospect that the drive to scale up treatment of acute malnutrition was unnecessary in both Jordan and Lebanon or at the very least, that limited resources might have been used to better effect elsewhere. It is difficult to put a figure on the level of resources devoted to scaling up treatment programmes but these are likely to have been considerable. For example, in Lebanon, 30 primary health care (PHC) centres had been ‘activated’ to treat acute malnutrition25, whilst further capacity is provided through mobile clinics26 and extensive community screening looking for cases. Furthermore, the importation of therapeutic feeding products has undoubtedly been costly in both Lebanon and Jordan27. It is interesting to note that whilst attention to GAM rates has defined a significant proportion of the Lebanon and Jordan nutrition response, this has not been the case in southern Turkey. We could find no reference to GAM in the refugee camps in Turkey, possibly because the Turkish Government and Turkish Red Cross (TRC) drives the shape and content of the response and the role of United Nation (UN) agencies and international NGOs is less influential.
In other aspects of the response (notably within Syria) there has been a lack of representative nutrition data to inform programming28. Small-scale assessments, in Idleb, Ar raqqa and Aleppo governorates in Northern Syria, described in an article by World Vision International29, found low levels of GAM (MAM < 2.6% and SAM <0.5%). Similarly, nutrition screening (mid upper arm circumference (MUAC) during a measles vaccination campaign) by MSF in Tal-Abyad District of Al-Raqqah governorate found a prevalence of 0.6% GAM30. However Médecins sans Frontières (MSF) supported clinics were identifying a higher caseload than prevalence figures indicated, leading to the decision to provide treatment for acute malnutrition treatment. Of those subsequently admitted 45% (119 cases) were infants under 6 months – an age group traditionally excluded from surveys and nutritional surveillance. Surveys have not been conducted in the hardest to access locations so a more serious situation may exist in the besieged locations. However, WHO have been strengthening nutrition surveillance through health centres in Syria in a number of conflict-affected governorates since April 2014 so that nutrition data should become increasingly available in the coming months31.
Infant and Young Child Feeding (IYCF)
The second main focus of the nutrition response has been on IYCF. Whilst breastfeeding is culturally accepted and commonly practised amongst Syrians (most mothers initiate breastfeeding)32, exclusive breastfeeding rates are low, and breastfeeding falls off considerably by 1 and 2 years of age33. Infant formula use is a recent and increasing form of infant feeding that is culturally accepted34. This context indicates a need for both breastfeeding and artificial feeding support, and flags the need for particular attention to complementary feeding given the low continued breastfeeding rates. Our compilation of experiences suggests the nutrition sector has largely fallen short of meeting the wider IYCF needs of infants and children.
Our collation of articles reflects that the programming emphasis has been particularly on breastfeeding support in a bid to protect and ideally increase breastfeeding rates. This has yielded some strong and necessary breastfeeding support programming in Lebanon35 and Jordan36 and is the focus of attention on IYCF support within Syria37. However, there have been large gaps in attention and action on support to non-breastfed infants (or infants who are breastfed but heavily dependent on infant formula), especially to refugees in host communities38 and in Syria. Support to non-breastfed infants has not been entirely absent – we feature articles on successful targeted programmes of support in Za’atari camp in Jordan (UNHCR/Save the Children Jordan) and in Lebanon (IOCC). But they are small scale and for the vast majority of Syrian infants dependent on infant formula, whether within Syria or in host countries, access to supply is unknown and by all accounts, either inaccessible or expensive in absolute terms or relative to other household needs39.
Undoubtedly, addressing IYCF needs have been challenging in this response, particularly in Syria where access is limited and remote programme management the only means to deliver40, and in host communities where refugees are scattered and difficult to identify and follow up41. The region has a track record of misuse of infant formula in crisis times42. An added complication is that standard IYCF indicators and programming options are heavily biased towards breastfeeding populations where infant formula use is the exception. Low breastfeeding rates identified in 2012 and 2013 assessments amongst Syrian refugees in Jordan and Lebanon created breastfeeding targets but no actions or advocacy around meeting the immediate nutritional needs of non-breastfed infants43. The Joint Rpaid Assessment of Northern Syria (JRANS) 2012, the Syria Integrated Needs Assessment (SINA)44 in Dec 2013 and GNC scoping mission in Syria45, data from surveys in Lebanon and Jordan, and articles we feature by GOAL, MSF, Action Contre la Faim (ACF), IOCC, WHO, UNICEF and Medair all noted need or demand for infant formula supplies and support. But for a few small scale exceptions (as outlined earlier), agencies were not willing to take it on, especially as they couldn’t ensure targeting or guarantee water, sanitation and hygiene (WASH) conditions (as recommended by policy guidance), or go against agency policy positions not to supply infant formula46. The consequences of poor coverage of support to formula dependent infants are not well documented – most infants are dispersed in host communities or within Syria. Some insight is provided in an article by ACF, where almost half of the infants aged 0-< 6 months admitted to ACFs acute malnutrition treatment programme in Lebanon had received infant formula, and breastfed admissions were not exclusively breastfed47. In the same programme, 70% of admitted children aged 6-23 months were using infant formula on presentation. An article by MSF from northern Syria found that more than half of the admissions to their treatment programme were infants under six months of age; the lack of safe formula feeding (supplies and conditions) was a significant contributing factor (high cost, erratic supply, low availability) and despite much advocacy, there were no programmes to support formula dependent infants on discharge48. This caseload was not picked up by surveillance or survey data as data on infants under 6 months were not included. This has been described as an information blind spot and is being challenged even in largely breastfeeding populations49.
It appears that complementary feeding support in this emergency response also falls short. Featured articles describe limited access to fortified complementary foods for children in Za’atari camp in Jordan; a three month ‘stop gap’ supply was provided in 2013 by UNHCR50 with only a sustained supply of SuperCereal Plus eventually established by WFP in February 201451. It was not well accepted by the community and significant follow up has been necessary to support its use52. No provision for complementary food for children living in the host community was made. Fortified complementary foods are not available in the Jordanian shops linked to the WFP voucher scheme, while fortified foods available in pharmacies are prohibitively expensive53. The WFP VASYR assessments in Lebanon in 2012 and 2013 pointed to extremely low dietary diversity amongst children and highlight the micronutrient status risk amongst both children and adults54 but no evidence of concerted action. In Lebanon, no one organisation was willing to undertake blanket distribution of micronutrient powders (MNPs) for children aged 6-59 months55. The consequences of inadequate support to complementary feeding are now reflected in the high prevalence of anaemia in both countries; amongst Zaatari camp refugees in Jordan is now at 48.4%, a “problem of major public health significance” according to WHO criteria56.
Questions are raised by a number of articles as to whether infant formula use has been overly ‘policed’ in this context. There were riots over access to infant formula in the early days of Zaatari camp in Jordan and subsequently, tensions around subjecting mothers to physical assessments to determine whether they could breastfeed or not57. Infant formula is excluded from the voucher programmes documented in Syria58 or in Jordan, only stocked in pharmacies and so not available through the WFP-supported food voucher schemes for non-camp refugees59. Tensions around infant formula supply were also observed in the Turkish refugee camps during the ENN’s field visit and are reflected in a number of case studies featured60,61. Breastfeeding support programmes amongst refugees in Jordan have seen improvements in knowledge but not practice62. Observations of a small anthropological study commissioned by the ENN also question63 the ambition and even appropriateness of the zeal and method of breastfeeding support, given the reality of the IYCF context. A postscript by Ann Burton asks whether the humanitarian sector is really ready to support ‘informed decisions’ by mothers to not breastfeed64.
There is no question that there is a need for protection and support of breastfeeding in mixed fed populations. These contexts are particularly challenging, and Lebanon, as an example, has a long history of struggling with inappropriate infant formula marketing both by companies and medical personnel, and widespread Code violations in both normal and crisis times. Experiences around IYCF in the 2006 conflict65 laid the groundwork for a Lebanese national programme focused on strengthening Code implementation66. It is important that humanitarian crises and the associated response don’t undermine national efforts to strengthen policy and programming around breastfeeding protection and support. A mother from Syria has the same right to support for breastfeeding as a mother in Sudan. But equally, a non-breastfed infant has the same right to humanitarian protection as a breastfed infant.
Many of the issues highlighted reflect a tension between the public health interest to support breastfeeding versus individual rights and realities.
The characteristics of the IYCF response indicate a lack of strong critical analysis of the IYCF situation, weak stewardship of the technical response and a lack of emergency preparedness by in country actors pre-crisis. Anticipating ‘trouble ahead’, attempts to secure funding for a regional IYCF expert in early 2013 were unsuccessful67. These experiences challenge us to rethink our conception of what IYCF in emergencies entails and the IYCF programming models in the Middle Eastern context68. Indeed the characteristics of the IYCF Syria response may have exposed a fundamental flaw in how we frame IYCF in emergencies in policy guidance, which influences programming approaches. Defined as the protection and support of optimal IYCF69, current guidance largely caters for artificial feeding in exceptional circumstances/as a last resort and is usually relative to breastfeeding. It could be that the IYCF development agenda has overly influenced IYCF emergency response, such that pragmatic compromises on global feeding targets in the immediate term are poorly catered for in challenging humanitarian contexts; we are loath to compromise our high standards. How to enable and see through informed choice by a mother is not well catered for. A reframing of the objectives of IYCF-E support in humanitarian terms, rather than in purely optimal feeding terms, would allow us to accommodate, at least at a policy level, contexts where infant formula use is prevalent. This would be one important critical action to emerge from this leaning. It remains that whilst elements of existing IYCF policy guidance have fallen short, the global Sphere standards on IYCF (2011) clearly state that “actions must enable access and supply of breastmilk substitutes to infants who need it”. Clearly, this standard has not - and continues not - to be met.
Applying an Afro-centric lens to a middle-eastern context
The ENN’s view is that there has been an over emphasis on the treatment of acute malnutrition and on IYCF and that the nutrition sector has (to borrow a quote from a previous and infamous evaluation of the Great Lakes Emergency in 1996) to some extent, ‘missed the point’. That’s not to say nutrition community didn’t respond in good faith to what was perceived to be an emerging nutrition crisis at the outset of the response, as described earlier. However the nutrition community appeared to adopt and stick with a largely Afrocentric lens to the nutrition problems in the region, i.e. the sector expects to see high mortality and increased GAM in an emergency or feels there is a need to demonstrate risk, with programmes put in place at the ready to treat. Whilst considerable IYCF emergency experiences also come from Asia, they draw heavily from predominantly breastfeeding populations. It may also be that acute malnutrition treatment and IYCF were the only ‘nutrition’ areas that donors would (eventually) fund; “selling nutrition to the wider humanitarian community was challenging without a glaring nutrition crisis (no severely emaciated children reported)”70 . Added to this, flawed/suspicious nutrition survey data in Lebanon and Jordan and the low breastfeeding rates helped paint the picture of a refugee populdifficult without a “ation on the brink of a nutritional crisis with the concomitant need to provide acute malnutrition treatment and promote breastfeeding at all costs.
Gaps in nutrition response
We feel that the momentum to scale up of treatment for acute malnutrition and promote breastfeeding may have distracted from undertaking a sector wide and thorough needs assessment of all the nutrition problems facing infants, children, mothers and other vulnerable groups (the elderly, the sick), including maternal and child anaemia (and possibly other micronutrient deficiencies), child stunting, overweight, and non-communicable diseases (NCDs) - all of which were prevalent in the Syrian population pre-crisis and very likely to remain a problem or even increase risk as a result of the crisis. The combination of an Afrocentric response model and the perceived need to seek donor funding for the more typical emergency nutrition problems, raises the question as to whether the nutrition sector should have focussed its attention on additional areas of need and advocated to donors to expand their nutrition lens to reflect the wider range of nutrition problems faced in the region. Donors may also have had a hand in the lack of sectoral critical analysis of this situation, for example by requiring signs of raised GAM rates before investing in a dedicated nutrition working group in Turkey71 or failing to resource strong regional IYCF leadership. To put it another way, have there been significant gaps in the emergency nutrition assessments and responses?
Anaemia
The data on anaemia suggests that it should have attracted more of an analytical focus. Whilst anaemia was prevalent in the Syrian population pre-crisis, the first survey of anaemia prevalence amongst refugees in Lebanon and Jordan only took place in 2014, i.e. some 3 years after the crisis began. Prevalence of anaemia amongst camp refugees in Jordan was found to have deteriorated from pre-crisis levels to 48.4% in under five’s, a problem defined by WHO as of ‘major public health significance’72. It remains prevalent amongst refugees in the Jordanian host community at 26.1%73 and in Lebanon at 21%74. The increase in the prevalence of anaemia in Lebanon and continued moderate levels in Jordan in a context of low and possibly declining levels of wasting points to inadequate access to high quality foods rather than a lack of calories– especially amongst children 6 months of age and above. We have already highlighted major constraints regarding access to fortified foods for complementary feeding. The UNHCR guidance on anaemia indicates that in high anaemia contexts, a low quantity Lipid Nutrient Supplement (LNS) (for 6-24 month olds) or blanket micronutrient powders (MNP) (for 6-59 months olds) can be considered to reduce levels of anaemia in emergency contexts75. We also know from recent work amongst other refugee populations that high levels of anaemia in refugee settings may indicate high levels of other micronutrient deficiency diseases76. Our articles describe how within Syria, WFP and UNICEF have been distributing micronutrient powders to prevent micronutrient deficiencies; in Jordan, there has been blanket supplementary feeding programmes (BSFPs) in Za’atari and Azraq camps but not to the host community; in Lebanon, MNPs distribution has been limited to PHCs after the child is seen by the paediatrician77. On balance, this reflects limited action to monitor micronutrient deficiency disease prevalence or to implement programmes to address anaemia (and other micronutrient deficiencies).
Stunting
Furthermore, little attention has been paid to child stunting in terms of discerning the trends, underlying causes or identifying potential interventions. Mortality associated with severe stunting (<-3 SD height for age) is higher than that for moderate acute malnutrition at 5.5 times (MAM 3.3 times)78. Given that there are contexts where severe stunting prevalence is higher than the prevalence of MAM (e.g. Zaatari camp Jordan (2014): moderate wasting 0.9%, severe stunting 2.9%; Lebanon (2013) 1.8% moderate wasting, 2.8% severe stunting), it would be justifiable for the humanitarian nutrition community to have highlighted stunting as a nutrition problem requiring further analysis and attention. Cautious intrepretation of figures implies that stunting prevalence had in some instances, seemed to halve from 23% (2009) by the early stages of the crisis and then deteriorate over the response, most notably in Lebanon (from 12.2% (2012) to 17.3% (2013). Child stunting has not featured in articles from the refugee hosting countries; an exception is a WFP article describing their cross line and cross border programming in Syria. Here, there has been the recent introduction of Nutributter® (a nutritional supplement) with a view to preventing childhood stunting amongst children aged 6-23 months. Distributions of the supplement started in May 2013 and fulfilled 71% of the plan for January 2014; over 17,240 children in Aleppo and Al-Hasakeh were assisted out of 24,249 children. As with anaemia, UNHCR has well developed guidelines and a menu of options for assessing and managing stunting in refugee populations which includes consideration of food supplementation products and a range of interventions spanning health, WASH and food security depending on the stunting prevalence. But the guidance appears not to have been put into practice.
It appears that emergency nutrition actors have not yet forged links with development actors to advocate for actions to address stunting and anaemia, which is a missed opportunity to ensure a ‘continuum of care’ in the context of child malnutrition. This is symptomatic of a much wider and global disconnect between the emergency and development sectors whereby efforts to address acute malnutrition are largely perceived as the domain of emergency nutrition response, and stunting and anaemia as the concern of development actors. However it remains that on the anaemia/stunting front, UNHCR has well developed guidance that includes wasting and stunting, along with wasting, as key nutrition indicators with associated programming interventions. A key question is therefore, what hampered putting this guidance into practice? Clearly, there are compelling reasons to identify and overcome barriers and foster more integrated, holistic policy and programmes which protect and improve nutritional status.
Non-communicable diseases (NCDs)
Another significant ‘gap area’ or issue which the emergency nutrition community has not yet raised relates to the treatment and prevention of NCDs that have a nutritional aetiology/management aspect, e.g. diabetes, hypertension and heart disease. The demographic and disease profile of Syrian refugees is that of a middle-income country, characterised by a high proportion of chronic or non-communicable diseases. A UNHCR survey in Lebanon in July 2014 found 14.6% of over 18 year olds had one chronic condition, with the prevalence highest amongst the oldest (46.6% in over 60 year olds)79. The main reported chronic conditions of nutrition interest were hypertension (25.4%), diabetes (17.6%) and ‘other’ cardiovascular disease (19.7%). The NCD problem amongst older people is also reported in other articles we feature by Caritas, HelpAge International and Handicap International80. Treatment is difficult to access for many of those with these pre-existing conditions (the UNHCR survey found 56.1% were unable to get access to care), is costly for service providers and requires long term commitment to care. There is a risk that following a low fat/salt diet has not been possible given the limited cash transfer (CT) or food voucher transfer resources available to refugees and the displaced; the ENN is not aware of any analysis that has taken place of the suitability or cost of foods available in relation to NCDs. A question for the nutrition sector is whether there should have been closer engagement with agencies like WFP and the International Committee of the Red Cross (ICRC) implementing food voucher programmes to ensure that the diets needed to manage these conditions were available, promoted and affordable. If so, does the sector have adequate guidance material to inform such assessment and analysis? If this isn’t the role of the emergency sector, what checks and balances are there for development actors to take on these considerations?
Added to this is the issue of overweight (18% prevalence overweight in U5’s pre crisis81) which is a risk factor for NCDs. Mean weight-for-height z-scores in Za’atari and outside the camp in the 2014 survey were above the WHO standard population mean, indicating that Syrian refugee children in Jordan on average were slightly overweight rather than suffering from wasting82. As with the artificial divide which separates policies and programmes for wasting and stunting, it is rare for overweight to be recognised and addressed in emergency programmes even where these are prevalent and the situation, as with Syria, is protracted. The (soon to be released) first Global Nutrition Report will highlight the fact that ‘multiple burdens are the new normal’ which raises a question for both the emergency and development nutrition communities as to how they can better assess and respond to the multiple needs of affected populations within their own programming and through engagement with each other...in other words, can our systems connect and embrace the ‘new normal’?
Vulnerability criteria
A critical issue for the entire humanitarian sector in the Syria response has been how to develop vulnerability criteria to assist with targeting decisions. CTs and in-kind distributions were initially implemented as blanket distributions for refugee populations in the two main hosting nations (Lebanon, Jordan) and for most of the camp populations in southern Turkey. However, appreciation of a greater complexity to what constitutes vulnerability and the need to conserve scarce resources in light of under pledging by donors to various Regional Response Plans (RRP) has led to greater targeting of increasingly scarce resources83. The pressure to target resources has meant development of vulnerability assessment tools such as the score cards used by UNHCR84 and the rounds of Vulnerability Assessment of Syrian refugees (VASyRs) implemented by WFP85; WFP’s e-voucher programme in Lebanon targeted 70% of refugees following the 2013 VASyR. However, apart from MUAC measurements in the 2012 VASyR, there has been very little use of anthropometry to help define and understand vulnerability or more specifically, nutrition vulnerability. Nutrition surveys could theoretically have been used to greater effect to help define population strata in most need of nutritional support or indeed to endorse the targeting decisions taken, e.g. monitoring the nutrition of households excluded from CTs. Furthermore, nutrition indicators (including anaemia and stunting) could have been useful to help define households for inclusion in CT programmes. Finally, given the unprecedented scale and duration of the CTs being implemented in refugee hosting countries (particularly in Jordan, Lebanon and Turkey) it seems as if the opportunity to conduct robust research into the nutritional impact of these programmes has not been capitalised upon. This is unfortunate given the dearth of published data on this in a global context where humanitarian CT programming is becoming more normalised. There is currently an enormous gap in understanding whether and how CTs either prevent or address undernutrition (wasting, stunting and micronutrient deficiencies) in humanitarian contexts.
Cash programming
The scale and scope of CT programming in the Syria region has been unprecedented within a humanitarian programme context. A large component of the CT programming has effectively replaced in-kind food aid or general rations86,87,88. Cash has also been used to support access to shelter, health care, heating supplies89, and promotion of livelihoods90. Much has been achieved and there has been enormous and invaluable lesson learning documented in this edition with regard to CT programming design and implementation91,92. Indeed this was one reason why the ENN sought to compile a special issue on the Syria crisis response and to capture as much of this experience as possible. There are two stand-out issues around CT programming which the ENN believe may be emerging in the Syria response:
The first relates to availability of global resources for large scale CT programming in a humanitarian context. Many agencies (including donors) are openly admitting that the current level of CT programming is unsustainable and that substantial reductions and increased targeting will be necessary over the coming months, especially in light of RRP 6 failing to meet its budget pledging targets93. A question that arises is whether the ‘sector’ can assume the same level of resource availability for CTs in humanitarian contexts as has been available for in kind food aid in the past. To put it another way, are donor resources for in-kind distributions completely fungible or exchangeable with regard to cash provisions? This question seems all the more pertinent given trends that may be emerging with regard to in-kind food aid availability and provision. There are suggestions94 that a number of factors related to trade (and trade agreements), climate change, and programming preferences, are in the process of coming together in a way that may reduce the reliability of in-kind food aid provision in the future with the implication that CTs may increasingly need to replace in-kind food aid in humanitarian contexts where conditions such as market functionality support their implementation. Given that the food aid system in the past has worked largely due to the mutual interests of multiple stakeholders (governments, farmers, business interests, and humanitarians) can we assume that a different set of stakeholders involved in CT programming will be able to leverage the same political support and therefore level of resources and how will this be assessed? Could it also be that we are seeing in the Syria region the first test of this?
A second set of questions arises in relation to the institutional architecture around cash programming in humanitarian contexts. We raise these issues as they affect and are impeding programming. The Inter Agency Standing Committee (IASC) system does not have a ‘Cash Cluster’ in that cash is subsumed under a multiple of working groups (or indeed clusters) in any given emergency depending on the level of conditionality95,96. The questions that might follow begin with who coordinates policy and practice and who is accountable for the overall coherence and convergence of cash programming in any given emergency. Going further, one could ask is there need for other technical agencies to support the type of conditional programming that WFP undertake, does the UN system need to re-configure the roles and responsibilities of the various technical agencies around CT programming and who defines these roles and responsibilities to ensure coherent programming (a related question is how are the UN agencies to be held accountable for CT programme performance). There is also a set of questions as to how the nutrition community fits into this architecture to ensure maximum nutrition impact of CTs. In the case of the Syria crisis, we have already highlighted the absence of nutrition assessment and analysis informing targeting and access to ncessary foods, e.g. complementary foods for children, infant formula, low sugar and low salt, etc. Is there a need to develop minimum standards (SPHERE) for cash programming in humanitarian contexts and should the nutrition sector be at the ‘head table’ in helping to define those standards? We would argue yes.
Nutrition coordination and leadership
The scale of the Syria crisis response has inevitably led to coordination challenges. The crisis has resulted in unprecedented numbers of internally displaced people in Syria and refugees being hosted in southern Turkey, Lebanon, Jordan and Northern Iraq. Whilst the main responsibility and financing for the refugee response has been by the host governments, UNHCR has been at the forefront of UN agencies with ultimate accountability for the wellbeing of refugees. A large number of national agencies (e.g. Turkish Red Crescent), international NGOs and other UN agencies supporting the governmental responses, all of whom require financing, information, coordination and technical leadership to assess and meet the needs of those affected. A number of articles in this edition give valuable insight into UN and international NGO coordination97.
Within Syria, agencies are responding to the needs of the internally displaced through operations running out of the capital Damascus in coordination with the Assad Government. Aid is provided to government and non-government (so called cross-line programming) held areas of Syria98. Fascinating insights into the these operations are shared in an article by WFP, which reflects on the rationale and experience of working with and through Government in an operation which has gradually negotiated and secured enough humanitarian space to help meet the food needs of 4.2 million largely displaced Syrians. Ironically, in the face of immense ‘nutrition’ achievement, as we go to press, WFP is on the brink of a dramatic scale down of its Syria operations in the face of a looming resource crisis. A second article by WHO describes their nutrition programme, closely coordinated with UNICEF and WFP, to rebuild nutrition surveillance, develop capacity to treat acute malnutrition, support breastfeeding, and prevent malnutrition through micronutrient distribution/Ready to Use Supplementary Food (RUSF) distribution in what remains a highly insecure and challenging operartional environment. This edition also features a variety of ‘cross border’ programming largely from southern Turkey which supply aid to the displaced in the northern non-government held areas of Syria99. Coordination of cross line and cross border programme are characterised as complex, highly political, fast changing and, particularly in the context of the cross border programme, highly sensitive, resulting in tensions amongst the international agency actors100.As a marker of the sensitivities, it is noteworthy that a number of articles about cross-border programming that agencies committed to write for this special issue have been withdrawn at various drafting stages due to concerns about the potential impact of the article on their agency’s activities. Despite all these challenges, the Syria response is hugely impressive in terms of the scale and level of programme innovation, the dedication of humanitarian staff working in this context, as well as the commitment and resourcing from the host and donor governments.
The IASC cluster mechanism has not been formally activated in the refugee hosting countries as UNHCR has overall responsibility for the refugee operation. Rather, sectoral working groups have been established covering food security, health, shelter, protection and education with UNHCR at the overall coordinating helm - pretty much in the mirror image of the cluster system101,102. Within Syria, similar working groups exist to coordinate the response103. Until very recently, nutrition working groups had not been established in any of the countries, possibly because the low levels of GAM were not seen by agencies (including donors104) to justify the need for dedicated nutrition coordination. Nutrition coordination in southern Turkey, Jordan and Lebanon has, therefore, been absorbed into a small sub-group of the health working group. In Turkey, despite considerable efforts by some international NGOs and the Global Nutrition Cluster (GNC) to garner increased attention to nutrition, as a sector it occupies a very small space in the overall information exchange and coordination meetings105. The Jordan nutrition sub-working group has been particularly active with infant formula control, access and management, arguably not a good use of coordination energies106. A nutrition sub working group has recently formed in Lebanon107. Coordination in the nutrition sector, in contrast to the other main sectors such as food security, health, and WASH has not had dedicated coordination staff. The GNC, recognising the need to get nutrition on a stronger footing and following a 1 week scoping mission in Sept 2013, deployed a cluster coordinator for southern Turkey for 3 months (Dec 2013 to Feb 2014)108. This deployment met with a number of difficulties and did not lead to a longer-term nutrition coordination appointment.
With the benefit of overview of the different country responses and multiple agency programming, the ENN has been surprised that a protracted Level 3 crisis should have had such marginalised nutrition coordination structures and focus. This may in part reflect the lack of a coherent sectoral overview, which could objectively clarify the nutrition situation for a wider audience to inform programme decision-making. Instead, nutrition has been limited to a focus on acute malnutrition treatment in the context of low levels of GAM and a sub-set of IYCF, namely breastfeeding protection and support. If we therefore accept that the nutrition community has not adapted its nutrition lens to reflect the range of nutrition needs that typify a Middle East emergency and has been almost entirely absent from the design and implementation of an unprecedentedly large scale social protection programmme (cash and vouchers), a number of questions about coordination and leadership arise, which include:
- Should the nutrition sector have had dedicated working groups to enhance analysis and response and/or should nutrition have been more mainstreamed in the overall response by having representation (sub-working groups) in other working groups like cash and WASH? If so, how and by whom should this have been coordinated and who should have resourced this?
- Should the Nutrition Cluster have remained active in southern Turkey’s cross-border programme and also been activated to address the nutrition needs of refugee populations in Lebanon, Jordan, etc, to share the load with UNHCR?
- Should the Nutrition Cluster have been activated to support the affected host community in refugee hosting countries?
- What is the role of nutrition-related development actors to prepare for a crisis and to actively influence the international emergency effort in delivering a context specific and timely response?
- Where is the responsibility for a coherent and objective nutrition sector assessment and response overview without which there has arguably been a poorly analysed and partial response?
Implicit in these questions is a question about leadership and the ability to critically analyse what is being done in the name of nutrition. Many of the obvious shortfalls in the collective nutrition response to the Syria emergency speak to a lack of leadership. Was there a clear, objective lead agency for nutrition in this crisis to oversee the scope and quality of assessments, analysis, and interpretation and in turn, the shape and content of the nutrition related considerations across all related sectors? Arguably, had there been robust leadership and ownership, the nutrition sector may have avoided the dominant emphasis on the scale up of treatment for acute malnutrition whilst failing to address anaemia. There could have been a more objective and context-specific appraisal of the IYCF situation that needed (and still needs) a more critical analysis of the situation, some innovation and new types of programming to address needs. In terms of objective overview, it is interesting to see what the Syria Needs Assessment Project (SNAP) has brought to the humanitarian sector in terms of humanitarian data sharing and analysis109; perhaps there are some lessons to be learned for the nutrition sector?
Accountability
One final thought relates to accountability within the nutrition sector. Given the missed opportunities in the nutrition response, how do we hold ourselves accountable and institutionalise learning to avoid making these mistakes again? The answer is a very difficult one as we still lack clarity around roles, responsibilities and leadership in the nutrition sector. At the very least, we think a sectoral evaluation following a large-scale emergency programme of this type would add real value to collective learning, Whilst there are many evaluations following each new emergency, these are either agency specific evaluations or on rare occasions, evaluations across the overall multi-sectoral response. The last sectoral evaluation for nutrition (and other sectors) following a multi-agency humanitarian response was in 1996 for the Great Lakes Emergency. Subsequent attempts at similar system-wide, collaborative evaluations (e.g. following 1998 Hurricane Mitch and the 1999 Kosovo crisis) did not bear fruit possibly due to lack of “effort and collective spirit”110. Without critically examining the overall coherence of our nutrition responses in emergencies, we risk repeating the same mistakes over and over again. Should there not be regular nutrition sector evaluations of emergency responses to ensure that we learn for the next time, do we have sufficient collective will to pull together on this, and if so, who should lead on this?
This Middle East emergency has, and continues to be, uniquely challenging in its scale and complexity. There has been an extraordinary response from a vast array of stakeholders across many sectors, and nutrition indicators suggest that a large-scale nutritional emergency has thankfully been largely averted. However, nutrition vulnerabilities remain poorly analysed and inadequately addressed and, indeed, such vulnerabilities may well worsen as the availability of resources for the Syria crisis rapidly decline. The nutrition community-both emergency and development is needed as much now as in the height of the crisis. Let’s hope we can rise to the challenge.
1 We focus on Lebanon, Jordan and Turkey given this is where we have documented experiences in this edition. We recognise that Iraq and Egypt have also hosted significant numbers of refugees.
2 For want of a better term, non-traditional humanitarian actors are those operating outside the ‘traditional’ UN agencies and NGOs effort and includes Arab donors, local NGOs, Syrian diaspora and businesses.
3? 2014 funding appeal. Currently 44% funded (correct as of 18th September 2014). Accessed at http://data.unhcr.org/syrianrefugees/regional.php
4 file:///C:/Users/Marie/Downloads/TurkeySyriaSitrep12.09.2014.pdf
5 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff . WHO response to malnutrition in Syria: a focus on surveillance, case detection and clinical management.
6 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff . WHO response to malnutrition in Syria: a focus on surveillance, case detection and clinical management.
7 Syria Family Health Survey (SFHS), 2009
8 Ministry of Health, Nutrition surveillance system report, Syria, 2011.
9 Najwa Rizkallah. UNICEF experiences of the nutrition response in Lebanon.
10 ENN interviews in Jordan and Lebanon.
11 Linda Shaker Berbari, Dima Ousta and Farah Asfahani. Institutionalising acute malnutrition treatment in Lebanon.
12 Jamila Karimova and Jo Hammoud. Relief International nutrition and health programme in Lebanon.
13 Gabriele Fänder and Megan Frega . Responding to nutrition gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Child Feeding education and malnutrition treatment.
14 Ruba Ahmad Abu-Taleb. Experiences of emergency nutrition programming in Jordan
15 Sura Alsamman. Managing infant and young child feeding in refugee camps in Jordan
16 James Kingori. UNICEF experiences on nutrition in the Syria response; Najwa Rizkallah. UNICEF experiences of the nutrition response in Lebanon; Ruba Ahmad Abu-Taleb. Experiences of emergency nutrition programming in Jordan; Linda Shaker Berbari, Dima Ousta and Farah Asfahani. Institutionalising acute malnutrition treatment in Lebanon.
17 James Kingori. UNICEF experiences on nutrition in the Syria response; Hala Ghattas Linda Shaker Berbari & Omar Obeid. The impact of the NiE regional training initiative: the Lebanon experience 2010-2014; Caroline Abla. Experiences on Nutrition in Emergencies Training for Syrian refugees response in Jordan
18 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee children and women nutritional needs in Jordan; Gabriele Fänder and Megan Frega. Responding to nutrition gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Child Feeding education and malnutrition treatment.
19 WFP VASyR assessment in 2013 MUAC based assessment found a prevalence of 1% MAM and 0.4% SAM. Susana Moreno Romero. WFP experiences of vulnerability assessment of Syrian refugees in Lebanon
20 Foot Linda Shaker Berbari, Dima Ousta and Farah Asfahani. Institutionalising acute malnutrition treatment in Lebanon; Najwa Rizkallah. UNICEF experiences of the nutrition response in Lebanon.
21 Centres for Disease Control and Prevention
22 Najwa Rizkallah. UNICEF experiences of the nutrition response in Lebanon; personal communication
23 Personal communication. It is not possible to confirm these suspicions, as was possible with the Lebanon 2013 data.
24 Bilukha O et al (2014). Nutritional Status of Women and Child Refugees from Syria — Jordan, April–May 2014. MMWR / July 25, 2014 / Vol. 63 / No. 29
25 Linda Shaker Berbari, Dima Ousta and Farah Asfahani. Institutionalising acute malnutrition treatment in Lebanon.
26 Jamila Karimova and Jo Hammoud. Relief International nutrition and health programme in Lebanon.
27 Sura Alsamman. Managing infant and young child feeding in refugee camps in Jordan
28 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff . WHO response to malnutrition in Syria: a focus on surveillance, case detection and clinical management.
29 Emma Littledike and Claire Beck. Experiences and challenges of programming in Northern Syria.
30 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van der Kam. Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria
31 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff . WHO response to malnutrition in Syria: a focus on surveillance, case detection and clinical management.
32 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van der Kam. Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria
33 Susana Moreno Romero. WFP experiences of vulnerability assessment of Syrian refugees in Lebanon
34 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van der Kam. Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria.
35 Linda Shaker Berbari, Dima Ousta and Farah Asfahani. Institutionalising acute malnutrition treatment in Lebanon.
36 Sura Alsamman. Managing infant and young child feeding in refugee camps in Jordan; Gabriele Fänder and Megan Frega. Responding to nutrition gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Child Feeding education and malnutrition treatment.
37 Hala Khudari, Mahmoud Bozo and Elizabeth Hoff . WHO response to malnutrition in Syria: a focus on surveillance, case detection and clinical management.
38 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee children and women nutritional needs in Jordan
39 Gabriele Fänder and Megan Frega. Responding to nutrition gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Child Feeding education and malnutrition treatment; Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van der Kam. Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria; Hannah Reed. GOAL’s food and voucher assistance programme in Northern Syria; Ann Burton. Commentary on experiences of IYCF support in the Jordan response.
40 Hannah Reed. GOAL’s food and voucher assistance programme in Northern Syria
41 Gabriele Fänder and Megan Frega. Responding to nutrition gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Child Feeding education and malnutrition treatment.
42Ali Maclaine and Mary Corbett (2006). Infant Feeding in Emergencies: Experiences from Indonesia and Lebanon. Field Exchange 29, December 2006. p2. www.ennonline.net/fex/29/infantfeeding
43 Inter-agency nutrition assessment Syrian refugees in Jordan. Host communites and Za’atari camp. Final report, January 2013.
44 In the SINA, 23.5% of key informants reported a predominance of exclusive breastfeeding, 72.3% reported mixed feeding, and 3.4% exclusively used infant formula. The use of animal milk to feed infants under 6 months was also reported. Key informants called for infant formula as a key priority.
45 Accessed via the GNC Global Coordinator.
46 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van der Kam. Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria; Linda Shaker Berbari, Dima Ousta and Farah Asfahani. Institutionalising acute malnutrition treatment in Lebanon.
47 Juliette Seguin. Challenges of IYCF and psychosocial support in Lebanon.
48 Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van der Kam. Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria
49 Kerac et al (2010).Prevalence of wasting among under 6-month-old infants in developing countries and implications of new case definitions using WHO growth standards: a secondary data analysis. Arch Dis Child. Published Online First: 2 February 2011. Open access at: http://adc.bmj.com/content/early/2011/02/01/adc.2010.191882.full
50 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee children and women nutritional needs in Jordan; Sura Alsamman. Managing infant and young child feeding in refugee camps in Jordan; Gabriele Fänder and Megan Frega. Responding to nutrition gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Child Feeding education and malnutrition treatment; Ruba Ahmad Abu-Taleb. Experiences of emergency nutrition programming in Jordan
51 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee children and women nutritional needs in Jordan; Sura Alsamman. Managing infant and young child feeding in refugee camps in Jorda.
52 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee children and women nutritional needs in Jorda; Gabriele Fänder and Megan Frega. Responding to nutrition gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Child Feeding education and malnutrition treatment
53 Ann Burton. Commentary on experiences of IYCF support in the Jordan response
54 Henry Sebuliba and Farah El-Zubi. Meeting Syrian refugee children and women nutritional needs in Jordan
55 Najwa Rizkallah. UNICEF experiences of the nutrition response in Lebanon
56 Bilukha O et al (2014). Nutritional Status of Women and Child Refugees from Syria — Jordan, April–May 2014. MMWR / July 25, 2014 / Vol. 63 / No. 29
57 Sura Alsamman. Managing infant and young child feeding in refugee camps in Jordan
58 Hannah Reed. GOAL’s food and voucher assistance programme in Northern Syria
59 Ann Burton. Commentary on experiences of IYCF support in the Jordan response
60 Luigi Achilli and Raymond Apthorpe. The social life of nutrition among Syrian refugees in Jordan.
61 Suzanne Mboya. Artificial feeding in emergencies: experiences from the ongoing Syrian crisis
62 Gabriele Fänder and Megan Frega . Responding to nutrition gaps in Jordan in the Syrian Refugee Crisis: Infant and Young Child Feeding education and malnutrition treatment.
63 Luigi Achilli and Raymond Apthorpe. The social life of nutrition among Syrian refugees in Jordan.
64 Ann Burton. Commentary on experiences of IYCF support in the Jordan response
65 Ali Maclaine and Mary Corbett (2006). Infant Feeding in Emergencies: Experiences from Indonesia and Lebanon.Field Exchange 29, December 2006. p2. www.ennonline.net/fex/29/infantfeeding
66 Linda Shaker Berbari, Dima Ousta and Farah Asfahani. Institutionalising acute malnutrition treatment in Lebanon.
67 Personal communication from four sources.
68 Suzanne Mboya. Artificial feeding in emergencies: experiences from the ongoing Syrian crisis.
69Operational Guidance on Infant and Young Child Feeding in Emergencies, v2.1 (2007). http://www.ennonline.net/operationalguidanceiycfv2.1
70 James Kingori. UNICEF experiences on nutrition in the Syria response.
71 Anon. Coordinating the response to the Syria Crisis: the southern Turkey cross border experience.
72 Bilukha O et al (2014). Nutritional Status of Women and Child Refugees from Syria — Jordan, April–May 2014. MMWR / July 25, 2014 / Vol. 63 / No. 29
73 Bilukha O et al (2014). Nutritional Status of Women and Child Refugees from Syria — Jordan, April–May 2014. MMWR / July 25, 2014 / Vol. 63 / No. 29
74 Najwa Rizkallah. UNICEF experiences of the nutrition response in Lebanon
75 UNHCR Operational Guidance on the Use of Special Nutritional Products to Reduce Micronutrient Deficiencies and Malnutrition in Refugee Populations. UNHCR, 2011. http://www.ennonline.net/unhcrogspecialnutritionalproducts
76 Seal A and Prudhon C (2007). Assessing micronutrient deficiencies in emergencies. Current practice and future directions. Nutrition Information in Crisis Situations. UNSCN (for example) Woodruff BA et al (2006). Anaemia, iron status and vitamin A deficiency among adolescent refugees in Kenya and Nepal. Public Health Nutrition. Vol 9, Issue 1, p 26-34.
77 Najwa Rizkallah. UNICEF experiences of the nutrition response in Lebanon
78 Khara, T, & Dolan, C. (2014). Technical Briefing Paper: Associations between Wasting and Stunting, policy, programming and research implications. Emergency Nutrition Network (ENN) June 2014. Report available at: http://www.ennonline.net/waststuntreview2014
79 Frank Tyler. Characteristics and challenges of the health sector response in Lebanon
80 Report summary. Insight into experiences of older Syrian refugees in Lebanon; Lydia de Leeuw. The situation of older refugees and refugees with disabilities, injuries, and chronic diseases in the Syria crisis.
81 UNICEF State of the World’s Children Report. 2014. http://www.unicef.org/sowc2014/numbers/documents/english/SOWC2014_In Numbers_28 Jan.pdf
82 Bilukha O et al (2014). Nutritional Status of Women and Child Refugees from Syria — Jordan, April–May 2014. MMWR / July 25, 2014 / Vol. 63 / No. 29
83 Hisham Kighali, Lynette Larson and Kate Washington. Aid effectiveness: determining vulnerability among Syrian refugees in Jordan.
84 Hisham Kighali, Lynette Larson and Kate Washington. Aid effectiveness: determining vulnerability among Syrian refugees in Jordan.
85 Susana Moreno Romero. WFP experiences of vulnerability assessment of Syrian refugees in Lebanon
86 Louisa Seferis. DRC experi
87 Kathleen Inglis and Jennifer Vargas. Experiences of the e-Food card programme in the Turkish refugee camps.
88 Ekram Mustafa El-Huni . WFP e-voucher programme in Lebanon
89 Christian Lehmann and Daniel T. R. Masterson. Impact evaluation of a cash-transfer programme for Syrian refugees in Lebanon.
90 Francesca Battistin. IRC cash and livelihoods support programme in Lebanon; Isabelle Pelly. Designing an inter-agency multipurpose cash transfer programme in Lebanon
91 Isabelle Pelly. Designing an inter-agency multipurpose cash transfer programme in Lebanon.
92 Isabelle Pelly. Designing an inter-agency multipurpose cash transfer programme in Lebanon
93 Simon Little. Towards a 21st century humanitarian response model to the refugee crisis in the Lebanon.
94 Personal communication, Ed Clay.
95 Isabelle Pelly. Designing an inter-agency multipurpose cash transfer programme in Lebanon
96 Leah Campbell. Meeting cross-sectoral needs of Syrian refugees and host communities in Lebanon
97 Key articles include: Alex Tyler and Jack Byrne. UN and INGO experiences of coordination in Jordan; Simon Little. Towards a 21st century humanitarian response model to the refugee crisis in the Lebanon; Profile: Syria INGO Regional Forum (SIRF); James Kingori. UNICEF experiences on nutrition in the Syria response; Anon. Coordinating the response to the Syria Crisis: the southern Turkey cross border experience.
98 Rasmus Egendal. WFP’s emergency programme in Syria.
99 Hannah Reed. GOAL’s food and voucher assistance programme in Northern Syria; Anon. Non-food cash voucher programme for IDPs in Northern Syria; Emma Littledike and Claire Beck. Experiences and challenges of programming in Northern Syria; By Kathleen Inglis and Jennifer Vargas. Experiences of the e-Food card programme in the Turkish refugee camps; Maartje Hoetjes, Wendy Rhymer, Lea Matasci-Phelippeau, Saskia van der Kam. Emerging cases of malnutrition amongst IDPs in Tal Abyad district, Syria.
100 Anon. Coordinating the response to the Syria Crisis: the southern Turkey cross border experience.
101 Alex Tyler and Jack Byrne. UN and INGO experiences of coordination in Jordan
102 Simon Little. Towards a 21st century humanitarian response model to the refugee crisis in the Lebanon. Note these coordinating mechanisms may have changed since.
103 Rasmus Egendal. WFP’s emergency programme in Syria.
104 Anon. Coordinating the response to the Syria Crisis: the southern Turkey cross border experience.
105 Emma Littledike and Claire Beck. Experiences and challenges of programming in Northern Syria; Personal communications.
106 Sura Alsamman. Managing infant and young child feeding in refugee camps in Jordan; Ann Burton. Commentary on experiences of IYCF support in the Jordan response.
107 Najwa Rizkallah. UNICEF experiences of the nutrition response in Lebanon
108 Emma Littledike and Claire Beck. Experiences and challenges of programming in Northern Syria
109 Yves Kim Créac'h and Lynn Yoshikawa. The Syria Needs Assessment Project
110 John Borton (2004). The Joint Evaluation of Emergency Assistance to Rwanda. HPN. Issue 26, March 2004.