Tech RRT IYCF-E support for Aleppo response, Northern Syria
By Isabelle Modigell
Isabelle was a Tech RRT IYCF-E Adviser from 2016 to 2017, prior to which she was part of Save the Children’s humanitarian surge team, rapidly deploying to emergencies to support assessments, programme design and set-up. Isabelle is currently working as an IYCF-E consultant, based out of Yangon, Myanmar.
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.
Turkey-Syria cross-border 2016
Technical area: Infant and Young Child Feeding in Emergencies (IYCF-E)
Location: Gaziantep, Turkey (Response: Aleppo, Northern Syria)
Period: 18 February – 30 March 2016
Requesting agency: Turkey-Syria cross-border Nutrition Cluster
Host agency (in-country): Save the Children Turkey
By 2016 an estimated 13.5 million people needed humanitarian assistance in Syria; 4.5 million of whom were in hard-to-reach and besieged areas. At the start of February 2016 intensified conflict caused a new wave of internally displaced persons (IDPs) to flood into the governorates of Aleppo (63,000) and Idleb (over 12,000), in addition to the more than two million IDPs already there. By February 2016 some camps were at triple capacity, with two or three families occupying tents intended for one or living in communal tents, informal settlements or under trees.
Prior to the Syrian crisis infant and young child feeding (IYCF) practices were already sub-optimal (46 per cent early initiation of breastfeeding, 43 per cent exclusive breastfeeding, 23 per cent continued breastfeeding at two years of age, 37 per cent timely introduction of complementary foods, and wide acceptance of the use of breastmilk substitutes (BMS) (UNICEF, 2012). Rapid needs assessments of IDP areas in Northern Aleppo in 2016 revealed a high-risk situation for infants and young children, with widespread distribution of infant formula, poor availability of complementary foods, lack of safe water supply, mothers reporting breastfeeding difficulties, low awareness of recommended IYCF practices and a lack of adequate skilled support for breastfeeding mothers. In addition there was a lack of protection and support for non-breastfed infants and regular one-off BMS distributions without any support or measures to minimise risks.
In early 2016 the Nutrition Cluster requested a Tech RRT IYCF-E adviser to work with cluster members for six weeks to lead and support an IYCF-E response to the recent wave of displacement.
Key deliverables of the deployment were:
- Mapping of IYCF-E priority needs and partner capacities;
- Provision of technical support to the Nutrition Cluster co-ordinator and IYCF-E technical working group (TWG) co-chair on IYCF-E;
- Provision of technical support on the procurement, management, distribution and use of BMS, milk products, commercial baby food and infant feeding equipment, and guidance on uncontrolled donations of these products;
- Support to establish links with other sectors, including the integration of IYCF into community-based management of acute malnutrition (CMAM) programming and the integration of IYCF into health and other clusters;
- Capacity building of Nutrition Cluster partners to set up/scale up IYCF-E activities through orientation, training and on-the-job remote support; and
- Facilitation of consensus on common messaging relating to IYCF-E and provision of technical support on a communication/advocacy campaign.
There were several operational challenges in this deployment. Firstly, the working language for most Nutrition Cluster partners is Arabic, which the Tech RRT IYCF adviser did not speak. This made it difficult to gain rapid insight into partner programming, identify pre-existing tools and produce outputs at speed. A translator was available, but only part-time. In post-deployment feedback, it was recommended that in future deployments potential language barriers should be anticipated in advance and a skilled translator, familiar with technical terminology, should be engaged early for the duration of the deployment.
There were also challenges associated with remote programming. It was not possible to enter Syria directly to observe operations, so the Tech RRT adviser was reliant on information provided by partners whose capacity to implement IYCF-E programmes still required strengthening. In such circumstances, a broader range of technology (such as web-based technology) could be used to facilitate remote ways of working, including remote supervision.
Due to low quality of data shared by partners it was difficult to gain an accurate picture of partner capacity, as well as current and future plans. The use of simpler formats for data collection (such as KOBO questionnaires – a suite of tools for field data collection for use in humanitarian/development contexts), all accurately translated into Arabic, was proposed to help improve this.
Another challenge emerged regarding BMS distribution. IYCF-E programming was relatively new to most implementers, many of whom had previously worked in a medical sector in which BMS prescriptions were the norm. Some actors distributing BMS did not respect minimum standards but, since they operated outside of the Nutrition Cluster, were difficult to hold to account. More comprehensive BMS distribution monitoring was needed; for example, within the planned monthly Whole of Syria (WoS) needs assessment and through wide rollout of a BMS distribution alert system (a smartphone-based online form that field staff can use to log BMS distributions and alert the Nutrition Cluster). These activities require strong advocacy and support from the Nutrition Cluster, particularly geared towards local NGOs, who often have the power to negotiate and act at local level when given the necessary information. In addition, it was recommended that Nutrition Cluster partners should align themselves with BMS standard operating procedures (SOPs) developed by the Tech RRT adviser and that community mobilisation and sensitisation efforts, including the use of social media, should be intensified.
An additional lesson learned was the great importance of integrating IYCF into the delivery of health services, particularly in a context where most of the nutrition actors originated from the health sector and so were frequently also implementing humanitarian health programmes. Sometimes practices within these very health programmes were negatively impacting IYCF practices. Existing programmes, such as integrated management of childhood illness (IMCI), provided an important opportunity for IYCF-E programming and needed to be strengthened to ensure that IYCF components were adequately implemented.
Despite the challenges, the deployment went well and achieved most of its deliverables. The value of the Tech RRT deployment was the provision of a dedicated resource to drive the establishment of the Aleppo IYCF-E response. The Tech RRT adviser could allocate all her time to building partner capacities, harmonising and coordinating IYCF-E activities, creating common consensus and goals, and ensuring that the response was technically sound, without having to deal with multiple competing priorities inevitable in programme management. There was a clear need and demand for such support given the magnitude of the emergency and the limited IYCF-E experience of those mandated to respond. Catalysed by the Tech RRT deployment, the IYCF-E response transitioned from a piecemeal approach implemented by partners working in silos to a collaborative effort with partners aligned to agreed standards, with shared resources and a common response plan. Over the course of the deployment there was a palpable change in the momentum of the IYCF TWG and partners visibly became more enthusiastic about implementing IYCF-E as their awareness and understanding grew. While significant work remained to be done in strengthening IYCF-E programming, the groundwork was laid by the end of this deployment for a more coherent IYCF-E response that could feed into the wider effort.
Turkey-Syria cross-border 2017
Technical area: IYCF-E
Location: Gaziantep, Turkey (Response: Northern Syria)
Period: 26 January to 13 February 2017 in-country and 14-24 February remote
Requesting agency: Turkey-Syria cross-border Nutrition Cluster
Host agency (in-country): Save the Children Turkey
During 2016 the Nutrition Cluster partners continued to advance the IYCF-E response, using the tools and mechanisms established during the 2016 Tech RRT IYCF-E deployment and guided by the development of a three-year IYCF-E strategy (2017-2020) accompanied by a detailed costed plan of activities, launched in 2017 (see article on Turkey cluster experiences in this issue of Field Exchange).
In 2017, the Nutrition Cluster requested a further deployment from the Tech RRT IYCF-E adviser (hosted by Save the Children Turkey), as well as a Tech RRT social behaviour change (SBC) adviser (hosted by International Medical Corps (IMC)). The purpose of the deployment was to help plan baseline knowledge, attitudes and practices (KAP) assessments and barrier analyses inside Syria (for implementation by an incoming IYCF-E adviser) and to provide technical support to establish a rapid response system for the frequent population displacements.
The IYCF-E adviser met with those involved in the Aleppo evacuation at the end of 2016 (see article on Turkey cluster experiences in this issue) to understand experiences and lessons learned. This provided several useful insights but came too late, with many lessons already forgotten. Partners were urged to strengthen systematic knowledge management to share learning which could feed into the ongoing response and other responses in the region. Following a review of existing tools and approaches, a context-specific minimum rapid IYCF-E response package was defined which addressed situations in which the provisions of the BMS SOP (developed in 2016) could not be met. In consultation with the IYCF-E TWG, acceptable compromises were defined and guidance was developed for interventions such as bottle sterilisation and on-site wet feeding for populations in transit.
In addition the Tech RRT IYCF-E adviser provided support for the ongoing IYCF-E advocacy campaign and supported engagement with other sectors.
By the time of this second deployment, IYCF-E programming had matured. IYCF-E coordinating mechanisms (the IYCF-E TWG) were working well with good attendance, enabling the Tech RRT IYCF-E adviser easy access to the appropriate audience for discussions and information sharing. Familiarity of the adviser with the context, operating environment and Nutrition Cluster partners and low local (Syrian) staff turnover meant work could be started quickly. Several tools developed in the 2016 deployment were being used routinely by Nutrition Cluster partners. It was noted that it is important to push for the finalisation of tools while still in-country as there is a risk of them becoming lost among partners’ multiple priorities later. BMS-related programming had evolved from basic advocacy to stop BMS distributions in 2016 to discussion with partners about necessary ‘compromised’ BMS programming.
There were several administrative/practical challenges with this deployment. Advisers were not able to arrive in-country simultaneously due to different regulations by hosting agencies, which made working together more difficult, particularly across different time zones. There were challenges for the SBC Tech RRT to balance remote support to the KAP survey against other normal (non-deployment) work. Some difficulties around the administrative planning for the KAP survey training and implementation ahead of the deployment () caused significant delays. This was further complicated by key staff changes in the Nutrition Cluster during this period. It was recommended that advisers should be allocated a few non-administrative preparatory days for non-urgent deployments to establish contact with those on the ground and understand the needs and level of readiness to receive the advisers and maximise the adviser’s time in-country. A checklist covering all aspects of trainings, workshops and assessments could support this type of discussion – perhaps a worthwhile non-deployment task. The six weeks budgeted for the KAP survey proved an unrealistic timeframe that did not allow for the provision of support during analysis and interpretation of data, a critical phase during which technical support is vital. The lack of a database of standardised IYCF-E KAP questions was a broader limitation; this was highlighted as a need which was discussed with the Centers for Disease Control and Prevention (CDC). Both the KAP and barrier analysis assessments were carried out, in March and August respectively, and reports are being finalised by the Nutrition Cluster. Oncecomplete, these reports will be available through the Nutrition Cluster as well as on the Tech RRT website (http://techrrt.org/past-deployments/). Despite these challenges the 2017 deployment was successful in moving the IYCF-E response forward, helped by the obvious growth in Nutrition Cluster partners’ commitment and technical abilities, initiated during the 2016 deployment.
For more information, contact: Isabelle Modigell
References
UNICEF 2012. The State of the World’s Children 2012: Children in an Urban World. United Nations Children’s Fund (UNICEF), February 2012. www.unicef.org/sowc2012/pdfs/SOWC 2012-Main Report_EN_13Mar2012.pdf