Letter to the editor

In 2022, we published an article outlining the rationalisation of nutrition services in Cox’s Bazaar as part of Field Exchange issue 67.1 The article explored how bringing nutrition services together as a ‘one-stop shop’ – or ‘one camp approach’ – yielded positive results for those residing in these camps, where a complex set-up of various agencies and programmes was operating. Rationalisation targets this multi-layered set-up and looks to implement common strategies across actors to ensure that refugees have equitable access to all basic services.

”œNutrition service rationalisation is recommended as it not only provides an opportunity to integrate multiple services, including for the nutrition (Outpatient Therapeutic Programme, Targeted Supplementary Feeding Programme, Blanket Supplementary Feeding Programme), it also supports a disability-friendly environment and allows the mainstreaming of gender and other protection services through a single programme” – Rahimov et al., 2022

In this letter, we return to Cox’s Bazaar to explore the recently compiled and analysed results of the formative evaluation of the nutrition service rationalisation in the Rohingya Refugee Camps. We hope this letter guides colleagues in shaping humanitarian nutrition reforms in their respective countries based on our experiences in Bangladesh’s Cox’s Bazar refugee camps.

The nutrition sector’s coordination unit, with the support of UNICEF, the United National High Commissioner for Refugees (UNHCR), and the World Food Programme (WFP), and with the agreement of all implementing partners and government stakeholders, ran a formative evaluation of the nutrition sector’s performance by comparing pre-and post-rationalisation periods. The main objective of running the evaluation was to understand how the beneficiaries of the nutrition services accepted the rationalisation.

The evaluation, conducted by the Centre for Injury Prevention and Research, Bangladesh, highlighted that most interviewed mothers (62.6%) assessed the quality of nutrition services as ‘good’ or ‘very good’ in the pre- and post-rationalisation periods – illustrating that once a child or mother is admitted for nutrition treatment, the quality of services was viewed positively both before and after service rationalisation. However, mothers also mentioned that any confusion, which sometimes occurred when selecting nutrition facilities, was eliminated once this number was reduced and integrated under the single roof of the integrated nutrition facility.

Service providers (i.e. international and national non-government organisations operating under the UN agreement) mentioned that rationalisation ended the sharing of camp services between multiple implementing partners. Before rationalisation, there was no clear segregation of blocks and sub-blocks (units for dividing the camp) within the same camp between implementing partners. Rationalisation stopped the overlap of nutrition services by introducing a single partner per camp. As such, conflicts between service providers, service duplication, and double reporting – which can all occur when sharing service space – were eliminated.

The beneficiaries indirectly appreciated the service rationalisation by mentioning the reduced number of repetitive home visits by the different NGOs covering the same subjects or aims – with 99 (24.4%) respondents stating they were ‘very happy’ with the reduction and a further 292 (71.9%) stating the change was a ‘good’ thing.

It was also essential to capture the views of nutrition facility staff in the camps. Staff noted that the rationalisation did not change the already high quality of the in-facility services. This conclusion was confirmed by a previously published2 analysis, featured in Field Exchange 67, of nutrition facility performance. Of 406 interviewees, 306 (75.4%) service providers agreed that no change in in-facility service quality was observed after the service rationalisation.

The formative evaluation also touched on the COVID-19 pandemic period, which changed regular nutrition service provision in the Rohingya camps. Frontline service providers adjusted, adopted, and followed up the different nutrition service delivery approaches, including campaigns.3 We hypothesised that, as rationalisation eliminated the duplication of the community outreach activities, this minimised the level and frequency of contacts and thus supported pandemic social distancing practices. COVID-19 infection control measures were also easier to monitor in the reduced network of nutrition facilities by concentrating more resources on the single nutrition point. This helped to keep all nutrition facilities open during the peak of the pandemic. Most nutrition service clients (97%) answered that services were not disrupted during the COVID-19 outbreak. All children and mothers received necessary nutrition treatment even during the complete lockdown in the camps.

Both the quantitative and qualitative analyses of the nutrition sector rationalisation confirmed the following:

• The nutrition sector rationalisation discontinued duplication and, as a result, stopped double counting of the community outreach services provided. A single partner per camp ensures the delivery of channelled comprehensive essential and integrated (Outpatient Therapeutic Programme, Targeted Supplementary Feeding Programme, and Blanket Supplementary Feeding Programme) nutrition services.
• The beneficiaries appreciated the service rationalisation for discontinuing repetitive home visits by several service providers covering similar subjects.
• The beneficiaries mentioned the improved clarity in regard to selecting the relevant nutrition facility, as all services are concentrated under the single roof of the integrated nutrition facility.
• The quality of in-facility services remains the same before and after the nutrition service rationalisation, which was confirmed both by service providers and beneficiaries.

The success of service rationalisation has multiple connected components. In the case of Cox’s Bazar, the presence of clear, long-term United Nations funding was essential. Besides the funding, the strong and continuous cooperation commitment of each United Nations partner in the nutrition cluster encouraged a win–win scenario for stakeholders. This may not be feasible in other settings. Therefore, rationalisation should be carefully studied before initiating such a change.

Furthermore, we believe the evaluation allowed national institutions to be trained in UNICEF’s programme evaluation methods. Relevant UNICEF staff worked closely with the research institution, and the experience demonstrated that the approach could also extend national programme evaluation capacity in Bangladesh – building stronger systems for the future.

Sincerely,

Bakhodir Rahimov, Chief of Field Office, UNICEF Poltava, Ukraine (former Nutrition Sector Coordinator for the Rohingya crisis)

Andrea Parks, Evaluation Specialist, UNICEF Dhaka, Bangladesh

Abid Hasan, Information Management Officer, UNICEF Cox’s Bazar, Bangladesh

The authors express their deep gratitude to all UN agencies supporting the nutrition response in Rohingya camps – including UNICEF, UNHCR, and WFP. In addition, the authors thank the Civil Surgeon's offices and the Refugee Relief and Repatriation Commissioner in Cox’s Bazar, Bangladesh. Also, we want to give special thanks to all implementing partners, staff of the integrated nutrition facilities, and people contributing to the evaluation.