Complementary feeding in emergencies programming – Sudan case study
This is one of four case studies in this special section of FEX to highlight the importance of a strong contextual analysis to guide the appropriate design, implementation and monitoring of actions and interventions, cross sector collaboration and integration, and proof of concept of localised initiatives that have the potential to be scaled up at national level.
Gwénola Desplats is a Senior Nutritionist with ENN.
Jodine Chase is the Infant Feeding in Emergency Core Group facilitator at ENN.
Introduction
This case study reviewed the complementary feeding programming implemented in Sudan, as the country was known for having made some progress despite a recurring fragile context (ENN and IFE CG, 2022).
Programming context
Sudan presents a complex emergency context where conflict, political and economic instability, infectious disease outbreaks, and drought all negatively impact poverty and food security and challenge optimum complementary feeding practices and programming.
Within Sudan, complementary feeding in emergency (CFE) interventions have been adapted to various contexts (localities with a relatively stable protracted situation, localities with possible access, and localities with limited access) and priority was given to lifesaving interventions during acute emergencies. The tailoring of complementary feeding interventions has been elaborated on in the newly developed Sudan infant and young child feeding in emergencies (IYCF-E) operational guidance.
Strong coordination mechanisms for nutrition were in place, with the government leading on CFE interventions via the national nutrition programme and the Nutrition Sector, as well as multiple infant and young child feeding (IYCF) specific platforms (IYCF technical working group, IYCF-E taskforce and a technical committee on complementary feeding) that supported the planning and development of guidance on complementary feeding. CFE programming did not happen as a standalone intervention but was included within the wider maternal and IYCF agendas. Across other sectors, the Nutrition Sector closely coordinated with water, sanitation, and hygiene (WASH), social protection and food security and health. Key informants also reported that joint planning for nutrition (including complementary feeding activities) was happening.
The policy environment to support CFE in Sudan appeared to be strong with various policies, strategies, plans, and guidance in place to govern IYCF and IYCF-E actions. The main policy documents included a national IYCF strategy and the recently developed national nutrition policy and IYCF-E operational guidance. A key gap, however, was lack of legislation on the International Code of Marketing of Breastmilk Substitutes (the Code).
Nutrition situation analysis: Drivers and determinants of young children’s diets
A situation analysis for complementary feeding programmes was conducted in Sudan to guide programming using existing household surveys that reported on anthropometry and feeding practices, as well as qualitative data. The analysis showed that wasting and sub-optimal complementary feeding (predominantly low dietary diversity) practices among children aged 6-23 months were a major concern. Complementary feeding practices were driven by several factors, including parental education and wealth. Findings from the analysis had helped to guide IYCF actions, including the prioritisation of improved dietary diversity among young children. However, there was still a need for updated data and analyses reflecting the current situation to better guide and inform complementary feeding interventions.
The barriers and challenges to CFE programming included context-specific factors such as food insecurity, poverty and social norms and programme-related factors including funding, poor implementation of the Code, and access to remote communities.
Interventions and actions for improving young children’s diets
Most of the recommended interventions from the UNICEF Programming Guidance were reported to have been implemented either nationally or in some localities, except for ‘responsive feeding’ – where a mother responds to her baby’s cues as well as her own desire to feed.
Interventions included nutrition counselling and social and behaviour change communication (SBCC) provided alone or in combination with other interventions depending on the area of intervention. For example, in areas where food insecurity was high, counselling and SBCC were coupled with interventions to improve access to diverse and nutritious foods at the household level, such as home gardening, the provision of fortified seeds, and/or cooking demonstrations. In food insecure areas, supplementary feeding was also provided to children aged 6-23 months with a mid-upper arm circumference above 13 cm as well as micronutrient powders. Cash assistance targeted families in vulnerable areas, specifically for pregnant mothers until their child reaches 23 months of age.
The main channels of delivery of services were the health system (primary health centres) and the food system. Social protection systems were also used to target families who were most in need. WASH was integrated with IYCF interventions including hygiene awareness, access to potable water, and sanitation. System strengthening actions were implemented to influence policy and strengthen capacity at the institutional and community/household levels:
Actions to strengthen the health system included influencing policy related to health and nutrition services, building the capacity of service providers on complementary feeding, and implementing behaviour change interventions through mother and father support groups which contributed to strengthening delivery at the community level.
The food system was strengthened through close planning and the implementation of nutrition and food security activities, supporting policies related to food fortification, implementing supplementary feeding, and supporting the food supply chain and behaviour of caregivers through home gardening interventions and cooking demonstrations.
Actions to strengthen the social protection system included integrating nutrition vulnerability criteria into social protection interventions and supporting cash assistance for caregivers of young children.
WASH system strengthening actions included developing a joint standard operating procedure to integrate IYCF, WASH and community-based management of acute malnutrition and to ensure access to water, hygiene, and food safety awareness and sanitation to vulnerable groups.
Monitoring, evaluation, learning, and reported outcomes
IYCF (including complementary feeding) indicators were monitored by the Federal Ministry of Health with support from UNICEF and other partners. Indicators on counselling and support groups were integrated within the National Nutrition Programme and were regularly collected.
Although no evaluations had yet been conducted on the outcomes of existing interventions (e.g., mother support groups and behaviour change techniques), these have since shown a positive outcome on caregiver feeding behaviour.
Key enablers and opportunities were identified by interviewees to address challenges, including addressing food insecurity through direct food assistance, ensuring emergency preparedness through existing plans and provisions, scaling up existing interventions (i.e., prioritise peer support by providing training on complementary feeding to community volunteers, sensitise communities on complementary feeding key messages, build capacity for delivery of programming on complementary feeding and implement SBCC campaigns), increasing investments in complementary feeding interventions and building on existing opportunities, strengthening reporting systems to provide evidence on the outcomes of interventions and to increase funding, and delivering complementary feeding interventions as part of an integrated programme using the multi-sector approach.
Conclusion
Several learnings emerged from this case study: having a package of interventions contextualised to the specific challenges of Sudan’s complex emergency, including insecurity, lack of access to food and safe water and hygiene, enabled a more effective response to context-specific needs. In addition to the importance of a detailed situation analysis to guide the design and implementation of interventions, the continuous and active appraisal of the evolving situation was crucial as well as having emergency preparedness plans with clear guidance on rapid assessment in place. Close collaboration and coordination between sectors, including the representation of different sectors in IYCF, IYCF-E and complementary feeding working groups facilitated engagement and joint planning. Finally, localised initiatives, such as the Kassala dietary diversity project, provided concrete examples with documented outcomes and built the momentum for scale-up and buy-in at the national level, thereby maximising impact.
For more information, please contact Jodine Chase at ife@ennonline.net
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References
ENN and IFE Core Group (2022) Complementary Feeding in Emergencies Programming in Sudan – A case study based on the action framework for improving the diets of young children during the complementary feeding period. https://www.ennonline.net/cfecasestudysudan