Building national capacities for emergency nutrition preparedness and response in East Asia and the Pacific

Asia and the Pacific are areas of the world that are extremely vulnerable to natural disasters, both in terms of the frequency of disasters and the high number of people affected (ADB, 2013). The region is also highly exposed to the impacts of climate change. Extreme climate events are expected to have increased impacts in the coming years on human health, security, livelihoods and poverty by aggravating pressures on natural resources and the environments (IPCC, 2014). This is expected to increase the risk of acute malnutrition in a region where the population already has extremely high levels of stunting. In recognition of this growing threat to nutrition, in 2017 the Association of Southeast Asian Nations (ASEAN) Health Cluster identified the urgent need to strengthen the emergency preparedness and response capacity of member states to improve regional nutrition resilience.

Also in 2017, UNICEF undertook a qualitative analysis of the level of nutrition emergency readiness in the region, based on the core Nutrition in Emergencies (NiE) competencies (Meeker et al, 2014), to inform the development of a regional NiE strategy. A resulting recommendation was to use the ASEAN platform to advocate for the prioritisation of NiE and provide technical assistance to member countries to strengthen local government and health system capacities to prepare for and respond to emergencies. Four countries - Myanmar, Indonesia, Fiji and Kiribati - were prioritised for this process, based on their level of disaster vulnerability (frequency and expected impact of disasters) and available national capacity for response. In 2018, UNICEF launched a regional NiE capacity-building initiative focused on these countries, with the aim of developing a pool of national NiE experts who could support NiE preparedness and response in-country and in other ASEAN member states (constituting a national/regional response team), act as NiE ‘trainers of trainers’, and strengthen health systems and existing service-delivery platforms to deliver routine nutrition services. In this article we present experiences of the rollout of this programme through context-specific national and sub-national trainings in Indonesia, Fiji and Kiribati, and resulting efforts to develop and improve national preparedness plans.

Indonesia straddles the seismically active ‘Pacific Ring of Fire’ and sees frequent earthquakes, volcanic eruptions, tsunamis and localised incidents such as landslides, floods and forest fires. In 2018, the country experienced its worst year in over a decade when more than 3,000 people died in tsunamis and earthquakes in Sulawesi, Lombok, and West Java and Sumatra islands. Subsequently, in 2019, the National Disaster Mitigation Agency (BNPB) recorded a total of 3,622 natural disasters across the country.

In September 2018, the United Nations Children’s Fund (UNICEF) in collaboration with Action Against Hunger (AAH) UK supported the Indonesia Ministry of Health (MoH) to host the first-ever ASEAN NiE training. The five days training gathered policy-makers and decision-makers from nine ASEAN member countries to orientate them on and advocate for capacity development, systems strengthening and public health planning for NiE response in their respective countries.

On 28 September, the day after the ASEAN training, an earthquake and tsunami struck the Central Sulawesi province in Indonesia, revealing critical gaps in the NiE response capacity. The disaster demonstrated limited NiE capacity at national and sub-national levels and a lack of NiE standard operating procedures and guidance. Even though Indonesian participants of the ASEAN NiE regional training had gained some initial knowledge, this was not sufficient to aid a fast and effective nutrition response to the emergency. Informed by this experience, Indonesia MoH made a policy decision to strengthen national capacity for NiE response, officially launching an NiE capacity-building initiative in November 2018. This was further informed by the findings of an ‘after-action’ review of the Central Sulawesi disaster, conducted in April 2019. A timeline of this and other important actions in Indonesia is presented in Figure 1.

Figure 1: NiE capacity-building milestones

Development of a national NiE training curriculum

A national NiE training curriculum was developed for the Indonesia context as part of the MoH capacity-building initiative. This was adapted from the global and the ASEAN NiE training packages. Adaptations were made with support from AAH UK to align the training to the national context and policies, including the national Integrated Management of Acute Malnutrition (IMAM) guidelines and infant and young child feeding (IYCF) policy. Lessons from the nutrition response to the Central Sulawesi earthquake and tsunami in 2018 were used to identify gaps in the system to further inform the curriculum, including a lack of coordination for a nutrition response and a lack of tools for assessment. There was a marked lack of capacity within the health workforce to support optimal IYCF - even after breastfeeding corners were established, there were no skilled IYCF counsellors to support breastfeeding mothers at community-level and trained counsellors had to be brought in from Jakarta. There was also very limited capacity to treat children with severe acute malnutrition (SAM), in spite of a reported prevalence of 10.2% in 2018, with no outpatient therapeutic programmes, few doctors trained in the inpatient management of SAM, and inadequate screening and referral of SAM cases at community level. Care was taken to include these aspects in the first iteration of the training curriculum. Figure 2 depicts the structure and components of the training course. It was not possible to include a whole session on multi-sector programming; however, cash and food interventions were brought into the session on MAM and aspects of food security and livelihoods were included in the needs assessment session. Aspects of government coordination were included in the cluster coordination session.

Figure 2: Indonesia NiE course content

National-level training

The first national-level NiE training using the new curriculum was conducted in April 2019. Nineteen participants attended, including staff from the MoH at national and provincial levels, national and local non-governmental organisations (NGOs), and key academic institutions. Around one third of participants had been involved in the emergency response during the preceding months in Indonesia. One full day was dedicated to an emergency simulation focused on nutrition response and cluster coordination. The latest simulation used in the NiE UNICEF training in Lebanon was used as a model but contextualised and adapted to the Indonesia context.

The training also included a day and a half workshop on next steps for NiE preparedness and implementation, led by the MoH. This led to the development of national Standard Operating Procedures (SOPs) for different areas of NiE, based on lessons learned in the training, simulation exercises and extensive discussions between participants on next steps. SOPs were developed for coordination, assessment, IYCF, micronutrient deficiencies and IMAM. Each TOR incorporated NiE response planning, as well as plans for emergency preparedness and post-emergency.

Following the national training, feedback from participants and facilitators was gathered. A follow-up workshop consisting of representatives from the MoH, academia and local NGOs was held in July 2019 to further review and adapt the curriculum and to further align the material to the national context and policies. A facilitators’ guide was developed and the curriculum translated into Indonesian language. Trainers of trainers (TOT) were identified from the initial participants of the national training course and further equipped through a micro-teaching exercise. Following the micro-teaching exercise, the module was pre-tested in two NiE regional trainings.

Sub-national regional training

Two regional trainings were held using the updated curriculum in September 2019 with 50 participants, covering 12 of the most disaster-prone provinces in Indonesia. These trainings were carried out by the national TOT team with technical support from UNICEF Indonesia.

Several adaptations were made for the sub-regional training, including the featuring of a simulated nutrition sub-cluster meeting to demonstrate effective facilitation techniques; completion, analysis and interpretation of the ‘4Ws matrix’ to support decision-making in nutrition sub-cluster contexts; and a practical exercise on the use of mobile data collection tools in assessment (kobo toolbox¹). Case studies were included to help participants identify appropriate nutrition-sensitive interventions in a response and demonstrate links that nutrition clusters can make with other sectors during emergencies, including health; food security and livelihoods; Water Sanitation and Hygiene (WASH); and logistics.

Participants were invited to develop an NiE implementation plan for their province at the outset of the course, drawing from lessons learned during each course session. At the end of each day, participants were grouped by province to discuss their learning and how this could be reflected in their NiE plans. At the end of the training, each province presented its plan to all participants for feedback on further improvement. After each regional training, the training curriculum was further adapted and improved. Efforts to accredit the NiE curriculum for delivery at local technical institutions and universities are ongoing.

Since the start of this process, the Government has doubled its disaster budget and the MoH has allocated a budget specifically to support the rollout of the training in the districts of each of the trained provinces. There is also now a national plan for scale-up for eight essential nutrition interventions to be delivered through the health system as part of the global financing facility to reduce stunting, some of which is expected to support the rollout of NiE preparedness plans.

Fiji is prone to landslides, flash floods and storm surges as a result of tropical weather phenomena, including depressions and cyclones. In 2016, Fiji was heavily hit by Tropical Cyclone Winston, a category-five cyclone which destroyed many infrastructures and compromised the livelihoods of almost 60% of Fiji’s population. In September 2019, the Head of Nutrition from AAH UK visited the main stakeholders involved in emergency response in Fiji. This included a two-hour consultative meeting with different departments of the MoH and NGOs involved in nutrition to understand the national context and gather relevant documentation. On this basis, the planned NiE training for Fiji was tailor-made for the national context and MoH needs and relevant practical exercises devised.

A five-day NiE training was held in November 2019 in Nadi attended by 25 participants from the Ministry of Health and Medical Services. The training covered concepts of NiE; needs assessment and situational analysis; IMAM (based on the updated but not-yet-implemented national IMAM guidelines); IYCF-E (teaching participants how to use the Operational Guidance on Infant Feeding in Emergencies²); micronutrients; and the use of NutVal³ to plan, calculate and monitor the nutritional value of food assistance. Participants applied real-life data from Fiji to NutVal, and in doing so were able to agree on the revised composition of the Fiji food basket, taking into consideration the high prevalence of non-communicable diseases in the country.

Throughout the course, participants were encouraged to highlight gaps that needed to be addressed to improve Fiji’s preparedness; for example, the need to develop a multi-cluster/sector Initial Rapid Assessment (MIRA) questionnaire to ascertain prevalence of wasting and the need to develop to develop an IYCF-E policy. On the final day participants worked in four self-selected groups (assessment, acute malnutrition, ICYF-E and micronutrients) to develop preparedness plans, using the 2013-2017 Fiji National Health Emergencies and Disaster Management Plan (HEADMAP) as a template. The intention is to use the resulting plans to integrate nutrition (which was previously mostly absent) into the updated HEADMAP, which is currently in development.

Kiribati’s location puts it at risk of numerous types of natural disasters, including earthquakes and tsunamis, and is rated high on the vulnerability risk scale for humanitarian crises and disasters.⁴ Since November 2016, the country has been increasingly affected by drought as a result of the depletion of freshwater supplies. This situation has been exacerbated by frequent storms, rising sea levels and coastal flooding, leaving wells and groundwater sources unusable.

A visit was conducted in Kiribati in September 2019, involving site visits and key stakeholder meetings. The NiE training, tailor-made to suit the national context and needs, took place in early December 2019. Although it focused on the same topics as the training in Fiji, the 18 participants came from very varied backgrounds, from paediatric doctors to members of the Ministries of Fisheries and Commerce, as well as project managers of NGOs. The training allowed for rich discussions on the management of acute malnutrition, since the paediatric team in Kiribati has not yet adopted the 2013 World Health Organization update on the management of SAM.⁵ During the training on NutVal, participants agreed on a basic ration to be advised to businesses making donations to the disaster-affected population and, on the last day, key interventions were designed to be included in the draft emergency preparedness plan of the MoH and medical services. This included a draft IYCF-E joint statement, questionnaires for assessments, and a plan to ensure a regular supply of F75/F100 therapeutic milks and micronutrient powders for the management of acute malnutrition and to pilot the use of ready-to-use therapeutic food (RUTF). There is currently no data on prevalence of wasting, although this is forthcoming.

The NiE trainings held in Indonesia, Fiji and Kiribati offer several lessons that can be used in other contexts to ensure that NiE training is effective and leads to concrete improvements in NiE preparedness and response at national and sub-national levels.

Adapt training to suit national context

The success of the trainings was greatly helped by adaptation of materials to suit the national context and respond to identified gaps in NiE preparedness and response in each country. This is most effective when course designers gain a good understanding of the nutrition situation, existing systems, and platforms and policies, taking into account actions in previous disasters where possible. In each country stakeholders were engaged in this process of learning; in the case of Indonesia, they were also engaged in the curriculum-development process, which was important in increasing national ownership of the capacity-building process. Care should be taken to ensure that training materials align with national policies and the nutrition context (for example, prevalence of wasting, stunting and non-communicable disease), including terminology used, to enable maximum synergy between lessons learned and post-training actions. In the Indonesia context, the adaptation of the training to the national context helped to improve local acceptance of global guidance, including the use of mid-upper arm circumference (MUAC) in addition to weight-for-height for the detection of SAM and the use of the supplementary suckling technique for complicated cases of wasting in infants under six months of age.

Use of simulation exercises

Simulation exercises were useful in translating classroom knowledge into practice and in motivating participants to apply learning to their contexts. They helped to identify skills among participants that needed further strengthening and missing local guidance, which could then be included in action plans going forward. Simulation exercises were especially useful when based on real-life data and scenarios for that country, such as in the Indonesia context, where many had first-hand experience of the recent Central Sulawesi disaster, and the application of national data in Fiji and Kiribati.

Incorporation of coordination aspects

Training, orientation and planning should include aspects of coordination to ensure that appropriate systems are put in place to sustain preparedness and response actions.

Include relevant stakeholders

In all three contexts, efforts were made in advance of the trainings to ensure buy-in from government, which was critical to their success. In Indonesia, MoH leadership and ownership of the capacity-development process was crucial for the implementation of actions identified during the training, including the development of TORs and funding for further curriculum refinement and sub-national trainings. In Fiji and Kiribati, senior participants from the MoH reported that they felt empowered to replicate the sessions specifically on the basics of nutrition, pathophysiology of SAM, implementation of the International Code of Marketing of Breast-milk Substitutes, and management of donations. The involvement of a wider range of stakeholders in all countries beyond the MoH, including local NGOs and academia, was also important and contributed to the development of NiE national teams and the further rollout of training and national plans, as well as an enriched learning process. The involvement of academia in Indonesia in particular facilitated efforts towards accreditation of the national NiE training curriculum and future plans to teach the curriculum in local universities.

Cascade training to sub-national levels

The Indonesia example demonstrates the need to train not just at national level, but right down to provincial and district levels to promote real change and enable meaningful emergency preparedness and response actions. The example of Kiribati shows the need to include capacity-building of health workers at each level to ensure that plans are actionable down to community and facility levels. Efforts are being made to institutionalise training in Indonesia and this should be encouraged where possible to ensure sustainability.

Incorporate time and support to develop action plans

All three examples demonstrate the value of giving time for participants to work together and immediately apply their learning to actionable preparedness plans to effect real change. In all three country examples, the MoHs have requested support for further training and development of preparedness plans, which indicates their intention to incorporate lessons learned into national strategies and plans. In Indonesia, following the ASEAN training, an NiE capacity-building initiative was launched by the MoH and an NiE coordination body composed of government, local NGO and United Nations representatives was set up, which demonstrates long-term commitment.

The example of NiE training in Indonesia, Fiji and Kiribati by UNICEF and AAH demonstrates the potential for using contextualised training materials to build the capacity of national and sub-national stakeholders in nutrition preparedness and response. As a result of this programme, a pool of trained personal in NiE is now available across the three countries that can be used to develop in-country nutrition preparedness and who can be called on during crises in their own countries and beyond. Furthermore, the training has resulted in buy-in from national governments to address NiE gaps in their countries and the development of concrete action plans that are now being taken forward in each context.

As a result of the capacity-building process, Indonesia has committed to the development of national guidance and standard operating procedures to guide the nutrition response in future emergencies, as well as to the streamlining of coordination mechanisms for nutrition between national and sub-national level and the strengthening of information management and standardisation of interventions packages. Capacity of local government and district-level staff is also being developed to implement these plans. Fiji and Kiribati are reviving their emergency food baskets to include healthier options and increase dietary diversity for children. They are also committed to building sub-national capacity for nutrition response. Across the region, UNICEF will continue to promote this nationally-led approach to NiE capacity development.

For more information, please contact Alexandra Rutishauser-Perera at a.rutishauserperera@actionagainsthunger.org.uk

Asian Development Bank (ADB). 2013. Food Security in Asia and the Pacific. © Asian Development Bank. 

IPCC, 2014: Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part B: Regional Aspects. Contribution of Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change [Barros, V.R., C.B. Field, D.J. Dokken, M.D. Mastrandrea, K.J. Mach, T.E. Bilir, M. Chatterjee, K.L. Ebi, Y.O. Estrada, R.C. Genova, B. Girma, E.S. Kissel, A.N. Levy, S. MacCracken, P.R. Mastrandrea, and L.L.White (eds.)]. Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA, pp. 688.

Meeker, J., Perry, A., Dolan C., Emary, C., et al (2014) Development of a competency framework for the nutrition in emergencies sector. Public Health Nutrition, 17 (3), 689-699. Doi:10.1017/S1368980013002607