Nutrition Technical Rapid Response Team: Experiences and lessons learned

By Andi Kendle, Tech RRT Programme Manager

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Andi Kendle is the Programme Manager for the Technical Rapid Response Team (Tech RRT), working for International Medical Corps (IMC). She has more than 15 years’ experience in humanitarian assistance and development contexts in Sierra Leone, Sri Lanka, Malawi, Zimbabwe, Sudan (Darfur), Bangladesh, Colombia, Ecuador, Liberia and Somalia, among others. Andi is a public health professional with a Master’s degree in Public Health from Tulane School of Public Health and Tropical Medicine.

The author acknowledges the contribution of Scott Logue, Tech RRT Assessment Adviser, in developing this article and galvanising the other advisers to contribute to a collective effort to document experiences. This article is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the Tech RRT team and do not necessarily reflect the views of USAID or the United States Government.

The findings, interpretations and conclusions in this article are those of the authors and do not necessarily represent the views of USAID/OFDA, UNICEF or others.

Context

In August 2015, International Medical Corps (IMC), Save the Children and Action Against Hunger joined forces to establish the Nutrition Technical Rapid Response Team (Tech RRT) – a rapid response mechanism to provide immediate nutrition technical expertise during emergencies. This need was identified, discussed and debated for several years among Global Nutrition Cluster (GNC) members as they repeatedly observed technical gaps when national capacities were overstretched and unable to tackle and/or scale up nutrition services. Response capacity of governments, United Nations (UN) agencies and international and local non-governmental organisations (NGOs) is often compromised as they struggle to find adequate human resources to meet urgent technical needs. With the GNC’s primary focus on coordination and information management, including support for people in these roles, it was agreed that GNC partners have the responsibility to ensure they have capacity to deliver nutrition in emergencies (NiE) response and that UNICEF, as the Cluster Lead Agency (CLA) and ‘Provider of Last Resort’, would then cover the capacity gaps. While UNICEF explored ways to provide this support, the Tech RRT came on board so that, countries could rapidly access support for technical nutrition programming in emergencies in the meantime. Demands in the areas of community-based management of acute malnutrition (CMAM), infant and young child feeding in emergencies (IYCF-E) and nutrition assessments were identified (as recognised in a 2015 evaluation of the GNC (Richardson and Ververs, 2015). The technical complexity of new emergencies has only exacerbated this need.

How the Tech RRT works

The Tech RRT consortium agencies work in close collaboration with the GNC and UNICEF, funded by Office of the United States Foreign Disaster Assistance (OFDA) of USAID until the end of 2017. The purpose of the Nutrition Tech RRT is to improve the quality of nutrition humanitarian response by deploying technical surge, providing remote support and building the capacity of nutrition partners when national capacity is overstretched or inexperienced in nutrition in emergencies.

The Tech RRT operates almost as an independent body, housed within IMC, with technical advisers employed according to each consortium partner’s area of technical expertise. The team consists of either four or five experienced nutrition professionals with expertise in assessment, IYCF-E, CMAM and social behavior change (SBC). Action Against Hunger provides the assessment adviser, Save the Children the IYCF-E adviser, and IMC employs the programme manager as well as two advisers with flexible specialties (IYCF-E/CMAM and SBC/CMAM/assessments). The programme manager receives and handles all requests, follows all stages of each deployment, communicates with the steering committee and donor and manages the team to ensure that as many requests as possible are responded to. The consortium partners meet on a monthly basis and there is a deployment steering committee with representatives from each consortium member as well as from the GNC Coordination Team and UNICEF.

There is a set of agreed criteria and priorities for deployment and remote support, based on and adapted from those of the GNC RRT mechanism, ensuring harmony of approach between the two mechanisms (see Box 1). To date, a key criterion is that identified work should improve the technical quality or scale and reach of the emergency response and should benefit the collective rather than the individual interests/needs of an agency. Tech RRT personnel are deployable within 72 hours (depending on visa procedures) and deployments are normally for up to six weeks, with a 50-50 split between field and remote time.

Any in-country agency (Nutrition Cluster/Sector group/government/ministry of health (MoH)/provincial lead/district lead/NGO) can make a request on behalf of the collective following appropriate consultation on the needs with partners in-country, specifically ensuring that both UNICEF, country and regional offices and other UN agencies and NGOs are aware of and involved in the request. The request is sent to the Tech RRT programme manager, after which a detailed terms of reference (TOR) document should be finalised within three weeks. The deployment steering committee  reviews requests and decides within 48 hours. In general, the TOR for a deployment is agreed by the Tech RRT and the requester before arrival in-country, but is only considered final following discussion in person between the adviser and their in-country supervisor. This brings the technical lens of the adviser together with the contextual knowledge of the supervisor to establish priorities for the short duration of the deployment.

All assignment-related costs, such as travel, staff costs, per diem and accommodation, are covered by the Tech RRT grant. Normally costs for in-country activities, such as to conduct an assessment or a training, are covered by the requesting agency or as a collaboration with other partners; however the Tech RRT can support or share some of these costs as they should not be an obstacle to the activities taking place. When this is the case, a budget is prepared and discussed with the programme manager.

The Tech RRT adviser may be hosted by the requesting agency, another agency on the ground, one of which could be one of the Tech RRT consortium partners. The host agency provides the adviser with administrative and logistical support, the most important aspect of which is security arrangements. When the hosting agency is not the contracting agency, a letter of understanding is signed with the host agency in-country (with the exception of UNICEF, where the Standby Partnership Agreement covers this). The most common scenario is that the Nutrition Cluster makes the request, via UNICEF, and therefore either UNICEF or a consortium partner hosts the Tech RRT Adviser and they sit with the Cluster Coordination Team or one of the Cluster’s Technical Working Groups, if it exists.

Occasionally, when there is more demand for Tech RRT support than capacity, or when a request goes beyond the current skill-set of the team, agencies within the partnership (such as Save the Children Humanitarian Surge Team or IMC) may second staff with the right skills, experience and language to the Tech RRT to support a deployment. This adds a great deal of flexibility to the system.

Box 1: Criteria and priority for Tech RRT deployment and remote support

Criteria for deployment (adapted from the GNC RRT mechanism):

1. Level 2/Level 3 categorisation where cluster or sector coordination mechanisms are in place.

2. Humanitarian crisis, including rapid-onset emergency such as natural disaster or slow-onset emergency as defined by OCHA, such as drought, political/economic crisis and global challenges (climate change, etc.).

3. Countries with limited technical capacity in nutrition in emergencies.

4. Does not duplicate other support on the ground or planned.

Priority:

1. Declaration of a Level 3 emergency.

2. Rapid-onset emergency OR rapid deterioration of pre-existing situation.

3. Threat or forecast of Level 2/Level 3 emergency.

General conditions for Tech RRT remote support

1. The work will advance or promote the global, regional or country-level agenda in one of the Tech RRT technical areas.

2. The work is in follow-up to country-level work that an adviser has been involved in, with the underlying aim for the country to take on these responsibilities, and using techniques to build their capacity to do so.

3. Technical support that goes beyond the role of the GNC helpdesk, usually requiring some dedicated time and attention but not requiring presence in a country.

4. The work is either short enough to ensure that it will be completed prior to any potential deployment or can be put aside should the adviser need to deploy.

Tech RRT country deployments

Typical activities of Tech RRT advisers in each of the four areas of expertise (assessment, CMAM, IYCF-E and SBC) are listed in Box 2; these are adapted to each country’s needs and are not exhaustive. Since August 2015 there have been 30 Tech RRT deployments, summarised in Table 1. Most have been to chronic emergencies as there have been few large-scale, rapid-onset emergencies in the last two years compared to previous years. Almost all deployments have been to countries with an active Nutrition Cluster/sector coordination mechanism (except Mozambique which in fact took on the same NiE coordination structure for the sector), likely reflecting the roots of the Tech RRT. Since the mechanism is still young and awareness of the Tech RRT is lower in countries without an established cluster or sector coordination mechanism, most deployment requests come out of proactive engagement with in-country actors. Each deployment is unique in terms of who makes the request, who hosts the adviser and who supervises their work, depends on the context and is designed for maximum efficiency and ownership by in-country stakeholders. Deployment within 72 hours has rarely been needed as countries need time to make requests, develop TORs and ensure the necessary in-country consultations and buy-in.

Figure 1 gives a breakdown of deployments by technical area, which likely reflects the relative maturity of each within the nutrition sector. IYCF-E is now understood to be important but technical expertise is lacking and therefore requests for technical support are the most common. CMAM is an established intervention and has a greater pool of technical expertise; support is only required when the scale of the problem is vast. SBC in emergencies remains poorly understood and likely explains why requests for Tech RRT SBC are the least common. Many types of assessment require support, but for the most typical (SMART and SQUEAC), longstanding support has been available through the ACF-Canada SMART team and the Coverage Monitoring Network. Therefore, requests for assessment support are also rare.

The Tech RRT also provides remote support during non-deployment time. This is currently guided by the consortium partners and their knowledge of gaps and involvement with global level forum within each technical area. These have included input into global initiatives, such as the revision of the Operational Guidance on IYCF-E (artificial feeding section) and the revision of the CMAM Toolkit (led by Save the Children). Remote support is also provided to countries linked to previous deployments, such as in Yemen to support the Assessment Working Group in the review and validation of survey protocols and assessment results; in Nigeria to review the 2017/2018 response plan; and in Turkey/Syria to draft IYCF components of the Food Security Assessment Report. The team can also respond to stand-alone requests for remote support from countries although not that common, such as in Afghanistan to support the standardisation of nutrition indicators in multi-sector assessments and in Puerto Rico to support the prioritisation of IYCF-E activities during the first phase of the hurricane response (2017).  These have come either directly to the Tech RRT or through the GNC Help Desk and, with priority given to country level needs, the Tech RRT makes every effort to respond and support these. 

Box 2: Typical activities of Tech RRT advisers

Tech RRT advisers usually work in close collaboration with Technical Working Groups or a Strategic Advisory Group (SAG) when present as part of the Nutrition Cluster, either under their direction or building their capacity.

Assessment: Expertise to assess the situation rapidly may be lacking at the outset of emergency response programmes. Tech RRT advisers can lead, plan and conduct nutrition assessments in close collaboration with nutrition partners and potentially with other sectors; identify and design assessment activities according to needs (this may include initial planning, selection of tools and methods, sampling and writing guidelines); collect information on background/context relevant to the assessment/survey; identify learning needs and build the capacity of different stakeholders in conducting nutrition assessments and methodologies; plan and facilitate technical capacity building/training for government ministries and partner agencies.

See Scott Logue’s article in this issue of Field Exchange on experiences providing Tech RRT assessment support in South Sudan, Mozambique, Iraq and Yemen.

CMAM: Where acute malnutrition is an urgent priority, technical expertise within individual agencies as well as for the collective response is required to set up or scale up CMAM quickly. Tech RRT advisers can provide technical training, strategic advice and operational support on CMAM rollout (or on a specific component, such as inpatient care, where expertise is needed); assess CMAM capacity building needs across partners; conduct training of trainers (TOT) and orientations for stakeholders; provide support to the MoH and cluster/sector in the development of a CMAM strategy, guidelines or mapping; lead assessments for CMAM set-up or scale-up and advocate for inclusion of CMAM in multi-sector rapid assessments; monitor and provide recommendations/corrective actions to improve the quality of CMAM programming.

See Simon Koranja’s article in this issue on his experiences as Tech RRT CMAM adviser in Nigeria and Yemen and Michele Goergen’s article on her experiences in Nigeria.

IYCF-E: In-country-expertise on IYCF-E is often insufficient and there is a need for technically sound and realistic programming support. Tech RRT IYCF-E advisers can lead IYCF-E assessments and advocate for the inclusion of IYCF-E in multi-sector rapid assessments; support the development of an IYCF-E strategy or response plan; lead mapping exercises; guide the establishment of systems for monitoring of the International Code of Marketing of Breastmilk Substitutes; assess capacity-building needs across partners and develop a plan to meet them; conduct TOTs and orientations for stakeholders; advise on integration with other sectors; and provide recommendations or corrective actions to improve the quality of IYCF-E programming.

See articles in this issue by Tech RRT IYCF-E advisers detailing their deployment experiences, including Michele Goergen (Niger and Haiti), Sebsibie Teshome (Iraq) and Isabelle Modigell (Gaziantep, Turkey, supporting cross-border operations into Northern Syria).

SBC: Effective SBC is a critical but often unrecognised tool to reduce deaths, disease and deterioration of nutrition status in an emergency; it can also contribute to improved programme uptake by helping communities to understand the value of these programmes. Tech RRT SBC advisers can provide SBC training, strategic advice and operational support relating to nutrition (as well as sanitation and hygiene); lead SBC assessments (such as barrier analysis); design appropriate and evidence-based SBC national guidelines, response plan and strategy; advise on integration of SBC nutrition and hygiene behaviours with other sectors; adapt and design monitoring and evaluation tools and indicators; assess SBC capacity building needs across partners and develop a plan for meeting them; conduct TOTs and orientation for stakeholders and monitoring; and provide recommendations/corrective actions to improve the quality of SBC programming.

See the article in this issue by Daniel Takea, who was deployed as Tech RRT SBC adviser to support IYCF-E programming in Iraq.

Table 1: Tech RRT deployments

Figure 1: Breakdown of deployments by technical area

Lessons learned

In the past two years, significant efforts have been made to observe the strengths of the Tech RRT mechanism as well as to learn from the challenges. Table 2 summarises some of the strengths and challenges observed to date. Several important lessons have been learned across the Tech RRT deployments, some of which are highlighted in the Tech RRT case studies in this issue.

Firstly, TORs must be well defined, ideally prior to the adviser’s arrival in-country to avoid delays at the start of deployment and to allow the organisation of activities, such as training, to be put in place in advance. Where activities are likely to take longer than the deployment period, such as the development of strategies and guidelines that require buy-in from stakeholders, the role of the Tech RRT should be carefully considered, clearly defined, and embedded within bigger process, led by the cluster, a partner, or a Technical Working Group.

There have been very few requests for deployments in rapid-onset emergencies (other than Haiti in 2016 and the Caribbean in 2017); in these situations there is often limited capacity to understand the need for nutrition support. The request, TOR development and approval process must be reconsidered for these situations so that the Tech RRT can provide support at the critical onset.

So far the Tech RRT has had a substantial focus on policy-level work, particularly on the development of strategy and guidelines, tasks that largely support UNICEF’s role in working with governments. These tasks are critical to ensure an enabling environment for appropriate humanitarian response – i.e. if a guideline isn’t in place and endorsed by the MoH, it is unlikely that health workers will be allowed to implement it. However, the Tech RRT wants to be more available and accessible to NGOs for support to their programming and has therefore now  opened the scope of potential deployments to individual agencies as well as the collective. This will enable the Tech RRT to make a greater and more immediate difference to the quality and scale of technical programming at ground level as well.

While working for the collective has been the aim of Tech RRT deployments, managing expectations of host agencies and their individual needs has been an important part of negotiating deployments. In principle, if all agencies have a chance to input into the TOR development, the support needs of individual agencies (be it the host agency or others) will likely be mirrored by others and should be captured in the TORs. However in practice this has not always happened, creating pressure on the Tech RRT adviser when the host agency asks the adviser to support additional activity not factored into the deployment work plan.

The Tech RRT, configured as a ‘project’ with bilateral funding, has experienced some challenges around the ability to respond to any type of emergency request, as well as the reliability and sustainability of the mechanism. Currently, for example, if a request comes in towards the end of the funding cycle or for a refugee situation, the Tech RRT is unable to respond (refugee situations are not covered by OFDA funding but by another branch of USAID). To overcome these funding-related challenges, alternative funding modalities are being explored, such as models for cost recovery and/or cost sharing to pay deployment costs, providing periodic trainings to generate adviser salaries, as well as looking into pooled funding possibilities.

Much of the work that the Tech RRT advisers have undertaken would, in fact, be carried out more opportunely as nutrition preparedness for emergencies. Eleven out of 14 deployments over the past year had such key activities, i.e. updating guidelines, developing strategies or carrying out certain assessments. With a large proportion of emergencies being of a chronic nature, the line blurs on when these types of activity should take place, but without them it becomes difficult to programme appropriately. The recent hurricane season has also demonstrated that rapid-onset emergencies are critically in need of nutrition-preparedness initiatives – protecting, promoting and supporting infant feeding was barely on the horizon in the Caribbean, likely resulting in increased morbidity and mortality for these most vulnerable infants. Similarly, new initiatives such as the CMAM surge approach (www.concern.net/resources/cmam-surge-toolkit) are also about preparedness, but to date there are few human resources with the necessary skills to support its implementation. These are key areas that Tech RRT advisers could provide support to during ‘quiet’ times. While it could be argued that this is a role for development actors, it is a job that must be done together, bringing the knowledge and understanding of the specificities of emergencies.