Postscript: Stop-gapping nutrition coordination for the Syria response
By Emma Littledike
This is a personal account of the experiences of Emma acting to stop-gap nutrition coordination around the cross border operations into Syria from Turkey.
The Global Nutrition Cluster (GNC) seconded a Rapid Response Team (RRT) Nutrition consultant to the Syria response for a three month period (13 Dec 2103-13 Feb 2014) to provide technical, strategic and coordination support to the Northern Syria Nutrition Sector response. On her departure, I was appointed as interim Nutrition Cluster Coordinator for a two month period to stop gap the lack of data and information on the nutrition situation. This appointment was on a voluntary basis, in addition to a busy full time job managing three large health and nutrition programmes for World Vision International (WVI).
In this role I have led weekly meetings and tried to build an evidence base for the nutrition situation. A key task in my role as coordinator was to evaluate critically existing data on the nutrition situation (e.g. review three anthropometric assessment surveys in Aleppo, Arraqqa and Idleb (see earlier article)) and emerging from this, to advocate for and help support securing more nutrition information, especially in areas where accessibility, food security and humanitarian assistance were poor. During my tenure, a lead partner and survey methodology (SMART) was eventually agreed for a representative SMART nutrition survey in each governorate and a purposive sample in sub-districts that were more likely to have malnutrition1. The survey is now underway in Idlib (May 2014) and other governorates will be surveyed post Ramadan.
There is a need to improve nutrition surveillance through clinics, community spaces and community workers. This is particularly important in areas where there is very little humanitarian support and for areas dependent on food assistance that can be affected by hibernation (when agencies have to suspend activities due to conflict) and border closure. Camps also need to screen new arrivals that may have travelled from highly food insecure areas. Many health actors do not record malnutrition in their health monitoring systems and few cases of malnutrition are reported amongst health partners (this may be due to low caseload and/or low awareness at management or field level). A Mid Upper Arm Circumference (MUAC) screening package with guidance materials and a training video is in development to help address this. The aim is to disseminate the screening kit to all actors and all community stakeholders and to offer online support to practice measurements via WebEx or Skype video. The cascade training of trainer’s model is not far reaching enough in this context. Provision of a screening package such as this, whilst not ideal, could be a partial solution to the problem of poor access. Referral facilities also need to be identified and incorporated into the screening package and they in turn, require training in the treatment of severely malnourished cases. There is also a need to incorporate data collection on underlying causes of malnutrition into all multi-sector rapid surveys to gather more information on camp and host community needs. A multi-sector assessment is currently in planning (May 2014).
A major coordination challenge has been around the management of breastmilk substitutes (BMS), including around untargeted distributions to the population (see earlier article).. To try and gain more information, in my coordination role, I advocated for inclusion of questions about BMS distribution in all general rapid surveys being conducted. A BMS distribution indicator was subsequently included in the Response Plan. Awareness amongst actors of the Operational Guidance on infant and young child feeding in emergencies (IYCF-E)2 and the International Code of Marketing of Breast-Milk Substitutes3 was improved through handouts and making resources available on the google drive established for the working nutrition sub-group.
Sourcing therapeutic food supplies has been problematic (see earlier article which reflects the issues well under ‘challenges’).
Nutrition coordination in itself has been challenging in this context. Nutrition is not considered a sufficiently important issue to be a stand-alone sector as there is no evidence of acute malnutrition. This has led to the formation of a nutrition sub-group in the health working group. However participation and engagement of agencies in the nutrition sub-group has been minimal. There are very few nutrition experts in-country and only six agencies implementing nutrition activities. Many structured sessions had to be postponed because of poor attendance. All agencies were regularly sent agendas, meeting presentations and technical guidance documents to ensure they were supported with adequate resources.
The focus of coordination on nutrition has been on assessments, management of acute malnutrition and on IYCF. The degree of scale up needed for these nutrition interventions is unclear due to lack of current data on acute malnutrition prevalence and IYCF practices. While there are cases of SAM reported, the number of reporting facilities and catchment populations is unknown. We suspect there may be high levels of SAM cases in specific pockets of the country with poor access to food distribution and humanitarian support.
Additional significant nutrition problems are stunting and micronutrient deficiencies which have received little programming attention. There is a need to build a solid evidence base and to focus on prevention activities in the immediate future. Syrian agencies have much greater access and need greater technical support from international NGOs to programme according to the needs they are witnessing in their areas of operation. In the immediate term, more nutritionists are anticipated to arrive to contribute expertise to the nutrition working group that may encourage participation.
My coordination time would have benefited greatly from more support with obtaining supplies such as ready to use therapeutic food (RUTF), safe feeding kits (for infants using BMS) and anthropometric equipment. Given the nature of the Syria response, the usual support of UNICEF with regard to supplies was not available. More support in securing Arabic speaking trainers would also have helped enable trainings. It is questionable whether a working group lead can be effective without good resource provision.
My coordination role has now ended and nutrition is incorporated into the health working group. There are advantages to this, as it allows nutrition issues to be discussed repeatedly with a larger group of actors for which it should be a concern. Integration into the health working group has led to increased attention and nutrition now comprises a substantial part of the new annual response plan. By July 2015, primary health facilities will improve screening and referral through standardised nutrition service packages. Treatment of acute malnutrition according to WHO protocols will be improved at designated health facilities. Access to support on IYCF practices will be improved through the training of focal points. Children and pregnant and lactating women will access micronutrients from targeted supplementary or fortified foods, supplements or multiple-micronutrient preparations. Encouraging the mainstreaming of nutrition activities into other sectors will also be very important. I continue to play an active nutrition role supporting with updates, discussion points and technical support to agencies on a voluntary basis.
For more information, contact: Emma Littledike, email: Emma.littledike@hotmail.co.uk
1 A specialist agency developed a database ranking areas by likelihood of higher prevalence of acute malnutrition using food security and health data from the Syrian Integrated Needs Assessment (SINA)
2An international policy guidance endorsed by the World Health Assembly. Available at: http://www.ennonline.net/resources/6
3Access the full Code at: http://ibfan.org/the-full-code