Philippines Nutrition Cluster: lessons learnt from the response to Typhoon Haiyan (Yolanda)

By Aashima Garg, Andrew Rene Bucu and Rene Gerald Garela

Aashima Garg is Nutrition Specialist based in UNICEF New York. At the time of writing, she was Nutrition Manager with UNICEF Philippines leading the nutrition emergency and regular programmes. She has over 11 years of experience in the area of Public health Nutrition programming across South Asia.

Andrew Bucu, MD, MPH is a SAM Management Scale Up Consultant, engaged by UNICEF Philippines.

Rene Galera MD, MPH is a Nutrition Specialist with UNICEF Philippines. 

The ENN team supporting this work comprised Valerie Gatchell (ENN consultant and project lead), with support from Carmel Dolan and Jeremy Shoham (ENN Technical Directors). Josephine Ippe, Global Nutrition Cluster Coordinator, also provided support.

The authors would like to acknowledge the following Government colleagues working in the National Nutrition Council, Department of Health who contributed to the document: Asec. Maria-Bernardita T. Flores, CESO II, Assistant Secretary of Health and Executive Director/Chair of the National Nutrition Cluster; Maria Lourdes A. Vega, Chief of the Nutrition Policy and Planning Division; Margarita D.C. Enriquez, Nutrition Officer II/IMO and Secretariat of the National Nutrition Cluster.

This article is a summary of a case study produced through a year-long collaboration in 2015 between ENN and the Global Nutrition Cluster (GNC) to capture and disseminate knowledge about the Nutrition Cluster experiences of responding to Level 2 and Level 3 emergencies (available at www.ennonline.net/ourwork/networks/gnckm). The documented findings and recommendations are those of the authors. They do not necessarily represent the views of UNICEF, its Executive Directors or the countries that they represent and should not be attributed to them.

Country overview

The Philippines is a middle-income country vulnerable to a wide range of natural hazards. It is affected by 20 cyclones a year on average and experiences frequent earthquakes and eruptions from 23 active volcanoes. On November 8 2013, Typhoon Haiyan (nationally known as Typhoon Yolanda) swept through central Philippines and was recorded as the strongest typhoon in the world. The damage to life and property was overwhelming, displacing 4.1 million individuals, including 1.7 million children¹. Three regions in the country were directly hit: a number of provinces in Regions VI and VII (Western and Central Visayas) were devastated, while Region VIII (Eastern Visayas) suffered the brunt of the damage, prompting the government to declare a state of calamity. In the wake of the devastation, the government requested international support to coordinate and implement the response.

Nutrition response to Typhoon Haiyan

Cluster leadership and governance

The government of the Philippines officially adopted the cluster approach in 2007 after an international response to Typhoon Durian (locally named Reming). Since then, sectoral coordination mechanisms, with a mandate to address both emergency response and preparedness, have been permanently integrated into government departments. These mechanisms are referred to nationally as ‘clusters’, although they are never deactivated. They focus on preparedness in normal times and respond to all emergencies when they hit. In response to large-scale emergencies where international assistance is requested, the ‘clusters’ receive international support (funding and human resources) through United Nations (UN) partners.

At the time Haiyan struck in late 2013, the National Nutrition Council (NNC) was still familiarising itself with its new role as government lead of the Nutrition Cluster (NC); it had limited experience and capacity to lead and manage the response. There was no focal unit in the NNC for emergencies and the internal coordination mechanisms, roles and responsibilities had yet to be clarified. UNICEF suggested that it co-lead to support coordination and technical assistance until the NNC was able to assume a full leadership role.  Sub-national nutrition clusters were activated for coordination in the Haiyan-affected regions in Tacloban (Region VIII), Cebu (Region VII) and Roxas (Region VI) cities. The sub-national NCs in Regions VI and VIII followed the same arrangement as the NC and were led by sub-national NNC with UNICEF in a co-lead role. However in Region VII, after initial coordination support from UNICEF, the NNC led the sub-regional cluster for most of the response phase with technical support from UNICEF as required/requested.

Nutrition situation assessment and initial response to Haiyan

When Haiyan struck, acute malnutrition prevalence was 8% and stunting was 30% nationally, with regional variation. Exclusive breastfeeding prevalence rate (34%) and minimum dietary diversity (15% in children aged 6-24 months) were low and anaemia prevalence was high, affecting 39% of infants (6-12 months) and 25% of pregnant women. A review of secondary data on the nutrition situation prior to Haiyan was conducted to inform the development of the Strategic Response Plan (SRP). The most recent data was from the National Nutrition Survey (NNS 2011) which indicated the following:

• Wasting in children under 7.8% to 8.5% across affected areas
• Exclusive breastfeeding rates of 50 to70% across affected areas
• Malnourished lactating women (10%) and pregnant women at risk of malnutrition (16 -33%)
• Widespread distribution of breastmilk substitutes (BMS).

At the time the SRP was developed, updated nutrition data was not available as the results of the 2013 National Nutrition Survey had not been released. It was perceived that acute malnutrition would increase due to the crisis. Partners working in the Philippines at this time had experience with Community based Management of Acute Malnutrition (CMAM), due to the largely CMAM-based response to the emergency in Mindanao in 2009. The SRP developed in December 2013 therefore focused on:

• Treatment of acute malnutrition for children and pregnant and lactating women
• Infant and young child feeding (IYCF) support (with a focus on support to breastfeeding mothers and caregivers of children 0-23 months)
• Monitoring BMS donations.

Limited activities on the following were also included in the SRP:

• Micronutrient supplementation for children (vitamin A) and pregnant women (iron and folic acid)
• Treatment of moderate acute malnutrition (six-month supplementary feeding programme supported by the UN World Food Programme (WFP))
• Distribution of micronutrient powders (MNPs) (short-term distribution by WFP of UNICEF supplies).

While IYCF counselling and complementary feeding were mentioned in the SRP, corresponding activities were not included in the partners’ funding agreements with UNICEF (Programme Cooperation Agreements (PCAs)), nor were the indicators included in the SRP to monitor and measure support to complementary feeding promotion activities.

Revised nutrition response

SMART surveys conducted in February 2014 (three months post-Haiyan) indicated that both global acute malnutrition (GAM) and severe acute malnutrition (SAM) among children 6-9 months old were low (4.1% and 0.3% respectively), but confirmed that stunting was high (30.6%). Based on these figures, it was clear that the original SRP overestimated the burden of acute malnutrition. Thus in May 2014, the SRP was realigned. Targets were recalculated, resulting in a decrease from 6,000 to 800 children with SAM to be treated, and the response was expanded to encompass a more comprehensive approach of managing SAM while preventing stunting. The aim was to increase and expand IYCF activities (improved complementary feeding with micronutrient powder supplementation and skilled counselling); capacity building (for IYCF, CMAM and nutrition in emergencies (NiE)); and strengthening of health systems (creation/ revitalisation of local nutrition committees to oversee all nutrition action in the local government units).

All seven local and international implementing partners supporting the nutrition response were receiving funding from UNICEF through PCAs. UNICEF reviewed and revised the PCAs with partners to adjust target numbers and shift focus of implementation and corresponding activities. Excess stock of ready-to-use therapeutic food (RUTF) (due to initial expectations of high caseload) was reallocated to other areas in the country with ongoing emergencies (Zamboanga City and Cotabato City).

Key challenges to the initial analysis and programme response were:

• Limited government capacity for coordination due to the recent shift in leadership of the NC
• High turnover of the NCC position at the outset of the response
• Situational analysis leading into the SRP did not reflect the breadth or scale of nutrition challenges (i.e. stunting and micronutrient deficiencies)
• Focus of partners on CMAM
  1. Agencies were slow to shift away from CMAM due largely to their lack of experience and capacity in preventative nutrition programming
  2. Closed partner selection processes by UNICEF created tension among cluster, government and partner staff
• Supplementary Feeding Programmes (SFPs) were ended after six months (due to WFP funding constraints) with no gradual phase-out
• Large number of BMS donations and lack of understanding of communities and partner staff on how to report violations of the International Code of Marketing of Breastmilk Substitutes (the Code)
• IYCF-specific challenges included:
  1. Lack of national guidance on IYCF in emergencies (IYCF-E) generally beyond breastfeeding support and lack of international guidance on how to mange non-breastfed infants
  2. Lack of a reporting mechanism for the identification, monitoring and reporting on non-breastfeeding mothers
  3. No reliable reporting system in place for community health and nutrition workers and counsellors to track progress in counselling of breastfeeding mothers
  4. Lack of skilled staff support on IYCF counselling in affected communities
  5. Large focus on support to breastfeeding at the cost of provision of support to complementary feeding.

Information Management (IM)

At the time of the Haiyan response, multiple health management information systems (HMIS) were already in place and only two nutrition indicators (exclusive breastfeeding rate and vitamin A supplementation) were included in one of the systems. While other indicators, including timely initiation of complementary feeding, multiple micronutrient supplementation and iron-folic acid supplementation were included, they were not being reported.

To strengthen IM, crucial to a quick and timely response, external support was provided by UNICEF through the deployment of three IM officers (IMOs) (one national, two regional) a few weeks after Haiyan hit until mid-late 2014. IMOs worked with government and partner staff to organise a reporting system and website for the cluster as no common pre-crisis reporting system was in place and different indicators were being used to assess undernutrition in different areas. Information in the reporting system included results of activities conducted by government and non-governmental organisation (NGO) partners on IYCF, CMAM and micronutrient supplementation programmes. The system supported regular cluster reporting such as bulletins and situation reports through email and the website.

Challenges to the IM in response to Haiyan included:

Reporting: Various forms existed at sub-national level for nutrition data collection and the full range of indicators outlined in the NC monitoring and evaluation plan and SRP was not included in any one form. In many areas during the early response, forms were not available to cluster partners and transmission of data was sporadic and unreliable (due to poor communication lines and long power cuts) when frequent reporting updates were expected. For some indicators (i.e. MNPs), data were received from inappropriate proxy locations (site distribution) rather than Rural Health Unit (RHU) or household-level recording/reporting.

Limited capacity building: While the IM officers worked alongside local staff, there were limited mentoring opportunities to support knowledge transfer to the local staff.

No existing system within which to build or integrate: While there was interest and buy-in from the government on IM, there was no existing surveillance system to build or integrate IM systems into and there was lack of clarity on who would collect what data at community level.

Limited local systems/structure for IM: Strengthening of local IM capacities was identified as an urgent need by the NNC during the response. While there were plans to build local IM capacities, at the time, there was no nutrition-specific IM training package endorsed by the Global Nutrition Cluster (GNC) or the NNC.

Capacity building for nutrition programme response

Lack of available experienced and competent implementing partners has been a recurring constraint in emergencies in the Philippines, including the Zamboanga City siege (September 2013), the Bohol earthquake (October 2013) and the protracted Autonomous Region of Muslim Mindanao (ARMM) conflict (started 2009). At the time Haiyan hit, UNICEF and partner NGOs were already responding to these other emergencies, which limited their capacity to support areas affected by Haiyan. The limited capacity on the ground for programming in nutrition highlighted the need for capacity building during the Haiyan response.

To this aim, UNICEF conducted a ‘training of trainers’ with partners and provided funding and technical support (an IYCF-E consultant) to partners to further train local health workers to strengthen the capacities of service providers at provincial and municipal level in the delivery of quality nutrition services. UNICEF also conducted cluster coordination training in July 2014 to build the capacity of NNC staff and Nutrition Programme Coordinators at sub-national level in coordination. Additionally, UNICEF provided technical support to NNC’s Surveillance Division to build capacities on how to conduct and manage SMART surveys.

Challenges to capacity building

Long-term development activities for nutrition were included in the National Nutrition Plan but implementation was variable across the regions and did not always correspond to quality nutrition service delivery (pre-Haiyan). Haiyan highlighted gaps in non-emergency nutrition service delivery and emergency preparedness for nutrition. While a training package to orient and train community workers on nutrition in emergencies had been adopted nationally, it had not been rolled out at the time of the response. Several partners were unaware of this, which resulted in overlap in the content of trainings run by partners. While there were plans at sub-national level for capacity development activities, there was no overarching capacity development action plan at national level. While a capacity mapping exercise was conducted, the resulting database did not include government nutrition response preparedness capacities. In an effort to complete activities before the funds expired, implementing partners often ran simultaneous trainings, which resulted in a competition for participants and significant absences of local health staff thus compromising health service delivery².

Transition

In line with the recommendation by the IASC (the primary mechanism for inter-agency coordination of humanitarian assistance) that formally activated Clusters are only a temporary coordination solution to be used when existing coordination and response mechanisms are overwhelmed or constrained, the NNC was quick to initiate a transition³ process back to the government-led emergency response coordination mechanism. The government decided shortly after the response began that the NC leadership and functions would transition back to the NNC in June 2014. This date was decided despite the SRP funding for a year (through October 2014) and in the absence of a capacity assessment of the government cluster lead agency.

The transition process included a series of activities: setting the structure and documentation framework for regular NC coordination meetings, developing capacity mapping tools, and initiating work on the nutrition cluster preparedness and response plan and the nutrition cluster advocacy plan. Some of these actions were initiated as part of the transition process but were completed after the cluster had officially transitioned, as the date for transition was pre-decided and not tied to activities or indicators of capacity. The transition process and challenges to this are fully outlined in the case study report on the Philippines transitioning experience post-Haiyan⁴.

Learning from the Haiyan response

Key lessons from the response to Typhoon Haiyan include the following:

Treatment of acute malnutrition is not necessarily the most appropriate response to a natural disaster, particularly in a middle-income country. CMAM has been seen as the default NIE response , but other interventions may be more appropriate. Initial assessment and analysis should consider prevalence of acute malnutrition, stunting, micronutrient deficiencies, food access and availability, IYCF indicators and non-communicable diseases. To ease the situational analysis process required for the SRP in future responses, the NC has drafted a situational analysis with data depicting various potential scenarios. This has been developed and included in the preparedness plan of the NC, which will be used as a guide for future emergency response.

There was limited experience amongst traditional emergency response partners in the prevention of stunting. The programmatic shift from emergency CMAM programming to more developmental nutrition programing (with a focus on IYCF and micronutrients) took time, largely due to lack of capacity of partners at country level to re-orient their response. There is limited documentation and guidance on how to operationalise an emergency response that considers stunting, how to develop capacity in coordination and surveillance as part of the response, and what capacity this requires of partners. 

A more comprehensive IYCF response was needed. In addition to increasing efforts to uphold and enforce the Code, approved national guidance is needed on how to identify and support non-breastfeeding mothers, non-breastfed infants and complementary feeding. Standard Operating Procedures (SOPs) are also required for how to report Code violations. Guidance and SOPs should be included in any community-level NiE training, as part of preparedness efforts.

IYCF in Philippines emergencies should include counselling on exclusive breastfeeding and complementary feeding, as well as cater for the needs of non-breastfed and mixed-fed infants. Essential competencies for implementers include skills in hand expression of breastmilk, alternative feeding methods such as cup feeding, relactation, and knowledge on the sourcing and preparation of appropriate complementary foods.

Social media and strong leadership from existing mother support groups facilitated the convergence of volunteer mother support groups, a valuable resource for the government during times of disaster. Future responses would be enhanced if a mechanism existed for nurturing, sustaining and recognising social media and existing groups to augment local health workers and government responders.

Response should focus on building existing systems and government capacity. Planning for cluster transitioning should be initiated as early as possible and aim to restore adequate and sustainable coordination and IM mechanisms. From the onset, the focus of all surge and regular staff should be on supporting government functions and building the capacity of the Government in emergency nutrition response, coordination and IM.

Engage sub-national nutrition clusters and government regularly to share information, make strategic decisions, discuss operational issues and develop plans and proposals. Regular calls between national and sub-national coordinators and cluster IMOs in the different regions should be scheduled regularly. Partner selection and PCA development should be discussed at national and sub-national level with the NCC to ensure that partners are working alongside government for common objectives. The SRP and project proposal development processes should be consultative and involve cluster coordinators at national and sub-national level as well as government and cluster partners to ensure its effectiveness.

Conduct capacity mapping and capacity development. Capacity-mapping that includes programme and coordination capacity of government and partners should be conducted (and regularly updated) as part of preparedness activities. This information would be beneficial to cluster members and if reviewed in monthly meetings could support an overall capacity development plan. It would be useful to develop a capacity development plan (including government and partner trainings), a central repository for all common training materials, and an overarching monitoring and evaluation framework early on in the response (or as a preparedness action) to provide a framework and direction for future capacity development activities. Capacity building activities should be part of preparedness plans and linked to on-going capacity mapping activities. Where possible, consideration should be given to timings of trainings so as not to compromise health service delivery.

Capacity building efforts should support existing government staff and related systems as well as existing training mechanisms. Development of core competencies in NiE should be the outcome measure for training, not number of trainings or participants.

Preparedness planning efforts on capacity mapping of partners should identify which partners (including local NGOs) have the technical and operational capacity to deliver specific programmes. Pre-response standby agreements should be developed through PCAs/Memoranda of Understanding, facilitating a fast-track future emergency response. Transfer of roles from surge staff to ministry should be an opportunity for capacity development. A responsibilities matrix with generic roles would serve as a helpful document to guide leadership on the process of who should prepare what, for whom and when.

IM

If prepositioned, forms and IEC materials would be more accessible to local governments and implementing partners. Pre-standing contracts with printing companies would allow for rapid printing during an emergency. It is necessary to establish or strengthen the existing Nutrition Surveillance system and nutrition reporting systems to support long term IM. A standardised training package for IM requires development, linking to nutrition surveillance both under regular and emergency programmes.

Transition

A transition plan should be developed at the onset of the emergency through open discussion at sub-national and national levels, based on government capacity and encompassing all activities in the SRP with an agreed timeframe.

Funding

It is challenging to raise funds for preparedness activities and surveillance systems, which are essential yet not as visible as actual service delivery. Funding for preparedness should be included in the NC advocacy plan and a fundraising strategy for nutrition preparedness developed, consistent with the Scaling Up Nutrition (SUN) costed national plan of action.

Rehabilitation and recovery activities should be incorporated in the SRP alongside nutrition interventions. The SRP should reflect the various stages of the emergency and include interventions, indicators and targets for rehabilitation and recovery activities and initiatives in the nutrition sector plan.

It is important to engage with development actors on preparedness activities. While the cluster may have access to resources for preparedness, discussion on activities needs to be held in collaboration with development actors (both nutrition and non-nutrition sectors). Funding, capacity development and advocacy for nutrition are all areas where the cluster could collaborate with development actors under an umbrella of preparedness.

Conclusion

The response to Haiyan highlighted the pre-existing capacity gap for nutrition in terms of government-approved NiE policies, IYCF capacity, surveillance systems, a capacity development strategy for nutrition, and official reporting formats and mechanisms for nutrition. However, in response to Haiyan, NC efforts have addressed many of these gaps and the Philippines is in a stronger place currently in terms of government capacity, availability of guidelines and policies for nutrition. Although the international response to Haiyan has officially ended, NC staff and partners continue to work together to influence and develop long term nutrition plans to address the outstanding gaps. There is significant potential for the Philippines to leverage the momentum of the SUN Movement, which the Philippines joined in 2014, to support the integration of emergency nutrition response and preparedness and include this within the costed, multi-sector plan for nutrition.

For more information, contact: Aashima Garg or at work 

¹ Nutrition Cluster SRP for Typhoon Haiyan, November 2013.

² Minutes of the Region 8 NC meeting, January 24, 2014.

³ Transition for the Philippine context entails the shifting cluster leadership back to government through a series of both formal and informal capacity building activities to help strengthen existingsystems and ensure its sustainability. 

⁴ Case Study Report by the International Solutions Group - Nutrition Cluster Transitioning Study on the Philippines experience post-Haiyan (2015)