Experiences of the ‘Whole of Syria’ coordination for nutrition
By Saja Farooq Abdullah and Lindsay Spainhour Baker
Dr Saja Abdullah is currently working as the ‘Whole of Syria’ (WoS) coordinator with UNICEF MENARO office. Saja is a medical doctor and holds a Master’s degree in Community Health. She has over 23 years’ experience in health and nutrition in emergency and development contexts in Yemen, Syria and Iraq with the United Nations, international NGOs and government. Previous roles include Chief of Nutrition for UNICEF and Nutrition Cluster Coordinator, both in Yemen.
Lindsay Baker is the WoS Nutrition Sector Co-Coordinator seconded to the Nutrition Sector by Action Against Hunger in Jordan. Lindsay holds a Master of Science degree in International Health. She has spent the last 13 years in South Asia and East Africa working in technical, management and coordination capacities for health and nutrition organisations.
The findings, interpretations and conclusions in this article are those of the authors. They do not necessarily represent the views of UNICEF, its executive directors or the countries they represent and should not be attributed to them.
Location: Whole of Syria
What we know: Coordinating delivery of humanitarian assistance in Syria is complex and challenging.
What this article adds: A Whole of Syria (WoS) coordination approach was established in 2015 to bring humanitarian actors working in Syria and in neighbouring countries (cross-border operation) together to increase the overall effectiveness of the response. It constitutes one comprehensive framework, a common response plan and a supporting coordination structure. The WoS Nutrition Sector is coordinated by the WoS Coordinator (UNICEF) based in Amman, with ACF as co-coordinator. Nutrition coordination mechanisms operate at ‘hub’ level (Turkey, Syria and Jordan). The WoS Nutrition Sector ensures suitable and single-sector input for humanitarian needs overview, periodic monitoring reports, the humanitarian response plan and related exercises (such as joint operational plans). Added value to date includes coordination between hubs with joint geographic presence to avoid duplication; ensure complementarity, enhanced collaboration between nutrition and food security; greater information sharing between hubs; flexible, responsive coordination; and joint planning. There has been considerable investment in national capacity development. The WoS approach has been instrumental in increasing the profile of nutrition, with a significant increase in the number of nutrition partners delivering nutrition activities and funding requests. Remaining challenges include limited funding; inadequate information about the nutrition situation in hard-to-reach and besieged locations; inadequate capacity of partners around nutrition; ongoing population displacements; and ever-changing frontlines.
The challenges humanitarian organisations face in their efforts to alleviate the suffering of people in Syria and to deliver assistance to meet their most basic needs are profound. Humanitarian partners provide assistance in Syria across three operational hubs (Syria, Turkey and Jordan) which are committed to working together under a ‘Whole of Syria’ (WoS) approach. This article describes the development, characteristics and added value of this approach with regard to coordination for nutrition.
Background
Nutrition was not a priority in Syria at the onset of the emergency due to the low prevalence of global acute malnutrition (GAM), lack of sufficient information on the nutrition situation and inadequate country capacity to understand and implement nutrition programming. The Nutrition Sector was only set up in Damascus in March 2013 after intense advocacy. Before the sector was established, there were limited partners carrying out uncoordinated nutrition activities for children under five years of age and women coming into Syria from neighbouring countries. In 2014 a series of United Nations (UN) resolutions enabled official cross-border humanitarian assistance in opposition-held areas. UN Security Council Resolution 2165, unanimously adopted on 14 July 2014, authorised UN humanitarian agencies and their partners to “use routes across conflict lines and the border crossings of Bab al-Salam, Bab al-Hawa, Al Yarubiyah and Al-Ramtha, in addition to those already in use,” to deliver humanitarian assistance to people in need in Syria. As part of this arrangement, the Government of Syria is notified in advance of each shipment of humanitarian assistance. A UN monitoring mechanism was established to oversee and confirm the humanitarian nature of consignments. The cross-border cluster system was subsequently activated and the WoS approach developed.
Country-specific challenges pre-cluster/sector activation and WOS approach
Coordination was difficult in the early days of establishing a Nutrition Sector in Syria (Damascus). Partners on the ground and donors did not perceive nutrition issues as priorities and donors prioritised other sectors because GAM prevalence among children under five years of age was low and infant and young child feeding (IYCF) activities were not classed as emergency interventions. In addition, the concept of nutrition sector coordination – its role and added value – was not fully understood by partners inside Syria. Consequently, the sector started with few partners; these were mainly UN agencies (UNICEF, World Food Programme (WFP) and WHO), the Ministry of Health (MoH) and the Syrian Arab Red Crescent (SARC). However after intensive advocacy it grew significantly, engaging local NGOs in the response, with technical and operational support from the three UN agencies. In the early days the sector focused on capacity development of local NGOs, SARC and MoH staff while providing preventative services, followed by establishment of curative interventions.
The nutrition response faced key challenges in timely reporting and situation analysis, aggravated by the lack of clear validation processes and inadequate in-country nutrition capacity. There were also challenges for the cross-border hubs from Turkey and Jordan before and during activation of the Nutrition Cluster/working groups and prior to the WoS approach. In Jordan, nutrition activities targeting children under five years of age and women occupied a small space in the health sector working group. In Turkey pre-cluster activation, the lack of an official UN role prevented access to certain humanitarian funding, such as the Central Emergency Relief Fund (CERF). There was also little consideration of nutrition supplies in inter-agency cross-border convoys.
Challenges common to all hubs included inadequate information sharing between the operational hubs, which led to programming gaps and duplication; limited access to the affected people in the hard-to-reach and besieged areas; limited capacity of organisations carrying out nutrition activities, particularly on community based management of acute malnutrition (CMAM), IYCF and assessments; lack of communication between hubs, making cooperation and information exchange between humanitarian actors difficult; and varied application of different standards and tools by organisations carrying out nutrition activities.
WoS approach
Coordination mechanism
The WoS approach constitutes one comprehensive framework, a common response plan and a supporting coordination structure. Bringing together over 270 international and national actors, it seeks to ensure strategic and operational coherence in the delivery of humanitarian assistance in Syria. The approach supports the use of a variety of response modalities to ensure that humanitarian assistance, including therapeutic and preventative supplies, reaches people in need throughout the country via the most direct routes. These include regular programming, inter-agency convoys, air drops, cross-border activities and remote programming. When needed, modalities are delivered to complement each other to maximise value and opportunity.
The WoS Nutrition Sector1 is part of the overall WoS structure that comprises sector-specific leads (UN agencies) and co-leads (NGOs) and the Inter-Sector Coordination Group (ISG), chaired jointly by the UN Office for the Coordination of Humanitarian Affairs (UNOCHA) and international NGOs, with participation of the sector lead/co-lead at the WoS level (see Figure 1 for coordination structure). A Strategic Steering Group (SSG) sits above the ISG, with representatives from key UN agencies and the NGO regional forum. The Nutrition Sector for the WoS provides technical and policy advice through the ISG to the WoS SSG to support decision-making throughout the humanitarian planning cycle. Final and strategic decisions regarding WoS coordination are made by the SSG.
Figure 1: Whole of Syria coordination structure
Evolution of approach
Following the adoption of the WoS approach, the Nutrition Sector at WoS level was coordinated by UNICEF’s regional nutrition specialist based in Amman, while ACF was elected co-chairagency and assigned a nutrition specialist for the coordination support. In 2016 UNICEF recruited a fixed-term WoS nutrition coordinator and an information management officer, both based in Amman, Jordan. Action Against Hunger Spain seconded an international staff member as the co-coordinator for the WoS sector, based in Amman.
Alongside WoS coordination on nutrition there are also national-level nutrition coordination mechanisms within each hub (see Figure 2). In Syria, the Nutrition Sector is based in Damascus and is led by a dedicated UNICEF Nutrition Sector coordinator together with the MoH, under which there are five sub-national Nutrition Sectors at field level. In Turkey, the unofficial cross-border sector working group transitioned to a cluster approach in 2015, with rapid response teams providing surge capacity in coordination. A UNICEF Nutrition Cluster coordinator was appointed early in 2016 on a long-term basis in Gaziantep and a co-coordinator was staffed by GOAL. The co-coordinator role rotates among agencies and is currently staffed by Physicians Across Continents (PAC). In Jordan initially there was no standalone nutrition coordination forum: nutrition was part of the health and nutrition working group led by WHO and there were no nutrition partners responding from Jordan. With the appointment of the WoS nutrition coordinator by UNICEF in Feb 2016, the staff took on extra responsibility to coordinate the nutrition working group in the Jordan hub and began to mobilise nutrition partners based in Amman for the South Syria cross-border response from Jordan. By the end of 2016 a standalone coordination group for nutrition under the leadership of UNICEF had been established, with at least five NGO partners implementing cross-border nutrition activities in southern Syria. In 2017 a co-coordinator for the South Syria cross-border response from Jordan was elected and is now staffed by Syria Relief and Development.
Figure 2: Nutrition coordination arrangement for Syria
Responsibilities of the WoS Nutrition Sector
The WoS Nutrition Sector is responsible for ensuring suitable and single-sector input for humanitarian needs overview (HNO), periodic monitoring reports (PMR), the humanitarian response plan (HRP) and all related exercises, such as joint operational plans. The WoS Nutrition Sector identified four strategic objectives in the HRP 2017, all of which have strongly linked humanitarian and resilience programming (see Box 1). Strategic objective one (SO1), for instance, addresses the main nutrition problems with short-term consequences but that also contribute to long-term problems, such as stunting. Hence the focus of SO1 is to prevent micronutrient deficiencies; promote, protect and support recommended IYCF practices in emergencies (IYCF-E); and optimise maternal nutrition. Likewise, for (SO2), while the emphasis is the treatment of acute malnutrition treatment in children and women to save lives, interventions to prevent long-term consequences (stunting) are also important. SO2 also considers in-country capacity development in preparedness and contingency planning in the event of pockets of acute malnutrition. Both SO3 and SO4 are vital to ensure updated information on nutrition for early warning and early action, as well as for long-term programming through the development of in-country capacity on robust, evidence-based information systems. This is also applicable to coordination because capacity development and intelligent joint programming are necessary to maximise impact and make efficient use of available resources.
Box 1: HRP 2017 WoS nutrition strategic objectives
- Strengthen life-saving preventative nutrition services for vulnerable population groups focusing on appropriate IYCF practices in emergency, micronutrient interventions and optimal maternal nutrition.
- Improve equitable access to quality life-saving curative nutrition services through systematic identification, referral and treatment of acutely malnourished cases for children under five years of age and pregnant and lactating women (PLWs).
- Strengthen robust, evidence-based system for nutrition with capacity in decision-making to inform needs-based programming.
- Establish coordinated and integrated nutrition programmes between and across relevant sectors through enhanced coordination and joint programming.
The WoS Nutrition Sector is responsible for coordinating sector assessments and needs identification. It has an operational coordination role which involves the coordination of interventions to ensure complementarity and prevent overlap and duplication, as well as to assess and prioritise countrywide gaps. Furthermore, the WoS facilitates agreement on joint advocacy messages at sector level across hubs when required and provides strategic backing to hub-level sector/cluster leads, including sharing of best practices and knowledge, capacity building and policy advice. In this way the WoS helps to standardise response approaches across hubs and ensure preparedness and complementarity between different programmes, while consistently working towards the goal of ‘do no harm’.
Added value of the WoS coordination
The WoS Nutrition Sector coordination team provides added value in this particularly challenging context in several ways:
Coordination of nutrition responses between hubs when more than one hub is responding in a geographic area: For example, the Nutrition Sector at WoS level is conducting coverage and gap analysis every month. Following the analysis monthly alerts are shared with the hubs, where joint geographic presence is identified to ensure no duplication and enhance complementarity.
Capacity development: This has targeted staff from key nutrition partners to establish a roster of trained personal on important nutrition topics across the hubs, such as SMART surveys, IYCF-E and cluster coordination. This initiative will ensure a good level of preparedness, so that the trained resources can run cascade trainings at their respective hubs should the response warrant scale-up.
Enhance inter-sector collaboration: Through joint collaborative efforts between Nutrition and Food Security Sectors at WoS level, harmonised joint information, education and communication (IEC) tools have been finalised between both sectors and shared with partners across the hubs; joint assessment tools have been agreed; and standard operating procedures to use common delivery platforms are under development. In addition, the Nutrition Sector across the hubs committed to and actively participated in the Integrated Food Security Phase Classification (IPC) exercise launched during 2017.
Facilitating information sharing between hubs: Regular communication between nutrition coordinators and co-coordinators at hub level involves quarterly face-to-face meetings and dial-in meetings once every two weeks at a minimum (more often when necessary) to discuss common issues and agree standards. An information-sharing protocol for the Nutrition Sector has been developed and used by the coordinators, information management officers and partners across the hubs; this facilitates information sharing between the hubs and the WoS, especially information related to capturing and monitoring the ongoing response, such as the sector 4 Ws (who, what, where, when) tool. The WoS Nutrition Sector website is accessible to all nutrition partners working in Syria; this is a one-stop location for obtaining all reports, trainings and tools: www.humanitarianresponse.info/en/operations/whole-of-syria/nutrition
Flexible and adaptable coordination: In the northeast of Syria, WoS coordinators across all sectors took on extra responsibility to coordinate the response between actors in the northeast who are operating across the border, mainly from Iraq and Qamishli (sub-national sector of Damascus hub), by facilitating information sharing on the response gaps for the Raqqa crisis and assigning roles to partners based on their access and operational capacity.
Harmonised assessments and monitoring: The WoS Nutrition Sector has led harmonised initiatives between cross-border programmes in the north and south of Syria, such as the nutrition surveillance system reaching hard-to-reach areas in Ar Raqqa and Eastern Ghouta to bridge the information gap and the joint barrier analysis for IYCF in the north and south of the country.
Joint planning: The WoS Nutrition Sector facilitates joint planning and has led the HNO and HRP development processes to generate a holistic and consolidated single plan. The latest HRP for Syria can be downloaded from: www.humanitarianresponse.info/en/operations/whole-of-syria/document/2017-syrian-arab-republic-humanitarian-response-plan.
Actions to support appropriate IYCF practices: Widespread random distribution of breastmilk substitutes (BMS) by different actors, including those providing health, nutrition and food services, is an ongoing problem. The WoS Nutrition Sector has worked hard over the past two years to address these obstacles to enable a coherent, coordinated and effective nutrition response to the people of Syria. Actions taken on IYCF include the development of an IYCF-E operational strategy for cross border-programming; a joint statement issued by cross-border partners to protect promote and support recommended IYCF practices; and development of standard operating procedures (SOPs) for the targeted distribution of BMS.
Initiatives to mainstream nutrition services in existing systems and programmes: Due to ongoing advocacy, awareness raising and capacity development, the Nutrition Sector has succeeded in raising the profile of nutrition in the context of Syria. For example, in close coordination with the MoH, the Syria hub integrated mid upper arm circumference (MUAC) screening into a measles vaccination campaign in May/June 2017. As a result approximately half a million children were screened for acute malnutrition through over 600 health facilities by MoH with UNICEF support. The screening is part of efforts to identify acutely malnourished children and link them to treatment centres that provide CMAM services. In the Turkey and Jordan hubs, an intensive IYCF awareness campaign has had a positive influence on partners. Nutrition activities have been mainstreamed in the essential health service package at all three levels (primary, secondary and tertiary) and the nutrition surveillance system has been integrated into the Early Warning Early Action (EWARN) system that monitors the communicable diseases, water, sanitation and hygiene (WASH) and the Expanded Programme on Immunisation (EPI) programmes.
Advocacy for greater funding and supplies: Internal advocacy efforts by the WoS Nutrition Sector team have played a big role in identifying and securing funding from UNOCHA for nutrition interventions that, in turn, have led to increased Syrian (local) NGO funding. External advocacy efforts by the WoS coordination team have highlighted the nutrition needs beyond acute malnutrition, bringing attention to the pockets of malnutrition, poor IYCF practices, micronutrient deficiencies and the consequences of underfunding; this has increased the visibility of nutrition needs in Syria. The WoS coordinators have also fed into inter-agency convoy planning by informing on needs and gaps to ensure that necessary nutrition supplies are included.
Inter-sector collaboration at WoS level
In 2016 both the Food Security and Nutrition Sectors at WoS level took the initiative to explore common themes and opportunities on which to work jointly in order to maximise the efficiency of the response and achieve shared results. Both coordinators reached out to their global counterparts, who provided support for the first nutrition, food security and livelihoods (FSL) workshop, held at WoS level in October 2016 in Jordan and attended by the global Nutrition and Food Security cluster coordinators and country-level coordinators and partners. At the workshop a set of opportunities was identified and recommendations were made to promote enhanced inter-cluster operational collaboration around four areas: assessment and analysis; general food distribution (GFD) as a delivery platform for nutrition-specific interventions; delivery of nutrition messages in FSL programmes; and capacity development.
This strategic workshop was followed by an operational workshop in March 2017, where an action plan was consolidated with participation from all hubs and key partners, including WoS coordinators and co-coordinators from FSL and nutrition, and nutrition country-level coordinators and co-coordinators. Concrete and actionable outputs were identified in each of the four areas, as well as opportunities for the two sectors to work closely together.
An SOP/Memorandum of Understanding (MOU) for the Nutrition and Food Security inter-sector coordination on the use of the general food distribution as a delivery platform for nutrition interventions was drafted and endorsed in March 2017 at WoS level. This was an output of the second joint inter-sector workshop. It outlines a recommended package of services to be jointly delivered through various delivery platforms (See Box 2), eligibility criteria, nutrition and food security respective responsibilities, and an action plan. Services are shaped and decided according to context, partner capacity and available resources. It was agreed to include nutrition vulnerability (children under five and PLW) as a criterion for food security vulnerability. According to the action plan in the SOP/MOU, an inter-sector strategic advisory group will be formed (both at WoS and at hub level) to act as a strategic guidance body; for ongoing planning, implementing and monitoring of the joint approach; and to update SOPs. Terms of References (TORs) for the group are under development.
Box 2: Nutrition and Food Security joint package of services
Platform one: Ready-to eat-foods for five days to a maximum of two weeks for new internally displaced persons (IDPs)
Nutrition interventions: High-energy biscuit (HEB) distribution for children under five years of age (6-59 months) and PLWs.
Platform two: Regular food parcels given on a monthly basis under GFD for a period of one year, with quarterly assessment of vulnerability status. Nutrition interventions include: Supply of HEB, Plumpy’Doz and micronutrient powder; nutrition messaging; MUAC assessment of mothers and children; revision of the food basket to ensure nutrition value; and adherence to Sphere Standards
Platform three: Cash and voucher-based transfer programme (CBT) targeting the most vulnerable groups and based on specific assessment according to mode of distribution. Nutrition interventions: Include PLWs and children under five years of age as eligibility criteria; provide recommendations to partners and beneficiaries on the nutritional value of different local foods as per their availability in the market; and advise on a healthy balanced meal.
Platform Four: Schools
Nutrition interventions: Provision of HEBs, nutrition messages and micronutrient supplements.
Platform five: Livelihoods programmes targeting people based on joint food security and nutrition vulnerability criteria with livelihood interventions.
Platform six: Agricultural programmes
Nutrition interventions: Development of nutrition-sensitive agricultural programming based on the capacity-building workshops currently underway across all hubs.
Target group and eligibility criteria
Food Security: Vulnerability criteria
Nutrition: Children under five years of age and PLWs
A set of harmonised IEC materials for nutrition was made available to partners for operational day-to-day use. These covered topics such as advice to workers on food distribution; job aids on micronutrient powder distribution; flyers/brochures on general messages for good nutrition, breastfeeding (poster, flyer, storybook), complementary feeding, food safety, IYCF counselling cards, Plumpy’Doz, and HEBs. The tools are available in Arabic at: www.ennonline.net/iectoolsnutritionarabic
Following the finalisation of joint assessment tools (questionnaire), Turkey and Jordan cross-border partners conducted a joint food security and nutrition assessment in 80 sub-districts, reaching 8,808 households. The assessment captured information on key IYCF practices. The quality of the data collected was challenged and several limitations were detected, hence it could not be used for the HNO 2018 but will be used to generate lessons for future learning. Feedback to Food Security partners was given following the analysis to improve data collection quality in the future.
Conclusions
The WoS coordination on nutrition has been instrumental in achieving well organised and systematic information sharing to enhance efficient and effective nutrition response coverage. Having standalone coordination forums for nutrition has allowed for better recognition of nutrition priorities, which were initially diluted under the health working group; facilitated more effective collaboration between partners and across sectors; and enabled joint planning and action to address nutrition priorities in both the short and long term. From just three appealing organisations in the HRP 2014 (WHO, WFP and UNICEF) with a total ask of US$29.9 million, this has grown to 20 in 2018, requesting US$70.7 million.
Many challenges for the Nutrition Sector remain in Syria. These include limited funding; lack of nutrition information from some hard-to-reach and besieged locations such as Dier ez Zor and Raqqa; inadequate capacity of partners around nutrition; ongoing population displacements; and ever-changing frontlines. Integration of nutrition activities in the health and food sectors is under continual negotiation and development. The WoS Nutrition Sector has worked hard with the Food Security Sector to develop joint assessment tools, conduct joint assessments and analysis and agree on common educational messages for nutrition and food security actors. However, there are opportunities to go further, such as integration of nutrition into the design and implementation of cash programming in Syria, particularly in areas with limited access for delivery of supplies and in conjunction with other sectors.
Through its unique operation and the 3RP2, the WoS structure has reinforced the importance of establishing regional and sub-regional coordination mechanisms for nutrition that can enhance and coordinate a connected response between countries; exchange experiences between similar contexts and with those affected by similar crisis; and serve as a rapid response mechanism for technical support in coordination and technical areas.
For more information, contact: Saja Abdullah or Lindsay Baker
Endnotes
1The term ‘sector’ is used to describe the existing nutrition coordination forums/mechanisms at the WoS level and Damascus/Syria hub, while the term ‘cluster’ is used by Gaziantep/Turkey and the term ‘working group’ is used by Amman/ Jordan hubs to describe the same concept. The three terms are equally relevant and the coordination forums share the same function at the three operating hubs, but slightly different functions at WOS level, as described in this article. The decision on which term to be used is taken by the humanitarian leaderships in the respective hubs based on consensus among the actors.
23RP is the Regional Refugee and Resilience Plan 2017-2018 in response to the Syria crisis. www.3rpsyriacrisis.org/the-3rp/